Achilles Tendonitis/Tendinosis/Tendinopathy PDF

Achilles Tendinitis/Tendinosis/tendinopathy Presented by Dina Othman Shokri Achilles tendinopathy (common overuse injury) refers to a combination of pathological changes affecting the Achilles tendon usually due to overuse and excessive chronic stress upon the tendon. It can be...

Achilles Tendinitis/Tendinosis/tendinopathy Presented by Dina Othman Shokri Achilles tendinopathy (common overuse injury) refers to a combination of pathological changes affecting the Achilles tendon usually due to overuse and excessive chronic stress upon the tendon. It can be seen both in athletes and non-athletes. It may or may not be associated with an Achilles tendon tear. A lack of flexibility or a stiff Achilles tendon can increase the risk of these injuries. Achilles tendon is the thickest and strongest tendon in the body. Origin from gastrocnemius and soleus muscles and Insertion on calcaneal tuberosity, about 15 cm (6in) long. The tendon can receive a load stress 3.9 times body weight during walking And 7.7 times body weight during running. The tendon is surrounded by a connective tissue sheath (Paratenon) rather than a true synovial sheath, which function like an elastic sleeve and increase freedom of movement against surrounding tissues. The paratenon also provides the major blood supply to the Achilles tendon. The vascular supply to the tendon comes distally from intraosseous vessels from the calcaneus and proximally from intramuscular branches. There is a relative area of avascularity 2 to 6 cm from the calcaneal insertion that is more vulnerable to degeneration and injury. Blood supply to the achilles tendon is evident at the muscle tendon junction and at the tendon bone insertion. Vascular density is greatest proximally and least in the midportion of the tendon. Achilles tendon injuries are commonly associated with repetitive impact loading resulting from running and jumping. Either the tendon or paratenon (or both) can become inflamed and symptomatic, resulting in tendonitis or peritendinitis. Achilles tendinopathy is a common overuse injury caused by repetitive energy storage and release with excessive compression. This can lead to a sudden injury, or in the worst case, can cause a rupture of the Achilles tendon. Achilles tendinopathy characterized by pain in the posterior part of the heel it can be both acute and chronic in nature. A common term for this posterior heel pain is Achilles tendonitis, but this term may be misleading as it implies acute inflammation within the tendon, whereas it has been shown that other pathological processes may also be the cause of pain. It is better to call it as "tendinosis. These are "overuse" or "misuse" conditions caused by excessive and/or repetitive motion, often associated with poor biomechanics. The end result is a microtrauma injury. The over-stretching or over-use of the achilles tendon causes achilles tendonitis. Achilles Tendinitis/Tendinosis/ tendinopathy classified into Insertional: within 2 cm of its insertion. Mid-substance or noninsertional – 2-6 cm proximal to its insertion. Causes of achilles tendonitis 1) Overuse injury occurs with forces within the physiological range, but when repeated with poor recovery time, therefore, causing fatigue to the tendon, making it susceptible to micro tearing. 2) Sudden loading of excessive force, especially with eccentric motion, can cause damage. 3) Poor flexibility to gastrocnemius and soleus increase the strain to the tendon and can result in micro tearing. 4) Muscle weakness of the gastrocnemius and soleus will result in micro tears and inflammation to the Achilles tendon. 5) Joint restriction of the talocrural or subtalar joints, pes cavus lead to decreased shock absorption or poor ability to adapt to uneven terrain. 6) Excessive pronation, pronation generates an obligatory internal tibial rotation, which tends to draw the Achilles tendon medially, creating a whipping action. The whipping action, when exaggerated, may contribute to overuse degeneration and inflammation or microtears in the tendon, particularly in its medial aspect. 7) Systemic disease, such as diabetes, lupus, gout, are all related to weakness within the tendon structure. 8) Corticosteriod injections may be a cause of rupture and there is controversy with its use. 9) Training errors 10) Poor footwear-too small, worn-out, poor heel counter for rear foot stability and poor shock absorption 11) Running on unyielding or uneven surfaces Physical examination and finding -Morning pain is a hallmark symptom because the Achilles tendon must tolerate a full range of movement including stretch immediately after getting up in the morning. -Diffuse pain in or around the back of the ankle (from the calf to the heel). The pain is aggravated by activity, especially uphill running or stairclimbing, and relieved somewhat by wearing higher-heeled shoes or boots. -Often, a recent increase in activity levels (such as more stair climbing) or a change in footwear is reported by the patient. -Observable, palpable edema and thickening of the achilles tendon (The