Achilles Tendon - ´opathy ´Consensus Project

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So the thread - Is compressive load a factor in the development of tendinopathy? got me quite excited ( sad init) and though maybe we should discuss what treatement is optimal for why type of Achilles pain and maybe come up with some possible clinical tests where there is none available to help with a more specific diagnosis.

So not so long ago - Achilles type pain was broken into 2 groups Achilles Tendonitis and Achilles Bursitis, then Tendonitis was out and Achilles Tendonopathy was where is at.

In fact articles were written about it -
Time to abandon the “tendinitis” myth. Yesterday I learnt a new word - enthesopathy to discribe pain at the insertion of the Achilles .

Why is all this important?

It is important because if we can work out the causative nature of the pain we can better decide a more appropriate treatment program.

So if we agree that at this moment most believe that increased tensile loads on the Achilles leads to pain.

Rather than too many words if we break it down like this feel free to add more if I missed something

Achilles Insertion related pain

1. Bursitis - compression of the Achilles Bursa which leads to pain and swelling

2. enthesopathy - compression of the tendon both internal and external which leads to pain

Mid tendon related pain

1. Tendonopathy - a breakdown in the micro cell structure taken from the above paper on tendinitis myth

2. Compression tendon stress ( from the plantaris tendon) - The plantaris tendon and a potential role in mid-portion Achilles tendinopathy , outside of the tendons Physiologic window

3. Shear and friction stress, outside of the tendons Physiologic window




each of these should have different treatment programs. Infact some of the treatment programs will be contraindicated for some of the subsections of diagnosis.

ie eccentric train work well for those patients with mid tendon tendonopathy but will be contraindicated in patient with pain from Compression and shear/friction issues.




And there maybe evidence that orthotic intervention may again become standard 1st line of treatment for certain sub sections of Achilles Tendon treatment - where they had become not seen as a appropriate treatment measure by some. STJ Axis Variations and Achilles Tendonitis

I will leave it here see if anyone wants to bash this issue around and then I will update a post with a consensus of the overview when we are done- or this thread will go into the I thought this was a good idea at the time pile.

What I though we need is a for each of the subsections re Achilles Tendon pain.

diagnostic name

description

Etiological statement

Diagnostic method

Treatment plan

- Short

- Long

Contraindicated activities list.

 

Consensus to be listed in this post over time................................. Hopefully

 

Hi Mike:
Not quite sure what direction you'd like replies to head......but since I do perform a lot of achilles surgical procedures, your post interested me.

Whether or not the following is accurate, I find myself dividing my patients into one (or more) of these clinical categories:

1. Achilles tendinitis with or without palpable fusiform "lump" (these patients have pain in the tendon proper, especially on palpation. If a mass is present in the body of the tendon, it is painful also. Acute or chronic)

2. Insertional enthesopathy (these patients have no pain on palpation of the tendon proper but pain at the insertion. Most have a palpable spur running medial to lateral along the posterior surface. These patients also have pain slightly more proximally at the posterior/superior margin at the level of the bursae on squeezing anterior to the tendon. Acute or chronic)

3. Haglunds (I limit this definition to posterior/lateral "pump bump" almost always in patients under 25. Achilles is normal, usually a rearfoot cavus. Bilateral.)

4. Myotendinous tendinopathy (pain at the myotendinous junction. I find these are usually active young adults)

5. Acute achilles rupture (partial or complete. Obvious clinical findings of a palpable void within the tendon. Rarely an avulsion)

6. Acute tendinitis (No real clinical findings other than pain on palpation Usually these heal in time on their own. I differentiate these from #1 in that they give a history of acute onset, usually a particular step or stride or mis step.)

That's my 2 cents

Steve