HOW TO TREAT 21
Table 1 . Identifying the provocative load and determining level of function
Box 2 . Passive adjuncts
Activity Reduce the provocative load
Identify dysfunction
Determine the level of function required
Identify risk factors that might affect response to treatment
CASE STUDY
ANDRE , 55 , and mildly overweight , presents with right Achilles pain that has been present for several months . He has an office job and plays golf twice a week . The pain is now present towards the end of his round and is affecting his game . His golf buddies have advised him he needs an MRI .
Andre has Achilles stiffness in the morning and takes about 10 minutes to warm up , especially the day after a golf game . He recalls some similar mild symptoms previously but cannot remember which leg it was , but this settled spontaneously in a few weeks .
His symptoms started after he did some bush walking on a holiday , with both hill climbing and beach walking .
1 . Which THREE statements regarding tendon pathology are correct ? a Tendinopathy is defined as pain and dysfunction in a tendon , without defining the pathology in the symptomatic tendon . b Symptoms occur in a pathological tendon in response to changes in load . c First-line approaches include rest , ice and medication . d Achilles tendinopathy is more common in older people and those who have been active .
2 . Which THREE are types of tendon loads ? a Shearing . b Energy storage and release . c Compressive . d Friction .
Detail
3 . Which TWO statements regarding Achilles tendinopathy are correct ? a Achilles tendinopathy most commonly occurs in the mid-tendon . b Achilles tendinopathy usually becomes more painful as the day progresses . c Acute onset occurs after an unusual load is placed
• Avoid the load that provoked the pain until the pain settles and the patient has the capacity to return to these higher loads after rehabilitation
• It is critical to identify this load on history ; if it is not identified , the Achilles tendinopathy will persist
• Examination will determine the starting level of exercise , whether the patient requires referral for a structured exercise program , and which activities the patient can continue to perform — Can the patient do a heel raise ? If so , how many and how well ? — Is their pain level high when they hop ?
• High levels of dysfunction are not compatible with high levels of loading during activity and this helps frame the decision about continuing activity
• This will assist the GP in deciding whether to institute an exercise program or to refer the patient to a physiotherapist : higher-level function requires a higher level of rehabilitation — Do they want to play golf or run 50km a week ? — Someone who simply wants to walk the dog or play golf can do well with a simple calf-raise program prescribed by the GP
• This may not be the ideal time to discuss weight management , but remember to discuss and investigate associated conditions later in rehabilitation
He thought the pain was from the new shoes he had bought for the trip , but the symptoms have not settled on return to his usual activities and footwear . He has sought treatment from a practitioner who massaged his tendon and advised him to ice it regularly and rest . The treatment did not help , but ibuprofen offers a brief , short-term pain relief .
Andre points to the midpoint of his Achilles as the painful spot . Examination of his lower legs from behind reveals some swelling in the right Achilles tendon and a smaller calf muscle bulk on the painful side . There is poor muscle definition in his legs . When Andre raises his heels up on both feet , he has little pain but
How to Treat Quiz .
on the tendon . d Cephalosporins have an important relationship with tendon symptoms and rupture .
4 . Which THREE assist in the diagnosis of Achilles tendinopathy ? a Ultrasound followed by confirmatory MRI . b Evidence of wasting of gastrocnemius . c Assessment during calf raises . d Range of dorsiflexion of the ankle .
5 . Which THREE statements regarding findings with the differential diagnoses of Achilles tendinopathy are correct ? a Single-leg heel raise is impossible with a ruptured Achilles tendon . b Crepitus may be palpable or audible with peritendon irritation . c Bursal involvement is always associated with an insertional Achilles tendinopathy . reports mild pain in his right Achilles when raising up on his right leg . A small jump and hop increase his pain substantially , hopping on the right leg causes pain of 7 / 10 . He is fearful of doing this movement and there is an obvious difference between legs in the ability to hop .
His foot and ankle posture and range of movement are unremarkable , and when examined in prone there is some thickening of the right tendon and some discrete lumps on the left . Palpation of the tendon is equally painful bilaterally .
The GP diagnoses right mid-Achilles tendinopathy following a change in load on the tendon . The history of previous pain and the changes in
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d Repetitive load in ankle plantar flexion such as in ballet causes Achilles tendinopathy .
