No Consensus on Optimal Treatment for Achilles Tendon Disorders
Despite the fact that every year, many people (athletes and nonathletes alike) injure their Achilles tendons, the best way to treat these injuries is still up in the air. Should you use ice? Are steroid injections helpful? Wear a cast? Have surgery? If surgery is needed, the questions start over. What kind of surgery? How invasive? Would a tendon transfer help?
The authors of this review article on tendon disorders of the foot and ankle provide suggestions from their experience in the management of these problems. They discuss treatment options for Achilles tendon overuse injuries, tendinosis, paratenonitis, insertional tendinitis, bursitis, and both acute and chronic Achilles tendon ruptures. For all cases requiring surgery, the authors describe and show (through photos) their preferred surgical techniques for the operative management of Achilles tendon disorders.
Treatment may depend on the cause of the problem. Inflammation from chronic overuse may respond to antiinflammatory drugs and physical therapy. Tendinosis (degeneration of the tendon without inflammation) from microtrauma or aging causes thickening of the tendon. This condition often responds well to rest and a slight heel lift or Achilles heel pad.
For athletes in training, training errors should be corrected. These might include a sudden increase in intensity (e.g., running more miles faster), change in terrain or surface, or wearing rundown shoes. A short time in a controlled ankle-motion (CAM) boot or molded ankle orthosis (MAFO) brace might be advised for older adults with tendinosis who are less active and for people with severe Achilles pain from this condition.
Surgery isn't usually recommended for tendinosis. In fact, the studies are so few and far between, there's not even agreement on who should have it or what works best. There have been a few small studies on the use of a tendon transfer to replace the diseased Achilles tendon. Before surgery is even considered, the authors suggest at least three to six months of conservative (nonoperative) measures, especially physical therapy. The therapist will help get the painful symptoms under control and then get the patient started on eccentric muscle strengthening, a technique that has been shown helpful in the past.
Paratenonitis, a common problem in middle- and long-distance runners is treated by correcting training errors, improving flexibility, and using nonsteroidal antiinflammatory drugs. Paratenonitis refers to inflammation of the paratenon, which is a thin membrane around the tendon. The paratenon helps the tendon glide up and down smoothly as the Achilles tendon contracts and relaxes to move the foot and ankle up and down.
Paratenonitis is another condition that should be treated with physical therapy and other nonoperative methods first before considering surgery. Eccentric stretching/strengthening, ice therapy, and correcting any limb alignment problems are first. Steroid injections aren't used because they can weaken the tendon structure and lead to tendon rupture. When surgery is advised, it's for chronic problems that just won't clear up with conservative care. The surgeon removes any adhesions or thickened areas of the paratenon.
Bursitis, a painful inflammation of the retrocalcaneal bursa is caused by compression of the bursa located between the Achilles tendon and the calcaneus (heel bone). A bursa is a round or oval pad that reduces friction between two areas that rub together. This condition occurs most often in uphill runners.
The physician confirms the problem by squeezing the Achilles tendon just above the bursa. Reproducing the pain with this test is a positive response for retrocalcaneal bursitis. Follow-up tests with X-rays, ultrasound, or MRIs can confirm the diagnosis. Once again, conservative care is recommended as the most effective treatment. Nonsteroidal antiinflammatories, combined with physical therapy and activity modification have been shown to work in 90 per cent of all cases. For chronic cases, cast immobilization can be helpful. Surgery can be done to remove the burse and shave the bone when a bump called Haglund's deformity is present and contributing to the problem.
And finally, tendon ruptures are handled according to the age of the patient, activity level, and patient/surgeon preference. There is no agreement yet as to the optimal treatment of acute tendon ruptures. The authors advise surgical management for tendon ruptures and they include a description of their surgical technique. Published studies so far show there are fewer reruptures after surgery, improved strength, and faster return to sports for affected athletes.
For patients with acute tendon ruptures who don't want surgery, conservative care continues to be used successfully by many people. Treatment begins with a cast that places the foot and ankle in slight plantar flexion (toes pointed down). After four weeks, the patient is recast or put in an ankle immobilizer in the neutral position. Rehab and a gradual return to activities follows cast or splint removal.
In the case of chronic Achilles tendon rupture, MRIs may be needed to show the extent of damage. Although the patient may have weakness and a limp, pain and swelling aren't always present and other tests used for acute tendon rupture are negative. MRIs give the additional information needed to make a treatment decision. Surgery is usually the only way to restore function in the young, athletic or older, active adult. The operation is a bit more tricky than with acute (fresh) ruptures.
By the time the patient has surgery, many weeks have passed by from the acute injury. That means the torn tendon has retracted (snapped back) away from the bone where it originally inserted. And the body has laid down scar tissue to try and heal itself. The surgeon will have to remove the scar tissue, pull the tendon back down and reconstruct the tendon-muscle unit. How this is done depends on how much distance must be made up between the tendon and insertion point on the bone.
The authors make note of the fact that although Achilles tendon injuries are fairly common, high-quality studies with conclusions about the best way to treat them are just lacking right now. Information on surgical techniques isn't the only area where questions exist. There really isn't much evidence to support one form of conservative care over another. Successful sports rehab treatment protocols is another area where future research is needed to help guide the management of Achilles tendon injuries, especially for competitive athletes.
Daniel S. Heckman, MD, et al. Tendon Disorders of the Foot and Ankle, Part 2. Achilles Tendon Disorders. In The American Journal of Sports Medicine. June 2009. Vol. 37. No. 6. Pp. 1223-1234.