Achilles Tendinopathy Toolkit: Section F - Medical and Surgical Interventions

Achilles Tendinopathy: Medical and Surgical Interventions[edit | edit source]

The purpose of this document is to summarize common medical and surgical interventions which may be considered for the management of Achilles tendinopathy – particularly if it is not responding adequately to more strongly supported conservative management strategies (see “Achilles Tendinopathy: Summary of the Evidence for Physical Therapy Interventions”).

Pharmacological Approaches[edit | edit source]

NSAIDS[1][edit | edit source]

Method Short term benefit in the acute stage of tendinopathy to minimise inflammatory process.
Proposed Mechanism Interrupts the chemical pathway of inflammation.
Benefit: Pros/Cons
 Pros: Inexpensive, easily accessible.
Cons:
  • Precautions and contraindications that accompany specific medications.
  • Inhibition of inflammation may delay soft tissue repair by impairing fibroblastic proliferation.
Evidence

Weak evidence for a modest effect in acute stage in Achilles tendinopathy.

Recommendation for a short course of NSAIDs for acute symptoms within 14 days.

No difference between oral or topical application.

Take Home Message
'Implications for Physiotherapy

PTs are involved in the treatment of tendon pain at all stages of
recovery. General knowledge of commonly used NSAIDS is important for treatment planning.

Corticosteroid (injection)[2][3][4][5][edit | edit source]

Method Short‐term benefit in acute stage. In chronic tendinopathy, the role of
inflammation is unclear, and the rationale for the use of
anti‐inflammatory injections is controversial. Many studies report an absence of cellular features of inflammation in chronic tendinopathy.
Proposed Mechanism Injection into the paratendon to interrupt the inflammatory process.
Benefit: Pros/Cons
 Pros:
  • Easily accessible.
  • Careful administration outside the structure of the tendon is considered ‘safe’ i.e., in the paratendon sheath.
Cons:
  • Invasive, painful.
  • Risk of infection (1%) ‘universal precautions’ required.
  • Destructive; risk of tendon rupture; impairs tissue repair mechanism.
Evidence There is a lack of high quality evidence to support the use of local corticosteroid injections in chronic Achilles tendon lesions. Generally, lack of well‐designed clinical trials.

Take Home Message
'Implications for Physiotherapy

PTs are involved in the treatment of tendon pain at all stages of recovery. The appropriate use of corticosteroid is important in treatment planning. There are animal studies that suggest risk of tendon rupture after corticosteroid injection. A greater risk of rupture in human tendons has not been demonstrated in comparison to the natural history of tendon rupture (case studies only). Caution is recommended in progressing the loading of the tendon within two weeks of injection (exercise precautions).

Glycerol Trinitrate (GTN)[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Injection Therapies[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Polidocanol[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Prolotherapy[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Platelet Rich Plasma (PRP) and Autologous whole blood[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

High volume injection (HVI) or Hydrostatic dissection[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Dry Needling[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Dry Needline using a Hypordermic Needle ("tendon fenestration")[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Surgical Approaches[edit | edit source]

Percutaneous tenetomy[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Surgical debridement[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Minimally invasive stripping[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Developed by Michael Yates, PT. BC Physiotherapy Tendinopathy Task Force. April 2012.

References[edit | edit source]

  1. ↑ McLauchlan , G, Handoll, H. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Collaboration of Systemic Reviews. 2009;2:1‐36.
  2. ↑ DaCuz D, Geeson M, Allen M, Phair I. Achilles paratendonitis: an evaluation of steroid injection. Br J Sports Med. 1988;22(2):64‐65.
  3. ↑ Shrier I, Matheson G, Kohl G. Achilles tendinitis: are corticosteroid injections useful or harmful? Clin J Sports Med. 1996;6(4):245‐250.
  4. ↑ Fredberg U. Local corticosteroid injection in sport: a review of literature and guidelines for treatment. Scand J Med Sci Sports. 1997;7(3):131‐139.
  5. ↑ Speed C. Corticosteroid injections in tendon lesions. Br Med J. 2001;323:382‐386.
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