Summary
Patients should normally be seen first by the physiotherapist. Eccentric exercises are the most evidence-based treatment modality, although they may be less effective in insertional than non-insertional tendonopathy. Combined cryotherapy and compression may be useful as an initial treatment. Simple analgesics such as paracetamol should probably be used in preference to NSAIDs. It is not necessary to stop Achilles tendon loading activities during the treatment programme.
For patients who fail eccentric exercises, ultrasound-guided sclerosant injections probably have the best support in the current evidence. Shockwave treatment may have some value in insertional tendonopathy, although further evidence is required and the equipment is expensive. For other treatments, including:
- GTN patches
- Peritendinous steroid injections (where the risk of rupture is probably <2%)
- Aprotonin injections
- Platelet-rich plasma injections
the current evidence is equivocal.
Physiotherapy
Unless there is a tear which needs surgery or initial splintage, all patients will begin by undergoing physiotherapy aimed at reducing pain, reducing Achilles tendon tightness and improving strength. Therefore, the physiotherapist, not a surgeon, should be the clinician of first contact, and should have appropriate skills and the authority to arrange further investigation and treatment.
Cryotherapy is sometimes used to reduce pain and swelling. Knobloch (2008) showed that combining compression and cryotherapy using the Cryo-Cuff produced improved tendon oxygenation over cryotherapy alone.
There are two trials comparing physiotherapy regimes for chronic Achilles tendonopathy(Mafi 2001, Roos 2004). Both showed a small advantage for eccentric versus concentric exercises. Both trials were small with some loss to follow-up. At 3-year follow-up in a cohort series of eccentric exercises (Ohberg 2003), the tendon was less thickened and ultrasound abnormalities had mostly resolved. The benefits continue at 4-5 years (Gardin 2010, Silbernagel 2011, van der Plas 2011). van der Plas (2011) found that half the patients had tried other treatments in the meantime, whereas Silbernagel (2011) reported this in less than 10%.
Knobloch (2009) found less improvement in pain and VISA-A scores in 25 females than in 38 males with midportion Achilles tendonopathy after 12 weeks' eccentric exercises. Savana (2007) also found less benefit in sedentary people.
However, Norregard et al (2007) found no difference between the results of eccentric exercise and stretching, and Sayana and Mafulli (2007) found eccentric exercise less effective in insertional than midportion tendonopathy. Indeed, Rompe found external low-energy shockwave treatment more effective than eccentric exercise for insertional tendonopathy, although he suggested exercise might still be tried first in view of its minimal cost.
Eccentric exercise reduces neovascularisation (Knobloch 2007) and increases type 1 collagen synthesis (Knobloch 2007). However, levels of the pain mediator glutamate are unchanged (Alfredson 2003). Eccentric exercise also leads to increased ankle dorsiflexion range (Mahieu 2007), which is interesting as the same authors (Mahieu 2006) found increased range of dorsiflexion to be a risk factor for Achilles overuse injury in army personnel.
Although further evidence is likely to emerge, an eccentric exercise programme is currently preferred for the initial rehabilitation of chronic Achilles tendonopathy.
Silbernagel (2007) found no difference in outcome between athletes who were randomised to continue running and jumping activities during a rehab programme and those who were instructed to stop such activities.
Nonsteroidal anti-inflammatory medication
Astrom (1992) found no benefit from piroxicam against placebo in a small but adequately powered RCT. Simple analgesia should be the first line of pain management in this condition.
Transcutaneous glyceryl trinitrate (GTN)
Paoloni (2007) reported an RCT comparing 6 months of daily local glyceryl trinitrate patches to placebo in midportion tendonopathy. At 3-year follow-up 88% of the GTN and 67% of placebo patients were asymptomatic. Differences in pain scores, hop test and return to sport tended to favour the GTN group but were non-significant.
However, Kane (2008) found no difference in pain relief between physiotherapy alone and physiotherapy with GTN patches in a RCT of 40 patients. Biopsies from patients who failed non-surgical treatment and underwent debridement showed no difference in collagen synthesis or neovascularisation in GTN-treated or non-GTN-treated patients, and there was no evidence of modulation of nitric oxide sythetase in GTN treated patients.
Steroid injections
Steroid injections into or around the Achilles tendon are highly controversial. The intention is to reduce peritendonitis - tendonopathy is a degenerative, non-inflammatory condition in which steroids have not been shown to have an effect. A RCT by daCruz (1988), comparing peritendinous methylprednisolone and bupivacaine with bupivacaine alone, showed similar rates of resolution (30% in control, 31% in treated), activity and pain improvement in both groups. Gill (2004) reported a safety trial using fluoroscopy control with some efficacy data indicating 40% had some improvement. Both these studies used small volumes of fluid.
As usual, there are very small risks of steroid-induced skin atrophy and infection. Shrier (1996) estimated the risk at about 1%, and in the series of Gill it was 1/43 (2.3%, 95%CI 0-12.3%). However, the main concern is that the injection will precipitate tendon rupture. Some series have attempted to establish methods to ensure that steroid only enters the paratenon but not the tendon to reduce the risk of rupture. Unfortunately, the real rate of rupture after steroid injection is not known. There have been numerous case reports. Using data from two reasonably good series gives a total rate of rupture of 0/77 (95%CI 0-4.7%). Coombes (2010) meta-analysed 41 trials including 2672 patients who had injection for various tendonopathies. Overall, steroid injections had a stong short term treatment effect, but no medium or long term benefits. Only 1/991 patients had a reported tendon rupture at any site, but not all trials reported adverse events adequately.
