|What is achilles tendonitis? | What does achilles tendonitis look like? | Insertional problems of the achilles | Symptoms of achilles tendonitis | Causes of achilles tendonitis | Treatments for achilles tendonitis | Physiotherapy for achilles tendonitis | Orthotic for achilles tendonitis | Shockwave Treatment | How soon should non-operative treatment of achilles tendonitis improve symptoms? | Imaging of the Achilles Tendon I Injecting achilles tendonitis | The surgical treatment of achilles tendonosis | What is the rationale behind the operations? | Post operative course following achilles tendonitis surgical treatment | Achilles Rupture | Return to normal activity after Achilles Tendon surgery | What is a Haglunds deformity? | What Is insertional tendonosis of the achilles? | Treatment for Haglunds deformity/or insertional achilles tendonosis | Non-operative treatment of Haglunds deformity, achilles tendonosis | Operative management of Haglunds deformity and insertional achilles tendonosis|
Treatments for Achilles Tendonitis?
Both operative and non-operative managements are available for Achilles tendonitis. Whether the underlying problem is one of a more superficial inflammation or a more comprehensively degenerative problem of the tendon this makes little difference to the initial treatment. Non-operative management includes an exercised based physiotherapy regime, a more passive physiotherapy based intervention such as ultrasound and deep tendon massage, orthotic offloading of the tendon as well as more invasive procedures such as “dry needling” of the tendon or injection of the tendon.
In general terms, non-operative interventions have success rates somewhere between 60-75%. The success rate with operative interventions is generally higher and a figure of 90% would be highly representative.
Physiotherapy for Achilles Tendonitis/Achilles Tendinosis
The types of treatment available can be split into passive (where the patient lies on a couch and has things done to the tendon by the physiotherapist) or an exercise based (active) regime. Both of these routes work both independently and also surprisingly when used in conjunction.
Passive treatment for Achilles tendonitis includes massage, manipulation and ultrasound applied to the tendon. An active treatment regime would include stretches and strengthening/loading exercises for the Achilles tendon.
Orthotic for Achilles Tendonitis
Long Aircast Boot
A manoeuvre which is likely to help is raising the heel relative to the front part of the foot, thus taking some tension off the Achilles tendon. A high heeled shoe or wedge type shoe would be a normal form of shoe wear that does this. An orthotic can be constructed to have the same type of effect. There is of course a limit to how much the heel can be raised without pushing it out of the shoe. A long Aircast Achilles boot is likely also to be of use, by reducing the movement of the tendon during gait. This is most often used when the symptoms are particularly acute and severe and need to be settled as immediately as possible. To allow the Achilles tendon to settle more definitively (as opposed to simply when the aircast boot is being used) would probably require the continuous use of a boot for all weight bearing activity for perhaps 6 or 8 weeks. This in itself is not a particularly practical suggestion.
Shockwave treatment is well established in various parts of the body and increasingly so for use with tendonopathy’s, not just the Achilles. It involves passing sound waves of a particular frequency and intensity through the skin directly into the painful area of tendon. The mechanism of action is not entirely clear but it does seem in a good portion of cases to stimulate a healing response in the area of degenerative tendon.
Treatment sessions usually last 5-10 minutes and are usually repeated on a daily basis over 3-5 weeks. The treatment itself is uncomfortable though can be done after local anaesthetic has been administered. This however does seem to reduce its effectiveness somehow. There is a small chance of a tendon rupturing after shockwave treatment and it is not unusual to be advised to limit activities after treatment sessions. It is effective in up to 70% of patients. The chance of this being the case is not affected adversely by failing to respond to initial physiotherapy treatment.
How Soon Should Non-Operative Treatment of Achilles Tendonitis Improve Symptoms?
Some symptoms from the Achilles tendon should improve soon, perhaps within days or weeks. Lasting improvement however takes longer and it may be up to 3-6 months before significant inroads are made into the symptoms. If the symptoms of Achilles tendonitis have failed to improve much by this stage, then they are unlikely to do so with further conservative treatment. All told, a success rate in the region of 50-75% can be expected with conservative management of the Achilles tendonitis.
If non-invasive treatments for the Achilles have failed then prior to proceeding either to operation or injection based therapies it is important to distinguish between superficial inflammation of the tendon (tendonitis) and deeper seated and more wide spread structural change of the tendon (tendinosis) both forms of imaging are equally sensitive ways of picking up structural change within the tendon (tendinosis) but probably in experienced hands an ultrasound is a more sensible investigation to identify more superficial degrees of information.
One big advantage of an MRI scan for the treating clinician is that it is straight forward to interpret. Ultrasound is far more user dependent on the type of image that is produced and report that results from this and does not provide the comprehensive multi planar images that an MRI does and which are of advantage in planning any operation. One big advantage of ultrasound imaging of the Achilles is that it does allow, at the same sitting as the imaging is being performed, intervention with some form of injection therapy to be used as well.
The key step is to be clear whether the underlying diagnosis is one of Achilles tendonitis (superficial inflammation) or Achilles tendinosis (where degenerative change to the underlying Achilles tendon substance exists).
If it is superficial inflammation that exists then it would be accepted practice to infiltrate into the superficial layers of the paratenon steroid combined with local anaesthetic. The chance of this settling tendonitis down is likely in the region of 70-75%. Small risks associated are some discolouration of skin and thinning of the fat where the injection is inserted and a very small risk of infection. If there is underlying significant degenerative change of the tendon an additional risk that exists is that the tendon may rupture as a result of the steroid having been used.
Injection techniques can however be used for Achilles tendinosis but these are either to “dry needle” the tendon or to inject fractionated plasma.
PRP Injection kit IMAGE from Donjoy
Fractionated plasma injections involve having a few mls of blood removed and this is then centrifuged there and then to yield the plasma fraction of the blood (yellow, straw colour fluid). This is injected directly into the tendon (as opposed to around the tendon with steroid and local anaesthetic). If there are relatively small areas of degenerative change within the tendon then this technique does work well. It should be noted that following this type of procedure it would be normal practice to need to use an aircast boot for 2 or 3 weeks, rather like after surgery.
The dry needling technique involves, under ultrasound guidance, “attacking” small areas of degenerative change by inserting a needle full depth into them and moving it up and down to create some localised tissue damage. As a result the tendon seems to respond and “heel” the areas of degenerative change. Again this works well for small areas of degenerative change. It would also be usual to use a long Aircast boot for several weeks following this type of procedure.
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