6 . Which TWO are risk factors for Achilles tendinopathy ? a A rigid pronated foot . b Sedentary lifestyle . c Mildly elevated lipid levels . d Diabetes .
7 . Which TWO active treatments are indicated in mild Achilles tendinopathy ? a Intensive program to assist in rapid return to previous activity level . b Sustained ( isometric ) contraction . c Slow walking on a treadmill to increase tendon strength . d Basic exercise program .
8 . Which THREE statements regarding passive management modalities are correct ? a The use of corticosteroid is helpful long-term .
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ACHILLES TENDINOPATHY
• Injection therapies : — These are not evidence based or rational from a pathological or symptomatic viewpoint .
— The concept that treatment is needed to restore normal structure is incorrect ; this is not required for functional recovery , as there is adequate tissue to achieve load tolerance . 39
• Hands-on treatments :
— Tendon friction and manipulation , machine-based treatments ( such as shockwave therapy ) and taping may not be harmful and can offer short-term pain relief ( hours / days ) but are not cost and time efficient . — Exercise is the best form of medicine .
• Shoe and orthotic interventions : — This has limited value . — The belief that foot pronation is a source of Achilles tendinopathy is not supported . 36 — Complex orthotic interventions , including custom orthotics , also lack evidence . 31 — Lifting the heel can be helpful in insertional Achilles and plantaris tendon conditions , but it is not that helpful in mid-Achilles
40 , 41 tendinopathy . — Achilles tendinopathy dislikes change , so keep shoes and surfaces consistent .
• Stay on firm surfaces with stable shoes during activity .
• Walking on sand is an aggravating factor and may be the reason for initial presentation .
• Medications : — These offer little as this is not an inflammatory condition .
42 , 43
— The use of corticosteroid is helpful short-term but not long-term .
both tendons suggest a degenerative pathology with symptoms due to load change .
Imaging of the tendon is not indicated as it will not change the diagnosis or management , and the GP explains this to Andre . The GP also explains that the tendon did not tolerate the extra walking on holiday and treatment includes strengthening the tendon and muscle with exercise ( a calf-strengthening program , initially
b Walking on sand is an aggravating factor and may be the reason for initial presentation . c The use of custom orthotics lacks evidence . d Taping may offer short-term pain relief .
9 . Which TWO are unhelpful in the management of Achilles tendinopathy ? a Crutches or walking boots . b Graded return to full loading . c Complete rest . d Monitoring morning symptoms .
10 . Which THREE statements regarding running with Achilles tendinopathy are correct ? a Using Achilles tendinopathy outcome measures can be helpful . b Patients need to stop physical activity while rehabilitation is in progress . c Lower load or substitution activities can be used if running is too provocative . d If morning pain is stable and the patient has the capacity to perform the activity , then they can remain active . double-leg but progressing to single-leg exercises when stronger ).
Options include a plan to modify Andre ’ s golf game by using a cart , reducing to nine holes or improving his swing at the driving range , as he needs to keep active during rehabilitation . Referral to a physiotherapist is indicated at six weeks if he is not adherent to his exercise or his improvement has stalled . The GP discusses follow-up for weight loss and blood glucose and lipid testing .
PROGNOSIS
ACHILLES tendinopathy is responsive to accurate diagnosis and adequate treatment . High-level athletes can return to full function after a bout of tendinopathy , so those who function at lower levels are also able to recover . Achilles tendinopathy is also recurrent , with a change in load causing a return of symptoms . Patient education about the awareness of excess tendon load and how to monitor tendon response is critical in preventing recurrence . Maintaining strength with twice-a-week heel raises also discourages recurrence .
Barriers to recovery are incorrect diagnosis ( the wrong source of pain is identified or there is more than one source ), reliance on imaging reports to determine management , inadequate patient education ( resulting in fear of loading and non-adherence to exercise-based rehabilitation ) and , most commonly , poor management . Strategies to reduce these barriers are context specific .
CONCLUSION
THE role of the GP is to correctly diagnose Achilles tendinopathy , identify risk factors , educate the patient and refer for rehabilitation as required . Although this is conceptually simple , there are multiple barriers to good patient outcomes . Persistence with correct management is the best option .
ONLINE RESOURCES
Barcelona Football Club will release a tendinopathy book late in 2021 . It will be free through barcainnovationhub . com .
References on request from howtotreat @ adg . com . au