treatment options Achilles tendinopathy

treatment for insertional achilles tendinopathy

Case Presentation

A 45 year old female who participates in triathalons presents to your clinic with stiffness and pain over the right heel.  The patient describes pain with activity that localizes to the calcaneus.  She is exquisitely tender over the Achilles insertion over the lateral portion and nontender over the midportion.  A plain radiograph shows a small Achilles enthesophyte over the insertion.  Which of the following initial treatment options is most appropriate for this patient?

A. Surgical referral
B. Cast and non weight bearing for 6 weeks
C. Physical therapy with exercise program
D. Extracorporeal shock wave therapy (ESWT)

Introduction

Insertional Achilles tendinopathy (IAT) is difficult to manage, and there is no definite consensus on which nonoperative treatment is superior over the others. Sports medicine providers will undoubtedly be involved in challenging cases involving IAT.

Treatments for tendinopathies are wide ranging, and include but are not limited to orthotics, physiotherapy, laser treatment, ultrasound, extracorporeal shock wave therapy, NSAIDs, peritendinous corticosteroid injections, platelet rich plasma injections, high volume saline injection, eccentric loading, sclerosant injection and surgery. This wide range of treatments reflects the limited consensus among clinicians on how this pathology is best managed.

Insertional Achilles tendinopathy (IAT) is located at the insertion of the Achilles tendon onto the calcaneus, possibly with the formation of bone spurs and calcifications in the tendon proper at the insertion site. Patients can complain of pain, stiffness, and sometimes swelling that can be firm or solid. On physical examination, the tendon insertion is painful. A swelling may be visible and a bony spur may be palpable [1].

Non-operative care is a first line approach for treating insertional Achilles tendinopathy (IAT). While surgical procedures for IAT have long differed from those done for midportion Achilles tendinopathy (AT), this disease-specific approach is relatively new in the field of rehabilitation.

The incidence of Achilles tendon pain is approximately 6% in the general population, and 24% of the people suffering from heel pain were diagnosed as insertional Achilles tendinopathy (IAT). The incidence of IAT increases with age and is significantly higher in patients with metabolic diseases (e.g., diabetes mellitus, hypercholesterolemia, and hypothyroidism) [2-3].

Figure 1.  Lateral x-ray showing achilles enthesophyte.  Adopted from [21].

Exercise is the primary treatment strategy for all patients with IAT, yet the ideal parameters are not defined.  The type, dose or combination with additional treatments are variable.   Eccentric exercises have long been considered the “gold standard” for exercise interventions for tendinopathy, but these have not been shown to be superior to other exercises for IAT.  In addition to eccentric exercise, physical therapists also use heavy slow-resistance training and isometric exercise, which have been shown to provide pain relief for other types of tendinopathy.  

The standard eccentric exercise protocol utilizing the full range of ankle dorsiflexion motion does have some therapeutic benefit with an average decrease of 1.8 to 2.8 in pain ratings on an 11-point scale at 3 to 4 month follow-up.  Reviews have shown, however, that an average pain of 2 to 5 on a scale of ten persisted in many individuals.  Moreover, there is a high rate of non-responders to eccentric exercise with end range dorsiflexion with 70% of participants reporting poor results [6-8].  This has led to many protocols not including full dorsiflexion for IAT.

Figure 2.  T2 MRI with insertional achilles tendinosis and retrocalcaneal bursitis .  Adopted from [21].

Eccentric exercise is many times modified for patients with IAT by reducing the range of motion during the exercise. By reducing the amount of ankle dorsiflexion, this modification reduces the amount of compression on the soft tissues at the tendon insertion and, based on clinical experience, also reduces the level of pain reported during the exercise. With a modified eccentric exercise protocol, pain has been shown to decrease from 5.4 at baseline to 3.0 at 3 months and 1.0 by 1 year [9]. Similarly, a case series of patients with IAT reported a relatively high rate of patient satisfaction with 67% able to resume their pre-injury level of activity [5]. In summary, all studies demonstrate a decrease in pain with eccentric exercise, yet this effect may be greatest when the exercise is modified for the IAT population.

In 2008, a randomized controlled trial by Rompe and colleagues found that extracorporeal shock wave therapy (ESWT) was more effective at reducing pain and IAT symptoms than a traditional eccentric exercise program at 4-month follow-up [10]. In 2006, Furia reported that ESWT in conjunction with anesthetics had an average pain reduction of 5 points on the VAS compared to 1.4 points in a control group treated nonoperatively [11]. These studies prompted further treatment protocols and studies.

More recently, a retrospective study found that ESWT resulted in a greater decrease in pain than a traditional eccentric exercise program at 6-month follow-up.  The average decrease in pain score was 3.9 for ESWT and 1.9 for eccentrics at 6 months and 3.6 and 1.5 at 18 months [12].  One risk of ESWT is high pain during the treatment, for example 6/30 patients in the study by Wei and colleagues discontinued the ESWT treatment due to “intolerable pain.” The use of an anesthetic may help patients tolerate the treatment, but it is unclear if this variation in application alters patient outcomes.

Two recent Level IV studies have also supported the use of shockwave therapy for IAT, yet the authors question the effectiveness for patients with enthesophytes [13-14].  One of these was with forty six patients and also showed that patients may need counseling on expectations of treatment and possibility that some pain may persist. 

