GENERAL ACHILLES INFORMATION FROM THE L.E.G. TEAM
Achilles Tendon - What is it?
What is the Achilles Tendon?
The Achilles tendon is a tough band of fibrous tissue that connects the calf muscles to the heel bone (calcaneus). The gastrocnemius and soleus muscles (calf muscles) unite into one band of tissue, which becomes the Achilles tendon at the low end of the calf. The Achilles tendon then inserts into the calcaneus (heel bone). The Achilles tendon is the largest and strongest tendon in the body.
Anatomically it has a centralised tendon and a superficial paratendon that acts to lubricate the slide of the tendon and “feeds” the tendon nutrition / blood
Achilles Tendon - How is it commonly injured?
How is it commonly injured
Acute tear- often feels like “being shot in the calf”
Overuse - many and varied reasons for the overuse of the tendon
Biomechanics - poor
Altered load - either too much from what you are use to or too little (tendons like to be used)
Achilles Tendon - Classification and signs and symptoms
Classification and Signs and Symptoms
The spectrum of Achilles tendon disorders and overuse injuries ranges from:
inflammation of the peritendinous tissue (peritendinitis, paratendinopathy),
structural degeneration of the tendon (tendinosis, tendinopathy),
insertional disorders (retrocalcaneal bursitis and insertional tendinopathy)
Achilles Pain - Types
The two main categories of Achilles tendinopathy are classified according to anatomical location and broadly include insertional and noninsertional tendinopathy.
Achilles tendon disorders include;
and frank rupture.
Achilles Tendinopathy: Pathophysiology, Epidemiology, Diagnosis, Treatment, Prevention, and Screening Joseph J Knapik et al
J Spec Oper Med. Spring 2020;20(1):125-140.
Achilles tendinopathy (AT) is a clinical term describing a nonrupture injury of the Achilles tendon where the patient presents with pain, swelling, and reduced performance and symptoms exacerbated by physical activity.
About 52% of runners experience AT in their lifetime and in the United States military the rate of clinically diagnosed AT cases was 5/1000 person-yr in 2015.
The pathophysiology can be viewed on a continuum proceeding from reactive tendinopathy where tenocytes proliferate, protein production increases, and the tendon thickens; to tendon disrepair in which tenocytes and protein production increase further and there is focal collagen fiber disruption; to degenerative tendinopathy involving cell death, large areas of collagen disorganization, and areas filled with vessels and nerves.
Inflammation may be present, especially in the early phases.
Some evidence suggests AT pain may be due to neovascularization and the ingrowth of new nerve fibers in association with this process.
Prospective studies indicate that risk factors include female sex, higher body mass index, prior tendinopathy or fracture, higher alcohol consumption, lower plantar flexion strength, greater weekly volume of running, more years of running, use of spiked or shock absorbing shoes, training in cold weather, use of oral contraceptives and/ or hormone replacement therapy, reduced or excessive ankle dorsiflexion range of motion, and consumption of antibiotics in the fluoroquinolone class.
At least 10 simple clinical tests are available for the diagnosis of AT, but based on accuracy and reproducibility, patient self-reports of morning stiffness and/or pain in the tendon area, pain on palpation of the tendon, and detection of Achilles tendon thickening appear to be the most useful.
Both ultrasound and magnetic resonance imaging (MRI) are useful in assisting in diagnosis with MRI providing slightly better sensitivity and specificity.
Conservative treatments that have been researched include: (1) nonsteroidal anti-inflammatory medication, (2) eccentric exercise, (3) stretching, (4) orthotics, (5) bracing, (6) glyceryl trinitrate patches, (7) injection therapies (corticosteroids, hyaluronic acid, platelet-rich plasma injections), (8) shock wave therapy, and (9) low-level laser therapy.
Nonsteroidal anti-inflammatory medication and corticosteroid injections may provide short-term relief but do not appear effective in the longer term.
Eccentric exercise and shock wave therapies are treatments with the highest evidence- based effectiveness.
Prevention strategies have not been well researched, but in specific populations balance training (soccer players) and shock-absorbing insoles (military recruits) may be effective. Ultrasound scans might be useful in predicting future AT occurrences.
GOLD STANDARD TREATMENT FOR YOUR ACHILLES
LEG - GOLD STANDARD ACHILLES REHABILITATION
The Lower Extremity Group offers to you the Gold Standard in Lower extremity injury rehabilitation.
