August 2016

Management of Achilles tendinopathy in runners

Orthotic-Devices-for-the-Win

By Howard Kashefsky, DPM

Sponsored by an educational grant from medi USA.

Achilles tendinopathy is a common lower extremity injury in athletes as well as nonathletes. The Achilles tendon is often a site of injury in runners and is the second-most common running-related musculo­skeletal injury, after medial tibial stress syndrome, with an incidence of 9.1% to 10.9%.1 The lifetime risk in former elite male distance runners is a whopping 52%.2

Factors that may contribute to Achilles tendinopathy include overuse, systemic disease, older age, sex, body composition, and biomechanics.3 Elevated biomechanical load has been shown to cause both microscopic and macroscopic failures.4-6

The Achilles tendon is the strongest and largest tendon in the body.7 This tendon connects the gastrocnemius and soleus muscles to the posterior aspect of the calcaneus. The group of muscles is collectively called the triceps surae, which serves as the primary plantar flexor of the foot and ankle, but also flexes the knee. Insertional fibers of the Achilles tendon are in continuity with the plantar aponeurosis. The Achilles tendon does not have a true synovial sheath, but rather a single layer of paratenon. The paratenon is responsible for a significant portion of the blood supply to the Achilles tendon, most of which enters anteriorly; studies have identified a hypovascular area of the Achilles tendon 2 cm to 6 cm proximal to its insertion on the calcaneus, which appears to be an area at risk for complete rupture.8,9

Achilles tendinopathy can be progressive and can be characterized using terminology that reflects the condition’s stage. In the acute phase, Achilles tendinitis refers to inflammatory changes at the tendon level, which may include the paratenon that surrounds the tendon.1 Achilles tendinosis depicts a more chronic and degenerative process. Achilles tendinopathy is our preferred term for Achilles tendon pain.

The two most common sites of injury in runners include midportion Achilles tendinopathy (2 cm to 6 cm proximal to the calcaneal insertion) and insertional Achilles tendinopathy (injury localized to the insertion of the Achilles tendon at the calcaneus).10 Less commonly, injuries may occur at the myotendinous junction.

Diagnosis

Differential diagnoses that should be considered in cases of suspected Achilles tendinopathy include posterior ankle impingement; retrocalcaneal bursitis; symptomatic Haglund deformity; bone stress injury (BSI) of the distal tibia, fibula, or calcaneus; peroneal tendino­pathy; and hindfoot arthrosis.11

In my opinion, one cannot overstate the importance of a good physical exam. In cases of Achilles tendinopathy, the exam includes finding the exact location of the pain and rating its severity using a scoring system with which the patient’s progress can be tracked. It is helpful to compare limbs and look for a relative temperature increase, thickening, or overlying erythema in the painful limb. The posterior calcaneus should be evaluated for a prominence of the posterior aspect that may suggest the presence of Haglund deformity or a large posterior spur.

Testing of muscle strength and ankle range of motion (ROM) are also helpful. Dorsiflexion ROM assessment should be done with the knee in full extension and in 90° of flexion to determine differences in ROM (the Silfverskiold test); less ROM in full knee extension suggests gastrocnemius tightness or contracture that may increase tension on the Achilles tendon.12 Evaluation of strength should include a series of single-leg calf raises and evaluating for pain, between-limb differences in heel height, and fatigue during this maneuver.11

If a patient’s history or the presence of a palpable gap in the tendon raises concern for an Achilles tendon rupture, Thompson’s test should be performed.13 The patient lies prone and the examiner squeezes the triceps surae distal to the knee in both limbs. Passive foot plantar flexion in both limbs suggests the painful Achilles tendon is contiguous with the calcaneus and unlikely to have a full-thickness tear. If there is no foot plantar flexion with calf squeeze on the affected side, there should be concern for Achilles rupture. Extensor lag and a palpable gap are also signs of rupture.

The calcaneal squeeze test is helpful to exclude a calcaneal BSI. The clinician presses both medially and laterally on the calcaneus and evaluates for pain localized to the calcaneus.11 Weightbearing radio­graphs (lateral and axial views of the heel) may be helpful to evaluate for Haglund deformity, calcific tendinopathy, or if the diagnosis is unclear. Magnetic resonance imaging (MRI) is appropriate if there is concern for a significant rupture of the Achilles tendon or to evaluate for a BSI.11 Ultrasonography is a useful modality that can help verify Achilles tendon injury.14

I also cannot understate the importance of a thorough history in the athletic patient. Thoughtful questions regarding training patterns may uncover the cause of the injury and assist in managing recovery and prevention of recurrence.

Treatment

In the acute phase, initial management includes rest, activity modification, a trial of heel lifts, and stretching the triceps surae. If the patient has significant weightbearing pain, a brief period of immobilization in a boot can help to alleviate this, but lengthy periods of immobilization should be avoided due to the risk of muscle atrophy and deep vein thrombosis. Local modalities—including ice, massage, and ultrasound—may reduce pain.15-17 Iontophoresis may also be considered to reduce inflammation associated with acute presentations.18 A short course of nonsteroidal anti-inflammatory drugs (NSAIDs) is commonly prescribed, though the degree of true inflammation is questionable in more chronic conditions. Topical nitroglycerin does not have clear evidence to support its use.19

After achieving pain control, treatment should focus on strengthening the Achilles tendon and triceps surae. Alfredson and colleagues demonstrated the efficacy of an eccentric loading protocol for addressing pain and strength in patients with Achilles tendinopathy.20 In this landmark study, 15 recreational athletes with unilateral midportion Achilles tendinopathy completed a 12-week session of a single-leg eccentric heel-drop program with progressive weight loading.

