In recent years there has been a change in the way Achilles tendon complaints are both labelled and managed, this has come about primarily as a result of there being more understanding of the actual histology of the painful structures. This understanding has seen movement away from the typical previous diagnosis of the complaint as being “Achilles tendonitis” to using a generalised term of Achilles tendinopathy and with in this blanket tendinopathy label you could further sub classify the pathology to:
- peritendonitis, with inflammation of the paratendon only
- peritendonitis, with tendinosis, with inflammation of the paratendon and abnormalities of the tendon
- tendinosis with abnormalities of the tendon only
- rupture of the tendon
Note: this classification of Achilles tendon pathology’s is not agreed upon across the whole medical profession but are some general classifications of Achilles pathology that some including myself like to use. Also worth noting here is that classification does not indicate cause of complaint.
Achilles Tendinopathy Is Typically A Non-Inflammatory Condition
Studies have shown the histology generally is non-inflammatory with no significant numbers of inflammatory cells, it is in fact a degenerative overuse condition with attempts at repair. .
With the previously known “Achilles tendonitis” using the suffex “-itis” implies inflammation however it is now recognised that the inflammatory process is absent in most patients and as a result “Achilles Tendinopathy” is used to describe the clinical syndrome of pain, swelling and impaired performance in the Achilles tendon, and “tendinosis” for histopathological findings.
Management Of Achilles Tendinopathy
As a result of the increased understanding of the histology, the management of Achilles tendon complaints has changed also to accompany the new understanding of what is happening at a cellular level. Some approaches to the management of Achilles tendinopathy include:
- Eccentric exercises: Eccentric exercises are the most evidence-based treatment modality however it is suggested eccentric exercises are less effective in insertional than midportion tendonopathy. The impact of eccentric exercises is to reduce neovascularisation and increases type 1 collagen synthesis.
- Shockwave therapy: Shockwave therapy is suggested to be more effective in insertional than non-insertional tendinopathy and comparable effects to that of eccentric training in insertional Achilles tendonopathy. The improvement in symptoms coming from shockwave are hypothesized to come from promoting neovascularization and angiogenesis at the tendon-bone junction and inducing degeneration of epidermal nerve fibers with subsequent reinnervation.
- Nonsteroidal anti-inflammatory medication (NSAIDS): Understandably considering the histology suggests an absence of inflammatory cells NSAIDS have been shown to have little benefit.
- Steroid Injections: The use of steroid injections into or around the Achilles tendon are controversial. Current prescription of a cortisone injection would have the intention of reducing peritendonitis, there is low risk of Achilles tendon rupture if cortisone is accurately guided via Ultrasound into the paratendon. The tendonopathy itself is a degenerative, non-inflammatory condition in which steroids such as cortisone would not have an effect.
- Platelet-rich plasma (PRP) and autologous blood injections:The aim with these injections is for the concentrated platelet derived growth factors to stimulate a healing response. It makes good sense however there is currently little evidence to justify a PRP injection with Achilles tendinopathy.
Achilles Tendinopathy: A Runners Complaint
Achilles tendinopathy is a very common complaint in a number of sports including tennis, volleyball, soccer, but specifically Achilles tendinopathy has a high incidence in top level runners. Accurate diagnosis of the tendinopathy is important so the most appropriate management can be offered and help in accelerating the recovery process.
Disclaimer: Sydney Physio Clinic does not endorse any treatments, procedures, products mentioned. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific advice or assistance regarding Achilles tendinopathy should consult his or her orthopaedic surgeon, sports medical specialist, general practitioner or physiotherapist.