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Achilles tendinopathy
What's new
Updated 2024 APTA guidelines for the management of midportion Achilles tendinopathy .
Background
Overview
Definition
Achilles tendinopathy is a non-rupture injury of the Achilles tendon characterized by pain, swelling, and reduced performance, with symptoms often exacerbated by physical activity.
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Pathophysiology
The pathophysiology of Achilles tendinopathy involves a continuum from reactive tendinopathy, where tenocytes proliferate and protein production increases, leading to tendon thickening, to tendon disrepair with further increase in tenocytes and protein production and focal collagen fiber disruption, and finally to degenerative tendinopathy involving cell death, large areas of collagen disorganization, and areas filled with vessels and nerves.
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Epidemiology
The incidence of mid-portion Achilles tendinopathy in the US is estimated at 235 per 100,000 person-years in the general population aged 21-60 years. Annually, 7-9% of runners experience Achilles tendinopathy.
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Risk factors
Risk factors for Achilles tendinopathy include a higher BMI, a history of tendinopathy or fracture, increased alcohol consumption, reduced plantar flexion strength, a high weekly volume of running, prolonged years of running, the use of spiked or shock-absorbing shoes, training in cold weather, and abnormal ankle dorsiflexion ROM. Other risk factors include male sex, the use of oral contraceptives, hormone replacement therapy, and fluoroquinolones.
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Disease course
Clinically, patients with Achilles tendinopathy present with symptoms localized 2-7 cm proximal to the Achilles tendon insertion, painful Achilles tendon midportion on loading, local thickening of the Achilles tendon midportion, and pain on local palpation of the Achilles tendon midportion.
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Prognosis and risk of recurrence
The prognosis of Achilles tendinopathy can vary widely among individuals, but generally, the condition is manageable with appropriate treatment.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of Achilles tendinopathy are prepared by our editorial team based on guidelines from the American Physical Therapy Association (APTA 2024,2018), the Dutch Multidisciplinary Guideline (DMG 2021), the Expert Group on Achilles Tendinopathy (AT-EG 2020), and the American College of Rheumatology (ACR 2018).
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Screening and diagnosis
Diagnosis: as per DMG 2021 guidelines, diagnose midportion Achilles tendinopathy based on the presence of all the following findings:
symptoms localized 2-7 cm proximal to the Achilles tendon insertion
painful Achilles tendon midportion on (sports) loading
local thickening of the Achilles tendon midportion (may be absent in cases with short symptom duration)
pain on local palpation of the Achilles tendon midportion.
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Differential diagnosis
Diagnostic investigations
History and physical examination
As per AT-EG 2020 guidelines:
Perform a physical examination to elicit the following:
pain on palpation of the tendon and the subjective report of pain in the midportion (2-6 cm above the calcaneal insertion) for diagnosing midportion Achilles tendinopathy
location of pain on palpation for distinguishing between an insertional or midportion injury and for the differential diagnosis; greater pain on palpation anterior to the tendon than in the tendon itself is suggestive of posterior ankle impingement or os trigonum syndrome; posterior ankle pain differential diagnosis also includes acute Achilles tendon rupture, accessory soleus muscle, sural nerve irritation, fat-pad irritation, and systemic inflammatory disease
the arc sign - palpation of tendon identifying thickened nodules - for confirming midportion Achilles tendinopathy
the Royal London Hospital test - pinching the tendon to identify the most symptomatic location with the foot at rest - for confirming midportion Achilles tendinopathy
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Use the Tampa Scale of Kinesiophobia to assess the degree of fear of pain with movement in athletes, as Achilles tendinopathy can lead to kinesiophobia, which can affect treatment participation and the perception of injury severity.
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Diagnostic imaging
Medical management
Nonpharmacologic interventions
General principles: as per APTA 2024 guidelines, consider offering multimodal treatment incorporating various interventions to enhance the benefits of exercise in patients with midportion Achilles tendinopathy.
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Exercise
Footwear and ankle support
Manual therapy
Acupuncture
Collagen supplements
Therapeutic procedures
Injection therapy: as per DMG 2021 guidelines, consider offering injection therapies (polidocanol, lidocaine, autologous blood, platelet-rich plasma, stromal vascular fraction, hyaluronic acid, prolotherapy, or high-volume injection) in case of insufficient effectiveness of patient education and loading advice in combination with continued exercise therapy. Be cautious when using corticosteroid injections.
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Iontophoresis
Laser and light therapy
Extracorporeal shockwave therapy
Therapeutic ultrasound
Surgical interventions
Indications for surgery: as per DMG 2021 guidelines, consider performing surgery only in patients not recovering after at least 6 months of active treatment. Discuss the expected effectiveness of surgical intervention compared with active non-surgical treatments and the potential surgical complications.
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Patient education
General counseling
As per APTA 2024 guidelines:
Provide education and counseling on Achilles tendinopathy, with either a pain science or a pathoanatomic focus, in combination with tendon-loading exercise for Achilles tendinopathy. Consider provifing education and counseling either in person or via telehealth according to the patient's preference.
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Advise patients with midportion Achilles tendinopathy that complete rest is not indicated and that they should continue with their activities within their pain tolerance.
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Preventative measures
Avoidance of fluoroquinolone: as per DMG 2021 guidelines, consider advising the avoidance of fluoroquinolone antibiotics if alternative antibiotics are available and the clinical picture allows in the context of the importance of preventing Achilles tendinopathy.
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Secondary prevention
Follow-up and surveillance
Indications for specialist referral: as per DMG 2021 guidelines, consider referring patients to a sports medicine physician or an orthopedic surgeon if there is continued uncertainty about the diagnosis or there is an unexpected course or change of symptoms during follow-up.
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Assessment of treatment response