8Medi-iStock10397031-copyIndividuals who completed this protocol (three sets of 15 repetitions, with both knees bent and straight, twice per day) had normalization of strength and reduction of pain, and all returned to running during the 12 weeks. A larger study using Alfredson’s protocol in athletes with a five-year follow-up reported that most individuals experienced gains in function, though nearly half pursued other therapies, and most reported mild pain.21 A modified version of Alfredson’s protocol with eccentric-load calf raises that do not include a heel drop has been proposed for insertional Achilles tendinopathy.11,22

Additionally, rehabilitation exercises that address the full kinetic chain are important, given the evidence suggesting that biomechanical factors—including reduced activity of the tibialis anterior, rectus femoris, gluteus medius, and gluteus maximus muscles—may contribute to Achilles tendinopathy.23,24 Foot intrinsic strengthening and restoring proprioception is important for this condition, as with any foot and ankle disorder.

Treatment for chronic refractory Achilles tendinopathy may include injection of platelet-rich plasma (PRP) at the affected site. In published case series, PRP injection has been associated with symptom improvement in patients with noninsertional Achilles tendinopathy.25,26 However, in a randomized controlled trial, PRP was no more effective than saline for supplementing the effects of eccentric exercise in patients with chronic midportion Achilles tendinopathy.27,28

Orthotic intervention

There is evidence that orthotic intervention may reduce Achilles tendon load in healthy runners29  as well as symptoms in runners with Achilles tendinopathy.30-32 Mayer et al documented significant reductions in pain symptoms in runners with Achilles tendinopathy following an intervention with semirigid orthoses.31 Donoghue et al evaluated the effectiveness of custom foot orthoses in runners with chronic Achilles tendon pathology.32 An improvement of 92% was noted in pain symptoms with the use of the orthoses.

A more recent study33 found that custom orthoses were no more effective than sham orthoses for people with midportion Achilles tendinopathy. However, the study participants were not athletes, and the orthoses were customized based on foot posture index alone, which could have affected the findings.

I have utilized foot orthoses clinically in runners with Achilles tendinopathy, in combination with other conservative therapies, and have consistently seen improvement. But more research is clearly needed to determine the mechanism of action, which will more accurately guide orthotic treatment.

Traditionally, the mechanism by which foot orthoses were believed to alleviate Achilles tendon pain involved reducing rearfoot eversion and vertically aligning the calcaneus, thereby reducing the shear stress experienced by the Achilles tendon.34 However, there is also evidence to suggest the mechanism of action may be multifactorial.35,36

A deep heel cup with extrinsic varus or valgus posting will control any subtalar eversion or inversion while ambulating.37 The full-contact orthosis shell is important for full functionality of the rearfoot posting and controlling midtarsal joint articulation. Proper casting is also critical. When suspension casting with plaster or a similar material, one must load the midtarsal joints to a pronated position while keeping the subtalar joint neutral.38,39

The effect of running shoe design on Achilles loading has been controversial. As often is the case, conflicting information has been published. In a study of 12 male runners, Sinclair et al found that Achilles tendon forces during running were higher for minimalist footwear than conventional or maximalist footwear, and suggested that running in minimalist shoes may increase the risk of Achilles injury.40 Conversely, Wearing reported that, in 12 recreationally active men, peak acoustic velocity (a measure of tensile load) during walking was higher when participants wore running shoes with a 10-mm offset than when they were barefoot.41 Although walking and running are different activities, one would expect the loading patterns to be similar. However, in this study the techniques used to measure load varied between conditions, and the study sample was small. More research needs to be done.

Surgery

If conservative care fails, one may consider surgery. Operative management of this condition may include debridement of degenerative areas of the tendon and repair of remaining healthy tendon. In cases of recalcitrant insertional Achilles tendinopathy, removal of an associated Haglund deformity and retrocalcaneal bursectomy can be beneficial. In individuals aged 50 years and older or with severe tendon degeneration, augmenting the repair with ipsilateral flexor hallucis longus transfer may provide additional benefit.42,43

Howard Kashefsky, DPM, is the director of podiatry services at UNC Healthcare at the University of North Carolina at Chapel Hill.

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One Response to Management of Achilles tendinopathy in runners

  1. teri green says:

    We try to use conservative care for Achilles tendonitis. We usually do aggressive stretching, PT and heel lifts. Depending on the level of achilles contraction with dorsiflexion of the ankle joint we will dispense a 6mm (1/4″), 9mm (3/8″) or 12mm (1/2″) heel lift. I found that a light weight cork heel lift works best. I am surprised more practitioners do not use cork heel lifts. They are inexpensive and really work well.

    Teri Green
    Atlas Biomechanics

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