It is currently the policy of East Lancs Foot and Ankle Service that we do not inject the Achilles tendon or its paratenon, as we do not feel there is enough information to be able to advise accurately patients on the risk.
Sclerosant injections
The demonstration of new vessel formation associated with pain mediator nerves in tendonopathy led to investigations of methods of ablating these neovessels. However, neovascularisation score before treatment did not predict the outcome of treatment (de Vos et al 2007). Alfredson (2005) reported an RCT comparing injections of the sclerosant polidocanol to lignocaine + adrenaline in non-insertional tendonopathy. Injections were directed with colour Doppler into areas of neovascularisation; the adrenaline was to simulate loss of vascular signal. Each patient had two injections initially 3-6 weeks apart. There were only 10 patients in each group, but this was on the basis of a preparatory power analysis. VAS pain scores improved from 77/100 to 41/100 in the polidocanol group but the control group showed no change (66 to 64). Five of the polidocanol group and all ten of the control group had additional polidocanol injections and the final VAS pain score in the treated group was 16/100. The flow through the trial and the total amount of treatment given are unclear. Probably this should be seen as a pilot study for a larger, better designed trial.
Willberg (2008) reported a RCT comparing injections of 5mg/ml and 10mg/ml polidcanol in which 70% of each group obtained pain relief at 14 months. Clementson (2008) reported a retrospective series of 25 patients injected with polidocanol, of whom 19 (76%) reported satisfactory results. However, Hamilton (2008) reported a rupture of the Achilles tendon after multiple sclerosant injections in an athlete.
Volume injections (brisement)
Another method of disrupting neovessels and the accompanying nerves is to inject substantial volumes of fluid into the space between the Achilles tendon and the paratenon, sometimes described as brisement.
Chan (2008) reported the injection of 50ml fluid containing bupivacaine and hydrocortisone under ultrasound control. 70% of patients responded and VISA-A scores improved from a mean of 44.8/100 to 76.2 at 30 months. Maffuli (2013) reported 87 patients who had failed other non-surgical treatments, had injections of 10ml bupivacaine and 62500 units of aprotonin. 35 had second injections (with steroid instead of aprotonin) and 8 underwent surgery for continuing symptoms. The mean VISA-A score improved from 42/100 to 75.
There have been no comparative studies or trials.
Prolotherapy
Injections of hyperosmolar dextrose with local anaesthetic are intended to create local inflammation that may initiate a healing response. Yelland (2009) reported an RCT in which 43 patients were randomised to eccentric exercises, prolotherapy or a combination of both. There were no significant differences in VISA-A scores between groups at 12 months. The authors note that "The improvements in pain at 6–12 months were inferior to those in uncontrolled observational studies of prolotherapy", reminding once again of the importance of rigorous trials of fashionable treatments.
Aprotonin
Brown (2006) reported a RCT of the protease inhibitor aprotonin injected to the peritendonous area in patients with non-insertional Achilles tendonopathy. Aprotonin or saline, with lignocaine, were injected on three occasions. All patients also had an exercise programme. There were no differences between the groups on pain scores or any other outcome measures. Orchard (2008) reported a large retrospective series of 430 patients in whom 76% considered themselves to have benefited from aprotonin injections.
Shockwave therapy
External shockwave treatment causes tissue disruption which is thought to produce a more effective healing response. It may also produce axonal damage in sensory nerves. It has been used in a number of degenerative soft-tissue pain syndromes.
In non-insertional tendonopathy, a RCT reported by Costa (2005) found no difference in pain between shockwave treatment and dummy treatment; two patients in the treatment group suffered Achilles tendon ruptures. Rompe (2007) found no difference between eccentric exercise and shockwave therapy. Rasmussen (2008) found a significantly larger improvement in AOFAS hindfoot score in patients treated with shockwaves than with dummy treatment; the difference was accounted for by the female patients and there was no difference in VAS pain score. The AOFAS hindfoot score seems an odd primary outcome measure for a trial on Achilles tendonopathy. Furia (2008) reported a retrospective case-control study comparing shockwave treatment with various non-surgical treatments and found significant differences in VAS pain scores and overall results in the shockwave group.
In insertional tendonopathy, Rompe (2008) found that shockwave treatment produced pain relief in 64% of patients compared with 28% for eccentric exercise. Furia (2006) had reported a retrospective case-control study in which VAS and Roles/Maudsley scores were significantly better in patients treated with shockwaves than non-surgical modalities; 83% of the shockwave group reported successful outcomes.
Currently it appears that shockwave treatment is more effective in insertional than non-insertional tendonopathy.
Platelet-rich plasma and autologous blood
The concept behind this treatment is the injection of concentrated platelet-derived growth factors to stimulate an impraved healing response. It is difficult to compare studies as the techniques and concentrates used vary. Although there have been some supportive uncontrolled series, an RCT by de Vos (2010) found no difference in outcome between platelet-rich plasma and eccentric exercises compared with eccentrics alone. This lack of effect was maintained at 1-year follow-up (de Jonge 2011).
Pearson (2011) compared eccentric exercises alone to exercises plus autologous blood injection around the tendon. Improvement was quicker in the autologous blood group, but there were no significant differences in VISA-A scores at 12 weeks. Bell (2013) reported another RCT comparing peritendinous injection of 10ml of autologous blood to insertion of a needle only. The mean improvement in VISA-A score was 18.6 in the treatment group and 19.9 in the non-treatment group (non-significant).