Chronic Achilles tendinopathy - what are the treatment options?
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We are often visited by patients with Achilles tendonopathy at PhysioQinetics. The Achilles tendon connects the calf (the back of the lower part of your leg) muscles to the heel bone, and helps you to push up on your tiptoes. It is a fairly common condition and can be a recurrent or chronic problem patients with foot biomechanical issues and athletes participating in certain sports such as tennis, badminton, or in runners. The classic symptoms include pain, stiffness, redness and swelling at the back of the heel; often present first thing in the morning and eases after a period of time. In fact, at our PhysioQinetics Staines Physiotherapy Clinic, which is situated in the Everyone Active Spelthorne Leisure Centre, we often see patients coming to see us in our on-site treatment room with recurrence of Achilles tendon pain after exercise classes or after a vigorous running session.
Some clinicians promote the use of injection therapy – sometimes with a mixture of steroid and local anaesthetics. The theory is that the local anaesthetic provides an immediate numbing effect for pain relief (short term), and the steroid will reduce tissue inflammation. However, whilst effective in modulating inflammation, steroid interferes with inflammatory cell function and tissue repair. This could often lead to poor healing, or even permanent tendon tear or rupture that require surgical repair [1]. The Cochrane review currently does not support the routine use of steroid injection for Achilles tendinopathy [2].
Other clinicians propose alternative injection therapy with high volume of saline mixed with local anaesthetics but without steroids - aiming to disrupt the abnormal scar tissue formation with the hypothesize that this will reduce new blood vessel formation (neovascularisation) and new nerve fibre infiltration within the inflamed Achilles tendon – in other words modulate or mediate the inflammatory response by mechanical means.
A recent study from the Netherlands published on the British Medical Journal (BMJ) disputed this approach in a new randomised controlled trial [3]. They recruited adult patients with clinically diagnosed chronic midportion Achilles tendinopathy with confirmed neovascularisation on ultrasound scan, and randomised them to receive either high volume saline injection without steroids versus placebo injection, and followed them up for 24 weeks. It showed no significant difference in pain score or functional score between the two groups. In other words, high volume injection therapy with saline has no added value to standard physiotherapy and exercise programme in patients with Achilles tendinopathy.
At PhysioQinetics, our specialist physiotherapists are experts in the diagnosis and treatment of Achilles tendinopathy; and we always emphasise our motto that there is no substitute to our expert ‘hands-on’ treatment. Our physiotherapists will assess and treat your foot and ankle, and sometimes even refer you to our in-house podiatrist for a comprehensive biomechanical assessment to correct any foot biomechanical problem. Our tailored exercise programme will then reduce the risk of recurrence in the future.
Reference:
1. Mahler F, Fritschy D. Partial and complete ruptures of the Achilles tendon and local corticosteroid infections. Br J Sp Med 1992; 26(1):7
2. Cochrane review : https://www.cochrane.org/CD010960/MUSKINJ_injection-treatment-for-painful-achilles-tendons-in-adults
3. Van der Vlist AC, can Oosterom RF, van Veldhoven PLJ, et al. Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy: randomised controlled trial. BMJ 9-Sept 2020; 370:m3027 (doi.org/10.1136/bmj.m3027)