We utilise a World Class rehabilitation program for Achilles tendinopathy, and this is deilvered to you online in the comfort of your own home. All you have to do is follow our easy to use evidence based plan to treat and manage your Achilles Pain.
This online program contains 4 complete weeks of revolutionary rehabilitation guides to help you manage and treat your Achilles Tendon issues every single day.
We deliver our evidence-based daily Achilles management program via our amazing app, which is very easy for you to follow and includes 28 days of;
Progressive neuromuscular exercises that will strengthen the muscles around the foot and ankle and help reduce the pain associated with Achilles Tendiopathy.
5 progressive levels of evidence based rehabilitation that do not require expensive equpiment
Passive and dynamic mobility exercises to increase range of motion and tissue extensibility of mucles and fascia
Myofascial massage exercises
We offer online consultations as a part of the rehabiliation precess to help you rehabilitate and manage your Achilles Issues.
Our experienced therapists have taken these aforementioned technical modalities and simplified them into easy to watch videos for you to follow and complete. These are delivered daily to your smart device within our Achilles management program.
Book in today - Online or in clinic
Using the app will enable you to understand when to apply the various exercises to help manage Achilles Pain
LATEST TRENDS IN ACHILLES MANAGEMENT
Of late LEG has seen patients that have successfully used stem cell implants in conjunction with our world calss Achilles Rehabilitation progreesions.
Orthop J Sports Med. 2020 Apr 30;8(4):2325967120915857.doi: 10.1177/2325967120915857. eCollection 2020 Apr.
Efficacy of Stem Cell Therapy for Tendon Disorders: A Systematic Review
Noortje Anna Clasina van den Boom
Background: Stem cell therapy is an emerging treatment for tendon disorders.
Purpose: To systematically review the efficacy of stem cell therapy for patients with tendon disorders.
Study design: Systematic review; Level of evidence, 4.
Methods: MEDLINE/PubMed, EMBASE, CINAHL, CENTRAL, PEDro, and SPORTDiscus; trial registers; and gray literature were searched to identify randomized controlled trials (RCTs) and non-RCTs, cohort studies, and case series with 5 or more cases. Studies investigating any type of stem cell therapy for patients with tendon disorders were eligible if they included patient-reported outcome measures or assessed tendon healing. Risk of bias was assessed through use of the Cochrane risk of bias tools.
Results: This review included 8 trials (289 patients). All trials had moderate to high risk of bias (level 3 or 4 evidence). In Achilles tendon disorders, 1 trial found that allogenic-derived stem cells led to a faster recovery compared with platelet-rich plasma. Another study found no retears after bone marrow-derived stem cell therapy was used in addition to surgical treatment. There were 4 trials that studied the efficacy of bone marrow-derived stem cell therapy for rotator cuff tears. The controlled trials reported superior patient-reported outcomes and better tendon healing. A further 2 case series found that stem cell therapy improved patient-reported outcomes in patients with patellar tendinopathy and elbow tendinopathy.
Conclusion: Level 3 evidence is available to support the efficacy of stem cell therapy for tendon disorders. The findings of available studies are at considerable risk of bias, and evidence-based recommendations for the use of stem cell therapy for tendon disorders in clinical practice cannot be made at this time. Stem cell injections should not be used in clinical practice given the lack of knowledge about potentially serious adverse effects.
RECOMMENDED MEDICAL LITERATURE HUB
Current Clinical Concepts: Conservative Management of Achilles Tendinopathy - Karin Grävare Silbernagel et al
J Athl Train. 2020 May;55(5):438-447. doi: 10.4085/1062-6050-356-19. Epub 2020 Apr 8.
Achilles tendinopathy is a painful overuse injury that is extremely common in athletes, especially those who participate in running and jumping sports. In addition to pain, Achilles tendinopathy is accompanied by alterations in the tendon's structure and mechanical properties, altered lower extremity function, and fear of movement. Cumulatively, these impairments limit sport participation and performance. A thorough evaluation and comprehensive treatment plan, centered on progressive tendon loading, is required to ensure full recovery of tendon health and to minimize the risk of reinjury. In this review, we will provide an update on the evidence-based evaluation, outcome assessment, treatment, and return-to-sport planning for Achilles tendinopathy. Furthermore, we will provide the strength of evidence for these recommendations using the Strength of Recommendation Taxonomy system.
Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial - Rikke Beyer et al
Am J Sports Med. 2015 Jul;43(7):1704-11. doi: 10.1177/0363546515584760. Epub 2015 May 27.
