Physio Penrith Mid Portion Achilles Tendinopathy Treatment
Treatment of Mid Portion Achilles Tendinopathy at Sydney Muscle & Joint Phsyio Penrith
What is mid portion Achilles tendinopathy?
Mid portion Achilles tendinopathy considers Achilles tendonitis and tendinosis under the one tendinopathy name. Achilles tendinopathy is specific localised pain that limits activity. The irritable pain is preceded by an excessive mechanical stressor, such as tensile loading and/or shearing, which initiates pathological changes in the tendon. This refers to exercise or physical activity that has increased abruptly and the tendon does not have the tolerance for the sudden increase. Examples can include increasing running mileage too quickly, previous sedentary person going on a 10 day walking tour during an overseas trip or starting a new job that requires walking, lifting, etc.
With increased loading to the irritated Achilles tendon, the tendon will undergo pathological changes can include tenocyte proliferation with tendon thickening, neovascularity, collagen fibril thinning and disorganisation, increase of non-collagenic, fat deposition and altered fluid movement. Failure to control hyperthermia that results during exercise, tendons will convert some of the stored energy to heat and contribute to pathological decline by causing local cell death. Tendon changes associated with the pathological process weaken the mechanical and material properties of the tendon, leading to a decrease in tendon stiffness and strength and ineffective force transfer. This may provide a rationale for the use of mechanical loading to potentially increase tendon stiffness. This is an important factor for our physiotherapists at Sydney Muscle & Joint Clinic, because it influences the active interventions that are used in the treatment of mid portion Achilles tendinopathy. Inflammation and degeneration are usually not mutually exclusive but can coexist to a varying extent throughout this process.
Risk factors for the presentation of mid portion Achilles tendinopathy include obesity, hypertension, hyperlipidemia, and diabetes.
What are the common symptoms of mid portion Achilles tendinopathy?
Mid portion Achilles tendinopathy will present with some specific type symptoms including localised pain located 2 to 6 cm proximal to the Achilles tendon insertion that began gradually and pain with palpation of the mid portion of the tendon. Pain and perceived stiffness in the Achilles tendon following a period of inactivity (sleep, prolonged sitting). Often the symptoms can reduce with an acute bout of activity and may increase after too much of the activity.
In runners and high volume walkers "heel-strikers" or those with altered posterior/anterior force displacement and an increase in laterally directed force distribution underneath the forefoot, may be a risk factor for developing Achilles tendinopathy.
Diagnosis of mid portion Achilles tendinopathy
In addition to the arc sign and Royal London Hospital test, clinicians can use a subjective report of pain located 2 to 6 cm proximal to the Achilles tendon insertion that began gradually and pain with palpation of the mid portion of the tendon to diagnose mid portion Achilles tendinopathy. Physical performance measures including hop and heel-raise endurance tests should also be included. Guideline-based treatment stipulates that physiotherapists need to identify interventions supported by current best evidence to address impairments of body function and structure- these impairments as they relate to mid portion Achilles tendinopathy include pain, reduced joint range of motion, weakness, reduced endurance and reduced power.
Our physiotherapists at Sydney Muscle & Joint Clinic Penrith also consider abnormal ankle dorsiflexion range of motion, abnormal subtalar joint range of motion, decreased ankle plantar flexion strength (calf muscle strength), increased foot pronation, and abnormal tendon structure as intrinsic risk factors associated with Achilles tendinopathy.
During differential diagnosis other common injuries that may need to be ruled in/out include acute Achilles tendon rupture, partial tear of the Achilles tendon, retrocalcaneal bursitis, posterior ankle impingement, irritation or neuroma of the sural nerve, os trigonum syndrome, accessory soleus muscle, Achilles tendon ossification, systemic inflammatory disease, plantaris tendon involvement, fascial tears and insertional Achilles tendinopathy.
Guideline-based treatment of mid portion Achilles tendinopathy
At Sydney Muscle & Joint Clinic Penrith our physiotherapists use guideline-based treatments when managing patients with mid portion Achilles tendinopathy. As such our physio's follow clinical recommendations taken from "Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018", published in the Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association.
Interventions that are recommended include:
Physiotherapists should use mechanical loading, which can be either in the form of eccentric exercise, or a heavy-load, slow-speed (concentric/eccentric) exercise program, to decrease pain and improve function for patients with mid portion Achilles tendinopathy without presumed frailty of the tendon structure. Further, for patients with non-acute mid portion Achilles tendinopathy, physiotherapists should advise that complete rest is not indicated and that they should continue with their recreational activity within their pain tolerance while participating in rehabilitation.
Physiotherapists may use stretching of the ankle plantar flexors with the knee flexed and extended to reduce pain in patients with mid portion Achilles tendinopathy who exhibit limited ankle dorsiflexion range of motion.
Physiotherapists may use neuromuscular exercises targeting lower extremity impairments that may lead to abnormal kinetics and/or kinematics, specifically eccentric overload of the Achilles tendon during weight-bearing activities.
Physiotherapists may consider using joint mobilisation to improve mobility and function and soft tissue mobilisation to increase range of motion for patients with mid portion Achilles tendinopathy.
Interventions that are NOT recommended include:
Heel lifts are not recommended because contradictory evidence exists, therefore no recommendation can be made for the use of heel lifts in patients with mid portion Achilles tendinopathy.
Physiotherapists should not use night splints to improve symptoms in patients with mid portion Achilles tendinopathy.
Orthotics are not recommended due to contradictory evidence existing, therefore no recommendation can be made for the use of orthoses in patients with mid portion Achilles tendinopathy.
Physiotherapists should not use therapeutic elastic tape to reduce pain or improve functional performance in patients with mid portion Achilles tendinopathy.