There are no studies on the use of corticosteroid or glucocorticoid injections specifically for the insertional form of Achilles tendinopathy.  For sclerosing therapy, using polidocanol to target neovascularization, there was one pilot study of patients with chronic IAT in which 8/11 patients reported decreased pain [13].  However, another case study cautioned against the use of sclerosing agents because of the risk of tendon rupture in an elite athlete [14]. 

In cases of isolated retrocalcaneal bursitis, corticosteroid injection may be considered, but care should be taken to avoid intratendinous injection. Other potential types of injection include those targeting neovascularization, such as the sclerosing agent polidocanol or simple mechanical disruption with high-volume saline, and hyperosmolar dextrose (prolotherapy). Although several small trials have studied these agents, most were not specific to IAT and provide insufficient high-quality evidence to support their use in routine clinical practice [15].

PRP or platelet rich plasma has become a very popular treatment modality in orthopedics and sports medicine. The majority of studies using PRP for AT have been in patients with midportion AT or mixed cohorts, and its use remains controversial.  A 2012 prospective case series by Monto found PRP to be effective in a mixed cohort of 30 patients with AT (8 insertional, 22 midportion) leading to satisfaction with treatment in 28/30 patients at 2-year follow-up. However, both treatment failures in this study occurred in patients with IAT (2/8).  Higher-level studies with randomization and blinding are needed specifically for IAT and PRP.

Figure 3.  Recent review and grade of recommendation for treatment options for IAT.  Adopted from [2].

Operative intervention may be considered in patients with recalcitrant IAT. A number of different operative techniques have been described with differences in approach and intervention. Most operative procedures include removal of pathologic tendon and calcifications, the posterosuperior calcaneal prominence, and the retrocalcaneal bursa.  For open debridement and decompression of the Achilles tendon insertion, a longitudinal midline incision is a popular approach.  Other techniques have been described also.

The consistently good postoperative outcomes, despite variations in approach and reattachment techniques, across a range of studies continue to support the use of operative treatment for IAT [17].  Postoperative outcomes, including patient satisfaction and self-reported function, for operative debridement are generally positive. Postoperative AOFAS ankle-hindfoot scores range from 81 to 96 and patient satisfaction is generally greater than 87 percent.  Yet there are potential complications including superficial wound infection, scar abnormalities (hypersensitivity, hypertrophy, and numbness), skin necrosis, hematoma, delayed wound healing, sural neuritis, tendon avulsion, deep vein thrombosis, and recurrence of pain [17].

Endoscopic procedures of the calcaneus and Achilles tendon may result in fewer wound-healing complications compared to open procedures.  However, A limitation of the endoscopic approach is that it may not be possible to entirely remove the bone spur or all diseased tissue in patients with full-thickness intratendinous calcifications. As such, it may be a more appropriate treatment for patients with disease characterized primarily by enlargement of the posterior superior calcaneal tuberosity.  There is less evidence supporting the endoscopic approach when compared to the open approach [17].

FHL tendon transfer is often used to provide augmentation when there is severe degeneration of the Achilles tendon.  McGarvey et al (2002) found that in adults with IAT, those over the age of 50 had a greater amount of degeneration, inflammation, and overall percentage of tendon involvement [18]. Therefore, it has been suggested that FHL augmentation may be of additional benefit in this age group. Den Hartog (2003) reported on a case series of 26 patients (29 procedures) that underwent FHL transfer with tendon debridement and decompression. The study found that FHL transfer improved patient outcomes in patients older than 50 with more advanced tendinosis [19].  However, a recent randomized, prospective trial (Level I evidence) consisting of 39 patients greater than 50 years of age suggests that FHL transfer may not result in better outcomes in this patient population [20].   

Percutaneous ultrasonic debridement of regions of degenerative/calcific tendinosis have shown promise in other anatomic locations such as the elbow and plantar fascia.  Potential advantages include decreased wound complications and accelerated recovery. There are also new probes that may be able to perform spur removal.  Ultrasound-guided microinvasive techniques for treatment of IAT are emerging, but there is limited data for IAT.

Summary

In summary, the majority of non-operative treatments for IAT have insufficient evidence to support treatment recommendations, with exercise and ESWT as exceptions. Exercise has the highest level of evidence supporting the ability of this treatment option to reduce IAT pain. When exercise is unsuccessful, ESWT appears to be the next best non-operative treatment option to reduce IAT pain. After failure of conservative care, open debridement and decompression for IAT is supported by many studies that report high postoperative function and patient satisfaction. 

Case Conclusion

Answer is C. The vast majority of patients with insertional achilles tendinopathy will start with non-operative treatment.  There is debate on whether full dorsiflexion should be involved in the treatment plan, but first line treatment would include an exercise program.  Extracorporeal shock wave therapy does have increasing usage for IAT but would unlikely be first line treatment.  Cast and non weight bearing and a surgical referral would be inappropriate treatment for this patient.

– More Achilles Tendinopathy @ Wiki Sports Medicinehttps://wikism.org/Achilles_Tendinopathy

More Ankle Painhttps://www.sportsmedreview.com/by-joint/ankle/

References

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