New Treatments for Chronic Achilles Tendinitis

[therapist101]

Hi there,

I am from New Zealand and compete in athletics (sprinting mainly) and have suffered from recurring achilles tendinosis for several years (it's the 'in' injury to have this year).

Does anyone have any effective treatments that differ from the 'norm'?

I have many contributing factors as to why I continue to suffer from recurring bouts of achilles tendinosis. I generally found that eccentric strengthening (following the Alfredson regime) was all I needed to get it under control - just bent knee calf raises, straight-knee do nothing for me. Unfortunately, now I think the changes within my tendon have tipped beyond the point at which it is sufficient to bring the tendon back from the depths of pain.

I believe I must have considerable neovascularisation in the tendon now and assume I am dealing with a fair amount of chronic pain and changes in the way my nerves function.

I feel like my days are consumed by stretching, eccentric exercises and then all the other exercises required for all the other contributing areas around my body.

Any tips from anyone would be great (sorry, I know this is a very broad question)...


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[gcoe]

Hi therapist101

Some sports physio out there night have some better ideas. However here are a few things that come to mind:

Have you had a look through this systematic review:

PEDro - Detailed Search Results

It does outline a few other techniques other than eccentric training with some evidence to consider.

Have you had it definitively diagnosed by and ultrasound? If not it might be worth doing this to be sure the diagnosis is right and if it is right to also look at the extent of diseased tendon. There are of course a number of related pathologies that may need checking out.

What about other kinesiopathological problems - have you had the balance between your lower limb muscles checked out. Could the achilles tendons be taking the brunt in your sprinting due to a muscle imbalance problem or motor control issue. What about any issues with the posture of the foot - eg pronated hindfeet?

the last thing might be worth considering - do you think you may now have a chronic pain component to the problem - so where the pain you are experiencing is disproportionate to the problem. If this is so taking a pain management approach might help.

[roycar]

as per gcoe, have you been diagnosed through ultrasound? color doppler ultrasound can be used to acscertain the degree of neovascularisation. a good sports doc can set you up with these.

have you given alfredsons protocol enough time, he advocates between 6-12 weeks of eccentric drops? do you perform maintenance eccentric strengthening during the times that you have been painfree?

there is level 2 evidence to support the use of nitric oxide donor therapy and in most up to date protocols this is the next step following on from unsuccessful eccentric strengthening. this is used in conjunction with the continuation of heel drops.

also sclerosing injections have shown positive results in small scale studies when used to treat areas of neovascularisation.

for the above two treatments you need to be under a sports doc. in your neck of the woods you shouldnt have too much trouble finding someone aware of the above treatments. here in ireland however...... i've only come across one doc who has even heard of sclerosing injections!

biomechanical assessment and treatment of soft tissue abnormalities is also nb.

[Yarok]

Hi

I agree with guys above.
Pelvis and lumbar back must be checked up.I can see only complex approach inc. eccentric exer, soft tissues (massage etc), dry needling , acupuncture, physical therapy, taping, even platelets injection, can solve the problem.

all the best
Jarek
Fizjomanual I Fizjosport - Start

[therapist101]

Thanks for all your input.

I had not had diagnosis by ultrasound. I ended up having 2 courses of platelets injection around the tendon. Not sure if I noticed much in the way of changes in the tendon following this.

I ended up flagging the third course of the injection because it was getting too close to my national championships. Each time I had one, the tendon was quite uncomfortable for several days which interfered with training. I ran with pain and managed a 5th place finish in my event with I deemed was reasonable considering my circumstances.

Took complete rest after nationals. Didn't bother doing any rehab at all. Got back into training 8 weeks later completely pain free - and have been asymptomatic for over 12 weeks now. Nothing quite like rest - something the athlete-patient is always extremely reluctant to do.

Now that I'm back into training, I do 3 x weekly eccentric soleus work and regular stretching to keep my achilles free from the evil clutches of Tendinosis.

Cheers.

[prateekgupta]

ACHILLES TENDON INJURIES
Achilles tendonitis, sometimes known as Achilles tendinopathy, is a very common running injury. It results in degeneration or inflammation of the Achilles tendon, and though the injury is usually short-term, without correct rest or treatment it can become chronic and cause tearing of the tendon.
Symptoms
Acute Achilles tendonitis transpires within days, with pain increasing as time progresses. Pain is often sharpest at the beginning of an exercise routine and lessens as you continue; the pain also diminishes during periods of rest, and the area around the injury may be tender to touch.
Chronic Achilles tendonitis is the progression of the condition due to a lack of treatment or an appropriate break from training. The pain will progressively intensify over weeks or months, and will be continuous during all exercise. Rest does not lessen the pain and increases stiffness in the tendon. In some cases lumps may develop in the tendon, and skin over the area can redden.
Causes
The injury is commonly associated with running because of the Achilles tendon’s role in supplying much of the energy required for the push off stage in walking and running. The tendon joins the heel bone to the calf muscles, and through overuse can become strained and irritated. Most commonly this involves a rapid increase in training, such as covering greater distances or running at greater speeds. Decreased rests and weakened muscles may also contribute to the injury, and a recent change in shoes or otherwise inappropriate footwear is another risk factor.
You should also look for a recent escalation in running up hills, as this causes the Achilles tendon to work harder than normal and produces quicker fatigue.
Biomechanical errors of the feet such as overpronation can also put excessive pressure on the tendon. In rare cases the injury can be caused by an infection.
Treatment
With acute Achilles tendonitis, resting the affected area immediately and taking anti-inflammatory medication with the approval of your doctor is often sufficient. You should not run or partake in activities that rely on the Achilles tendon. Icing the area and shielding it from overuse by wearing a heel pad will be beneficial.
Medical Attention
If the pain persists after 1 to 2 weeks of rest and self-treatment, and especially if the pain becomes chronic, consult a medical professional. They will examine the foot and might use an x-ray to dismiss other possible causes. A doctor can pinpoint the reasons for your injury and prescribe suitable medication, shoe inserts or an alteration in training routine if necessary. They may recommend a sports therapist, massage program or other suitable rehabilitation methods.
Prevention
Make sure to look after the tendon effectively following recovery, otherwise it is likely to return. This may involve changing shoes and modifying your exercise habits to be more conservative with your activity, only increasing the length or speed of your training gradually. Appropriate stretching, as well as strengthening of the calf muscles is an effective way to avoid injury. Try switching between high and low-impact exercise, with activities such as cycling and swimming placing far less strain on your Achilles tendon.
If you do suspect that the injury is returning, begin treatment early to avoid the possibility of the condition becoming chronic.


For more details please contact:
Dr. Prateek Gupta (Senior Surgeon)
Arthroscopy Surgery Clinic
C2/5 Safdarjung Development Area (SDA),
Aurobindo Marg, New Delhi - 110016
INDIA
Telephones: +91 9810852876, +91 11 26517776
24 x 7 Helpline & Appointment: +91 9810633876
Email: [email protected],
[email protected]
Website: Sports Medicine Clinic Delhi :: A+ Orthopaedic & Sports Medicine Clinic - Arthroscopy - Joint Replacement Surgery - Sport Injuries