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PAGE 18 the stiffness of the tendon and expose it to risk of overload and tendinopathy . 30
Elevated cholesterol has been associated with tendon pathology and the risk of tendinopathy . 30 Deposition of LDL cholesterol in the tendon ( tendon xanthoma ) occurs because of its affinity for decorin , the small proteoglycans in tendons . It is unknown at what level of serum cholesterol deposition will occur , but it is likely to be the high levels seen in familial hypercholesterolaemia rather than more mildly elevated levels . There is little research into serum lipid levels and tendon deposition .
Foot posture , specifically pronation , has long been thought to cause Achilles tendon pathology . There is strong evidence to support the absence of this association , and that orthotics do not offer better outcomes than sham orthotics . 31 There is strong evidence that a rigid supinated foot ( pes cavus ) and limited range of dorsiflexion are associated with Achilles
15 , 32 tendinopathy . Menopause has been associated with Achilles tendon rupture . 33 , 34 Clinically , menopause is also associated with other tendinopathies such as gluteal tendon pain . 35 Management with short-term hormone replacement therapy as an adjunct to rehabilitation may be beneficial . 35
Systemic diseases , such as Crohn ’ s disease and psoriatic arthritis , are associated with enthesitis , which may be indistinguishable clinically from insertional tendon pathology associated with overload . Insertional Achilles tendinopathy , especially if bilateral , unprovoked and associated with persistent morning stiffness , requires assessment for underlying systemic disease . Some genetic polymorphisms have been associated with Achilles tendinopathy , however offer little for management . 36
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MANAGEMENT OF MID-ACHILLES TENDINOPATHY
ONCE a clear diagnosis is made and the provocative load identified ( see table 1 ), institute a systematic treatment program .
Active treatment
There are two treatments to initiate . The first , a sustained ( isometric ) contraction , can improve pain for several hours . 37 In standing , the patient raises both heels , then transfers their weight to the affected side . They hold this position for up to 45 seconds , or for as long as they can hold it well . This is repeated five times with a rest of about two minutes between each exercise . It may be slightly painful on the first contraction but the pain eases
as the exercise progress . This simple exercise can be used when pain is affecting function .
The second treatment is to institute a basic exercise program for people with lower activity levels . Exercise improves the strength , endurance and power of the affected muscle tendon unit and increases tendon stiffness , which all improve the capacity to tolerate activity . Based on the assessment of calf capacity , start the exercise program with the number of quality calf raises the patient can perform . They can start with a single set twice a day and increase the number as their ability increases . The patient should perform the calf raises on each leg independently , as improving the unaffected leg
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Figure 9 . Site of superficial bursa pain .
can increase strength in the affected leg by up to 20 %. 38 The aim for recreational activity is 20 single-leg calf raises ( once a day when up to these repetitions ) on each leg , and this may take up to 12 weeks to achieve . Adherence is the key factor in a successful outcome , so discuss strategies to improve this . Most patients will be capable of performing this exercise , as it takes around five minutes to complete .
Good quality calf raises require a slow movement ( two seconds up and three seconds down ) to full height ( this can be checked by assessing full height with a double leg heel raise ) and not inverting towards the end of range ( see figure 11 ). These ‘ cheating ’ strategies make the exercise ineffective .
As strength improves , morning symptoms should decrease in the presence of consistent load . Further exercise options are based on individual presentation and may be best left to other practitioners .
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Adjuncts
These passive modalities appear in box 2 .
Education
Education is critical ; there is disinformation online and in the clinical community . Tendon pain is unique because of its strong association with load . Patients thus become frightened of activity and of loading the tendon ; add to that a concern that ‘ it might rupture ’, and kinesiophobia is the result .
The terms used in imaging reports such as ‘ tears ’ and ‘ splits ’ add to the patient ’ s ( and clinician ’ s ) fear . These concerns are baseless , as the pathology does not involve the whole tendon , with research showing that the tendon has sufficient healthy tissue to
tolerate loads . 19 Highlight the patient ’ s modifiable risk factors and any muscle wasting , and set goals to empower them to improve their calf capacity and function .
Advise and educate the patient to ‘ listen ’ to their tendon and monitor their morning symptoms . If they are stable , then the tendon load was not excessive the previous day . If they are getting worse ( longer stiffness times and / or more pain ), then the load the day before was excessive . As Achilles tendinopathy is recurrent , this is a good strategy for them to take into recovery .
What not to do
Relying on imaging to help with clinical decisions and advising the patient to
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Figure 10A , B and C . Location of medial tendon pain ( blue ), lateral tendon pain ( yellow ).
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Figure 11 . Full-height calf raise in A . double-leg , and B . single leg . C . Height and alignment can be checked by drawing a line through the second metatarsal and the centre of the talocrural joint ( right ).
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rest are poor management decisions . Patients will always feel better when not loading the tendon , until they try to return to their usual load , when the symptoms will return with a vengeance . Crutches or walking boots are not useful to reduce pain . Resting simply reduces the capacity of the tendon , muscle and kinetic chain to tolerate load , with poorer outcomes after rest .
Stretching is not helpful and can be provocative in insertional and plantaris-associated tendinopathy and is not recommended as a treatment . Icing is similarly unhelpful , so do not include this in a treatment plan unless a patient reports benefits from ice after activity .
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Running with Achilles tendinopathy
The decision to stay active is important , and the key clinical question is ‘ How active ?’ Using Achilles tendinopathy outcome measures can be helpful ; if morning pain is stable and the patient has the capacity to perform the activity , then they can remain active .
Rehabilitation may take place simultaneously to increase the tolerance of the tendon to a higher load . Lower load activities such as walking ( not hills ) are often tolerated , and substitution activities such as cycling and elliptical trainer can be used if running is too provocative .
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Referral
When and whom to refer to can be complex . Interventions such as injections and surgery have little place in the management of Achilles tendinopathy . However , the exception may be persistent plantaris issues and ongoing pain despite excellent rehabilitation ( remember the differential diagnoses with non-resolving pain ).
Start with physiotherapy , choosing a practitioner experienced in working with tendons , as tendon loading is essential . A good practitioner can assist the patient to return to full activity . Exercise practitioners may also be helpful but may not be as well versed in the progression of load in tendinopathy .
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