tendon can appear to have subtle changes in outline, becoming thicker in the A-P and M-L planes). -Achilles tendons will often have a painful and prominent lump or nodules within the tendon. -There may be crepitus during plantar and dorsiflexion. -A positive arc sign The patient lie on the examination table in prone position with the ankles clear of the table. First, the clinician palpates the Achilles tendon in a distal to proximal direction, between 2 and 6 cm above the insertion into the calcaneus, gently squeezing the tendon between the index finger and the thumb feeling for localized thickening of the tendon. Afterward, the palpating fingers stay on the area of swelling and the patient is asked to dorsiflex and plantarflex the ankle. In tendinopathy of the main body of the tendon, the area of swelling moves with dorsiflexion and plantarflexion. If the palpable thickening does not move but stays relatively still with palpable crepitation, the tendon sheath might be suspected as the area of injury. The use of a stethoscope might be a helpful addition in case crepitation cannot be felt. If an area of swelling cannot be identified, an area in the tendon 3 cm proximal to the calcaneal insertion is palpated during the movement. -Positive Royal London Hospital test (RLH) for Achilles tendinitis The patient can be in prone or sitting position with the foot over the edge of the bench. The ankle is in neutral or slight plantar flexion while you palpate the achilles tendon for tenderness. In midportion tendinopathy, this is commonly the case 2-5cm from the calcaneal insertion or right at the calcaneus in insertional tendinopathy. The patient is then asked to move the ankle into maximum dorsiflexion. The tendon is then again palpated at the previously found tender spot. Then the patient moves the foot into maximum plantarflexion and the tender spot is again palpated. The test is considered positive for achilles tendinopathy if the pain on the tender spot initially found is absent in the maximally dorsiflexion. The authors have no explanation as to why the pain disappears on maximal tension on the tendon. -Decreased ankle dorsiflexion (from tightness in the gastrocnemius– soleus tendon complex) and hamstring tightness are commonly found in patients with Achilles tendon pathology. -Calf atrophy is common in any Achilles tendon dysfunction (Atrophy is an important clue to the duration of the tendinopathy and it is often present with chronic conditions). -There is usually pain with passive dorsiflexion and on active or resisted planterflexion. -In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify. Bone spurs (extra bone growth) often form. it can rub against the tendon and cause pain.  Diagnosis Diagnosis depends on history, symptom behavior and clinical tests. X-ray: provide clear images of bones. X-rays can show whether the lower part of the Achilles tendon has calcified, or become hardened. This calcification indicates insertional achilles tendinitis. In cases of severe noninsertional achilles tendinitis, there can be calcification in the middle portion of the tendon. Insertional achilles tendinopathy with calcific enthesopathy -Ultrasound is the imaging modality of first choice as it provides a clear indication of the tendons width, changes of water content within the tendon and collagen integrity, as well as bursal swelling. -Magnetic Resonance Imaging (MRI): Although magnetic resonance imaging (MRI) is not necessary to diagnose Achilles tendinitis, it is important for planning surgery. Differential Diagnosis Plantar fasciitis Calcaneal fracture stress Heel pad syndrome (deep, bruises and pain in the center of the heel) Haglund deformity - this is a prominence of the calcaneus that can cause bursitis between the calcaneus and the Achilles tendon Sever's Disease - Irritation of the back of the calcaneus at the growth plate. Occurs in young children and adolescents, particularly around puberty and during growth spurts. Posterior Ankle Impingement Medial Tendinopathy Retrocalcaneal Bursitis Sural Nerve Lumbar Radiculopathy Ankle OA Deep vein thrombosis Management ❖ Medication ❖ Physical therapy ❖ Corticosteroid Injections ❖ Platelet-Rich Plasma Injections ❖ Operative Surgery Aims of treatment of physical therapy treatment ▪ Optimize foot biomechanics. ▪ Control the symptoms, decrease pain, edema and inflammation. ▪ Protected the inflamed tendon and enhance tendon healing ▪ Optimize the muscle activity balance.  Physical therapy To Control the symptoms (pain, edema and inflammation) using RICE +using physical agents to control symptoms and promote healing. Rest. The first step in reducing pain is to decrease or even stop the activities that make the pain worse. If you regularly do high-impact exercises (such as running), switching to low-impact activities will put less stress on the Achilles tendon. Activities such as biking and swimming are low-impact options to help you stay active. For patients with nonacute Achilles tendinopathy, clinicians should advise that complete rest is not indicated and that they should continue with their recreational activity within their pain tolerance while participating in rehabilitation. Cross-training activities: Exercise of the opposite ankle should be encouraged. Vigorous exercise of the uninvolved contralateral ankle muscles produces a neurological stimulus in the injured muscles (the "crossover effect"), and helps to prevent atrophy. Ice. Placing ice on the most painful area of the achilles tendon is helpful and can be done as needed throughout the day. Electrotherapy Modalities: Ultrasound and low level laser therapy may be used. Iontophoresis using dexamethasone in the acute stage. Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged area. Protected the inflamed tendon by using taping, Ant pronation taping is supported, many consider using taping, possibly prior to orthotics in the acute stage, then using orthotics (Air Heel Brace and Night Splints). Ant pronation taping taping If the pain is severe, you may recommend a walking boot for a short time. This gives the tendon a chance to rest before any therapy is begun. Extended use of a boot is discouraged, though, because it can weaken the calf muscle. Foot orthotics may be needed if abnormal mechanics at the foot and ankle contribute to the onset or recurrence. Shoe wear: Firm, closed fitting heel counters. Heel pads and wide heel base for rear foot stability. Avoid stiff soled shoes: this increases the work of the muscle tendon complex. Figure 2. Heel Pads Air Heel Brace Heel lift can decrease stress on the tendon by effectively shortening it during weight bearing. As elevation of heel with small heel lift (1/4to3/8 inch) to decrease excursion of tendon. Transverse friction massage may to improve circulation and promote healing. Optimize the muscle activity balance by increase the flexibility of shorted muscle (calf muscle) and increase the strength of weak muscle (planter flexor muscle) at first unloaded isometric then concentric then eccentric then loaded exercises. Stretching of the tight and shortened gastrocnemius/soleus muscle complex. Gentle stretching should be started early, putting a linear stress on the tendons and stimulating connective tissue repair. Strengthening exercises that focus on the eccentric (negative) component have been shown to improve the healing of tendons and accelerate return to sports participation. These exercises should be progressed to closed-chain, heavily loaded eccentric exercises by carrying weight while doing heel raise to stimulate collagen fiber re-orientation and strengthening. The patient is instructed to sit then stand on the edge of a stair, do a toe raise up, then rapidly drop the involved heel as far as possible, returning by pushing back up with the uninvolved leg. Isometric Loading- Achilles tendon holds: Isometric tendon loading act as a mainstay of tendinopathy treatment. Isometric tendon loading has been found to have pain-relieving effects on tendons, while simultaneously maintaining some baseline strength. Isotonic Loading- Calf raises These exercises are often commenced once the athlete's pain level and the tendon’s irritability reduces. There are no ‘hard and fast’ rules for when to start an athlete on isotonic loading for the rehabilitation of Achilles tendinopathy. Graduated isotonic loading is initiated once they have less than 5/10 pain on NRS or tolerable and acceptable pain on repeated single leg calf raises, and their morning tendon stiffness has been reduced significantly. The ultimate goal of the isotonic exercise is to develop strength in the tendon and the surrounding muscles. Isotonic seated calf raises Isotonic standing calf raises should be performed at the mid-range of the muscle’s movement. The benefit of performing Heavy slow resistance (HSR) exercise in the mid-range is that it will avoid the compression of the tendon at end of the range Energy Storage Loading- Plyometric Exercises: The crucial last stage of rehabilitation is the initiation and execution of ‘energy storage’ tendon exercises. These exercises include deformation of the tendon with jumping and hopping based exercises. These exercises help the tendon to regain its capacity to absorb and then release energy via the stretch- shortening cycle, The ankle mobilizations can be used for dorsiflexion limitation of the talocrural joint and varus- or valgus limitation of the subtalar joint. Balance exercises; Balance boards can introduce activities on uneven surfaces and add stress to mimic function in WB. Pool exercises can be appropriate to promote progression in weight bearing activities. N.B: The patients should ice the tendon area after activities until he has returned to normal activities. Prevention Prevention can be facilitated with -Proper foot wear -Maintaince of strength and flexibility for calf muscles -Monitoring activities and balancing any mechanical abnormalities at the foot and ankle. -Counterforce straps may decrease symptoms and tension to the achilles tendon. -Proper conditioning and warm-up, Almost all sport injuries can be avoided when proper warm-up and cool downs are used during and after practice. -Heel raises is a good warm-up.