Background: Previous studies have shown that eccentric training has a positive effect on Achilles tendinopathy, but few randomized controlled trials have compared it with other loading-based treatment regimens.
Purpose: To evaluate the effectiveness of eccentric training (ECC) and heavy slow resistance training (HSR) among patients with midportion Achilles tendinopathy.
Study design: Randomized controlled trial; Level of evidence, 1.
Methods: A total of 58 patients with chronic (>3 months) midportion Achilles tendinopathy were randomized to ECC or HSR for 12 weeks. Function and symptoms (Victorian Institute of Sports Assessment-Achilles), tendon pain during activity (visual analog scale), tendon swelling, tendon neovascularization, and treatment satisfaction were assessed at 0 and 12 weeks and at the 52-week follow-up. Analyses were performed on an intention-to-treat basis.
Results: Both groups showed significant (P < .0001) improvements in Victorian Institute of Sports Assessment-Achilles and visual analog scale from 0 to 12 weeks, and these improvements were maintained at the 52-week follow-up. Concomitant with the clinical improvement, there was a significant reduction in tendon thickness and neovascularization. None of these robust clinical and structural improvements differed between the ECC and HSR groups. However, patient satisfaction tended to be greater after 12 weeks with HSR (100%) than with ECC (80%; P = .052) but not after 52 weeks (HSR, 96%; ECC, 76%; P = .10), and the mean training session compliance rate was 78% in the ECC group and 92% in the HSR group, with a significant difference between groups (P < .005).
Conclusion: The results of this study show that both traditional ECC and HSR yield positive, equally good, lasting clinical results in patients with Achilles tendinopathy and that the latter tends to be associated with greater patient satisfaction after 12 weeks but not after 52 weeks.
Effect of High-Volume Injection, Platelet-Rich Plasma, and Sham Treatment in Chronic Midportion Achilles Tendinopathy: A Randomized Double-Blinded Prospective Study - Anders Ploug Boesen et al
Am J Sports Med. 2017 Jul;45(9):2034-2043. doi: 10.1177/0363546517702862. Epub 2017 May 22.
Background: Injection therapies are often considered alongside exercise for chronic midportion Achilles tendinopathy (AT), although evidence of their efficacy is sparse.
Purpose: To determine whether eccentric training in combination with high-volume injection (HVI) or platelet-rich plasma (PRP) injections improves outcomes in AT.
Study design: Randomized controlled trial; Level of evidence, 1.
Methods: A total of 60 men (age, 18-59 years) with chronic (>3 months) AT were included and followed for 6 months (n = 57). All participants performed eccentric training combined with either (1) one HVI (steroid, saline, and local anesthetic), (2) four PRP injections each 14 days apart, or (3) placebo (a few drops of saline under the skin). Randomization was stratified for age, function, and symptom severity (Victorian Institute of Sports Assessment-Achilles [VISA-A]). Outcomes included function and symptoms (VISA-A), self-reported tendon pain during activity (visual analog pain scale [VAS]), tendon thickness and intratendinous vascularity (ultrasonographic imaging and Doppler signal), and muscle function (heel-rise test). Outcomes were assessed at baseline and at 6, 12, and 24 weeks of follow-up.
Results: VISA-A scores improved in all groups at all time points ( P < .05), with greater improvement in the HVI group (mean ± SEM, 6 weeks = 27 ± 3 points; 12 weeks = 29 ± 4 points) versus PRP (6 weeks = 14 ± 4; 12 weeks = 15 ± 3) and placebo (6 weeks = 10 ± 3; 12 weeks = 11 ± 3) at 6 and 12 weeks ( P < .01) and in the HVI (22 ± 5) and PRP (20 ± 5) groups versus placebo (9 ± 3) at 24 weeks ( P < .01). VAS scores improved in all groups at all time points ( P < .05), with greater decrease in HVI (6 weeks = 49 ± 4 mm; 12 weeks = 45 ± 6 mm; 24 weeks = 34 ± 6 mm) and PRP (6 weeks = 37 ± 7 mm; 12 weeks = 41 ± 7 mm; 24 weeks = 37 ± 6 mm) versus placebo (6 weeks = 23 ± 6 mm; 12 weeks = 30 ± 5 mm; 24 weeks = 18 ± 6 mm) at all time points ( P < .05) and in HVI versus PRP at 6 weeks ( P < .05). Tendon thickness showed a significant decrease only in HVI and PRP groups during the intervention, and this was greater in the HVI versus PRP and placebo groups at 6 and 12 weeks ( P < .05) and in the HVI and PRP groups versus the placebo group at 24 weeks ( P < .05). Muscle function improved in the entire cohort with no difference between the groups.
