Thoracic Outlet Syndrome Treatment Basics

Achilles Tendinopathy/Tendinosis/Tendinopathy

• Achilles tendinopathy is a common overuse injury.
• It is a combination of pathological changes affecting the Achilles tendon.
• It's usually caused by overuse and chronic stress on the tendon.
• It can occur in both athletes and non-athletes.
• A lack of flexibility or a stiff Achilles tendon can increase the risk.
• The Achilles tendon is the thickest and strongest tendon in the body.
• Its origin is from the gastrocnemius and soleus muscles, and it inserts on the calcaneal tuberosity.
• It's approximately 15 cm (6 inches) long.
• The tendon experiences 3.9 times body weight during walking and 7.7 times during running.
• It's surrounded by a connective tissue sheath (paratenon) instead of a synovial sheath.
• The paratenon provides the major blood supply to the tendon.
• The blood supply is distal from intraosseous vessels of the calcaneus and proximally from intramuscular branches.
• An area of avascularity exists 2-6 cm from the calcaneal insertion, making the tendon vulnerable to degeneration and injury.
• Vascular density is greatest proximally and least in the midportion.
• Repetitive impact loading from activities like running and jumping commonly leads to Achilles tendon injuries.
• The tendon or paratenon (or both) can become inflamed, leading to tendonitis or peritendinitis.
• Excessive compression during repetitive energy storage and release can lead to sudden injury or, rarely, rupture.
• "Tendinosis" is a more accurate term than "tendonitis" because inflammation isn't always present.
• The condition is classified as insertional or mid-substance/noninsertional based on location.

Classification of Achilles Tendinopathy

• Insertional: within 2cm of the insertion.
• Mid-substance/noninsertional: 2-6cm proximal to the insertion.

Causes of Achilles Tendonitis

• Overuse: Forces within the physiological range repeated with poor recovery time lead to tendon fatigue, making it susceptible to micro tears.
• Sudden loading of excessive force, particularly during eccentric motion.
• Poor flexibility in the gastrocnemius and soleus muscles, increasing strain on the tendon.
• Muscle weakness of the gastrocnemius and soleus muscles resulting in micro tears and inflammation to the tendon.
• Joint restrictions (e.g., pes cavus) decrease shock absorption and affect adaptability to uneven terrain.
• Excessive pronation creates an internal tibial rotation, drawing the tendon medially and causing a whipping action.
• Systemic diseases like diabetes, lupus, and gout related to weakness within the tendon structure.
• Corticosteroid injections can contribute to tendon rupture.
• Training errors, such as poor footwear choices (too small, worn-out, inadequate heel counter) or running on hard or uneven surfaces.

Physical Examination and Findings

• Morning pain is a hallmark symptom as the tendon must tolerate stretching immediately after waking.
• Pain is diffuse in the back of the ankle (calf to heel).
• Activity aggravates the pain, especially uphill running and stair climbing.
• Pain is somewhat relieved by wearing high-heeled shoes or boots.
• Patients often report an increase in activity levels or a change in footwear.
• Observable, palpable edema and thickening of the Achilles tendon.
• Painful lumps or nodules within the tendon can be present.
• Crepitus during plantar and dorsiflexion is possible.
• A positive arc sign: the examiner palpates the tendon, and the patient performs dorsiflexion and plantarflexion.
• If the palpable thickening doesn't move but stays still with crepitation, it may indicate a tendon sheath injury.
• In the area of no swelling, 3cm proximal to the calcaneal insertion, palpation during movement.
• Positive Royal London Hospital test (RLH), pain on the tender spot disappears in maximal dorsiflexion.
• Decreased ankle dorsiflexion and hamstring tightness are common.
• Calf atrophy suggests a chronic condition.
• Pain during passive dorsiflexion or active/resisted plantarflexion is common.
• Damaged tendon fibers may calcify.

Diagnosis of tendinopathy

• History of symptoms
• Symptom behavior
• Clinical tests
• X-rays: can reveal calcification or hardening of the lower part of the tendon, indicating insertional tendinopathy. More severe non-insertional tendinopathy can show calcification in the midportion of the tendon.
• Ultrasound: A useful imaging tool indicating tendon width, water content, and collagen integrity, as well as bursal swelling.
• MRI: Not necessary for diagnosis but helpful for planning surgery.

Differential Diagnosis

• Plantar fasciitis
• Calcaneal fracture stress
• Heel pad syndrome
• Haglund deformity
• Sever's disease
• Posterior ankle impingement
• Medial tendinopathy
• Retrocalcaneal bursitis
• Sural nerve
• Lumbar radiculopathy
• Ankle osteoarthritis
• Deep vein thrombosis
• Partial Achilles tendon rupture

Management

• Medical: Nonsteroidal anti-inflammatory drugs.

• Botulinum injections: Temporarily reduce pain and spasm from neurovascular compression.

• Surgery (for severe cases): Supraclavicular scalene surgery. Transaxillary resection of the first rib.

• Physical therapy: Improves foot biomechanics, reduces pain/edema/inflammation, protects the inflamed tendon, enhance tendon healing, and optimizes muscle activity balance.

• Rest, ice, compression, elevation (RICE) for initial symptom control.

• Cross-training and exercise of non-involved muscles.

• Orthotics (Air heel brace and/or night splints)

• Heel-lifts.

• Transverse friction massages

• Stretching & strengthening exercises.

• Isometric loading of the Achilles tendon.

• Isotonic calf raises.

• Plyometric exercises.

• Mobilization techniques for the ankle and surrounding joints.

• Proper foot wear

• Maintenance of strength/flexibility for calf muscles

• Monitoring activities and balancing mechanical abnormalities at the foot and ankle

• Counterforce straps (to decrease symptoms and tension)

• Proper conditioning and warm-ups during/after exercise

Thoracic Outlet Syndrome (TOS)

• Compression of neurovascular structures (nerves, blood vessels, or both).
• It can happen in the three spaces between the ribs: Interscalene triangle, Costoclavicular space or Sub-coracoid tunnel/sub-pectoralis minor space.
• May be categorized as vascular (vTOS, 3%) or neurological (nTOS, 97%), including true and disputed cases.
• Symptoms: Numbness/tingling in arm/fingers, pain/aches in neck, shoulder, arm, or hand, arm fatigue, weakening grip, possibly color changes (cyanosis or pallor)
• Etiology: Anatomical defects (extra rib, fibrous bands), poor posture, muscle imbalances, trauma (macro/micro), repetitive activity.
• Diagnosis: History, physical examination, provocative tests.
• Provocative tests: Roos test, scalene cramp test, scalene relief test
• Special vascular tests: Adson's Maneuver, Wright's test
• Electrodiagnostic tests/EMG studies help determine if nerve function is involved.
• Imaging tests (e.g., X-rays, venography, arteriography) may assess bony abnormalities or vascular narrowing.
• Management: Conservative (medical, physical therapy), Medical: NSAIDs, Botulinum injections, Surgery (for extreme cases), PT: First rib mobilization, neural/joint mobilization, postural correction, stretching and strengthening of related muscles, exercises, patient education/activity modification, disturbed sleep patterns.