📌 Treatment of Achilles tendinopathy

History

Athletes, especially, middle-aged, middle-distance and long-distance runners are the classic demographic who are susceptible to non-insertional Achillis tendinopathy (NIAT)

Examination🔍

Patients often present with symptoms plus or minus a swelling on the posteromedial side of the tendon and tenderness can usually be elicited with palpation over this bump.

An assessment of gastrocnemius-soleus complex tightness should be made using Silfverkiold’s test.

All foot and ankle patients should have at least a clinical evaluation of the neurovascular status of the limb.

Imaging🎥

Since the pain in AT is closely correlated with the extent of neovascularisation within the tendon, ultrasound with the addition of power Doppler can provide a form of functional imaging of the tendon.

The reason for the correlation between pain and neovascularisation is that new, pain transmitting nerve endings grow into the tendon with the new vessels. Treatment modalities which reduce the amount of neovascularisation have shown a reduction in symptoms.

Non-surgical treatments

The first-line treatment of NIAT should always be non-operative and surgery should only be considered once conservative measures have failed.

Exercise therapies

Exercise enhances tendon healing partly by promoting nerve withdrawal from the tendon proper, which has been found as a major factor in the underlying pathophysiology.

Eccentric exercises have the most evidence of effectiveness in the treatment of NIAT.

Eccentric exercises that are clinically effective have been demonstrated to reduce neovascularisation within the tendon. 

The compliance of training over around 3️⃣ months, the same time needed for new tendon cell formation, is essential for effectiveness and mostly requires intense supervision by a physical therapist to be successful.

🔖Eccentric strengthening should be considered as the first-line option, as it has the most evidence for its effectiveness, no special or expensive equipment is required and there appears to be no risk associated with it.