Conclusion: Treatment with HVI or PRP in combination with eccentric training in chronic AT seems more effective in reducing pain, improving activity level, and reducing tendon thickness and intratendinous vascularity than eccentric training alone. HVI may be more effective in improving outcomes of chronic AT than PRP in the short term. Registration: NCT02417987 ( ClinicalTrials.gov identifier).
Exercise Progression to Incrementally Load the Achilles Tendon - Josh R Baxter et al
Med Sci Sports Exerc. 2021 Jan;53(1):124-130. doi: 10.1249/MSS.0000000000002459.
Purpose: The purposes of our study were to evaluate Achilles tendon loading profiles of various exercises and to develop guidelines to incrementally increase the rate and magnitude of Achilles tendon loading during rehabilitation.
Methods: Eight healthy young adults completed a battery of rehabilitation exercises. During each exercise, we collected three-dimensional motion capture and ground reaction force data to estimate Achilles tendon loading biomechanics. Using these loading estimates, we developed an exercise progression that incrementally increases Achilles tendon loading based on the magnitude, duration, and rate of tendon loading.
Results: We found that Achilles tendon loading could be incrementally increased using a set of either isolated ankle movements or multijoint movements. Peak Achilles tendon loads varied more than 12-fold, from 0.5 bodyweights during a seated heel raise to 7.3 bodyweights during a forward single-leg hop. Asymmetric stepping movements like lunges, step ups, and step downs provide additional flexibility for prescribing tendon loading on a side-specific manner.
Conclusion: By establishing progressions for Achilles tendon loading, rehabilitative care can be tailored to address the specific needs of each patient. Our comprehensive data set also provides clinicians and researchers guidelines on how to alter magnitude, duration, and rate of loading to design new exercises and exercise progressions based on the clinical need.
Eccentric and Isometric Exercises in Achilles Tendinopathy Evaluated by the VISA-A Score and Shear Wave Elastography Matthias Gatz t al 2020
Randomized Controlled Trial
Sports Health. Jul/Aug 2020;12(4):373-381.doi: 10.1177/1941738119893996. Epub 2020 Jan 31.
Background: Apart from eccentric exercises (EE), isometric exercises (ISO) might be a treatment option for Achilles tendinopathy. Shear wave elastography (SWE) provides information for diagnosis and for monitoring tissue elasticity, which is altered in symptomatic tendons.
Hypothesis: Isometric exercises will have a beneficial effect on patients' outcome scores. Based on SWE, insertional and midportion tendon parts will differ in their elastic properties according to current symptoms.
Study design: Randomized clinical trial.
Level of evidence: Level 2.
Methods: Group 1 (EE; n = 20; 12 males, 8 females; mean age, 52 ± 8.98 years) and group 2 (EE + ISO; n = 22; 15 males, 7 females; mean age, 47 ± 15.11 years) performed exercises for 3 months. Measurement points were before exercises were initiated as well as after 1 and 3 months using the Victorian Institute of Sports Assessment-Achilles (VISA-A) score, American Orthopaedic Foot & Ankle Society score, and SWE (insertion and midportion).
Both groups improved significantly, but there were no significant interindividual differences (VISA-A; P = 0.362) between group 1 (n = 15; +15 VISA-A) and group 2 (n = 15; +15 VISA-A). The symptomatic insertion (symptomatic, 136.89 kPa; asymptomatic, 174.68 kPa; P = 0.045) and the symptomatic midportion of the Achilles tendon (symptomatic, 184.40 kPa; asymptomatic, 215.41 kPa; P = 0.039) had significantly lower Young modulus compared with the asymptomatic tendons. The midportion location had significantly higher Young modulus than the insertional part of the tendon (P = 0.005).
Conclusion: Isometric exercises do not have additional benefit when combined with eccentric exercises, as assessed over a 3-month intervention period. SWE is able to distinguish between insertional and midportion tendon parts in a symptomatic and asymptomatic state.
Clinical relevance: The present study shows no additional effect of ISO when added to baseline EE in treating Achilles tendinopathy. Different elastic properties of the insertional and midportion tendon have to be taken into consideration when rating a tendon as pathologic.