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Prediction of the success for treatment of insertional achilles tendinosis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, May 4, 2007.

  1. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1

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    Prediction of the success of nonoperative treatment of insertional achilles tendinosis based on MRI.
    Nicholson CW, Berlet GC, Lee TH.
    Foot Ankle Int. 2007 Apr;28(4):472-7
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. posalafin

    posalafin Active Member

    Hi

    Seeking advice for the best treatment of insetional calcific achilles tendinopathy. Seems to be a lot of information about calcific tendinopath of the rotator cuff tendons but not a great deal on calcific achilles tendinopathy.

    Thanks,

    David
     
  4. David some info for you.

    Hope that helps
     
  5. Lawrence Bevan

    Lawrence Bevan Active Member

    Is anyone aware of whether these results can be extrapolated to the use of diagnostic ultrasound ?

    Lawrence
     
  6. Mart

    Mart Well-Known Member


    Hi Lawrence
    [
    Nicholson, C. W., G. C. Berlet, et al. (2007) stated

    “The resultant classification is based on sagittal STIR images of the Achilles tendon at its insertion (within 2 cm of its bony insertion): type I, thickened tendon (6 to 8 mm) with nonuniform intramural splits or foci of punctuate degeneration (Figure 1); type II, thickening of the tendon (more than 8 mm) with uniform intramural degeneration involving less than 50% of the width of the tendon (Figure 2); and type III, diffuse thickening of the tendon (more than 8 mm) with uniform intramural degeneration involving more than 50% of the width of the tendon (Figure 3). Each patient who was evaluated with MRI was classified according to this system”

    also


    The current investigation suggests that tendons with greater intrasubstance degeneration, as documented on sagittal MR, often require operative intervention. These areas tend to be large and contiguous (types II and III) rather than small and focal (type I) lesions, which often are seen in asymptomatic individuals. In our patients, only 12.5% of those with symptomatic type I findings required operative intervention

    Then

    It must be noted, however, that most patients (54 of 83) in the nonoperative group did not have MRI. Most of these patients did have warm, red, swollen heels with obvious inflammation on physical examination. Although inflammation is not a component of tendinosis, the two frequently coexist. Thus, the inflammation component was likely the predominant factor in these patients and likely explains why most of this group responded to conservative measures

    But

    I have not seen anyone with insertional tendo-calcaneus tendonis which I have confirmed with US exam presenting with visible inflammation. I was wondering if most of the the non operative group actually had tendonosis?

    As far as similar study using US rather than MR I am not aware of one. However I think it reasonable to infer similar dimensional qualities from US plus ability to see neovascularisation which I am not sure if interpretable on MR and may add a useful classification system especially in view of apparent symptom reduction associated with therapeutic elimination of those neovascular elements.

    Cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
    Last edited: Aug 25, 2010
  7. drsarbes

    drsarbes Well-Known Member

    Hi Mart:

    Wondering why, if the classification is based only on the tendon thickness, why we can't measure that on US and grade these patients without using an MRI.

    As you know, I have a lot of experience with surgically repairing these. I still look first at the posterior superior angle of the os calcis on plain films. If it's hypertrophied (and sometimes osteolytic) these patients rarely (if ever) have long term resolution without surgery.

    Also, I'd like to comment on the pain in these patients. First, I need to state that this discussion is on INSERTIONAL TENDINITIS. This is quite a different animal than achilles tendinosis (proximal to the insertion).
    I sometimes feel these are getting grouped together.
    In any event, the pain with insertional tendinitis, although sometimes painful on medial lateral compression of the tendon, is "almost" always most sensitive either on palpation of the bursa area at the post-superior angle and/or over a large exostosis (sometimes fractured) usually lateral-posterior.

    I think trying to base indications for surgery or treatment outcomes solely on the tendon thickness is the wrong approach. There "may" be some type of statistical correlation but this does not prove any cause and effect relationship.

    Steve
     
  8. Mart

    Mart Well-Known Member

    Hi Steve.

    Yes I agree about using US for measuring thickness as index, and that it would likely correlate strongly with MR measurements. However for other structures there has been repoted slight differences between MR and US meaurements, since to my knowledge this hasnt been studied for tendo-calcaneus there may be some slight disparity.

    No quesion about likley different injury perpetuating forces for insertional vs non in sertional in my mind. The insertional stress I think is complicted by compressive as well as tensile plus possible calficied irritants. Most often the insertional lesions I see have degenerated zones adjacent to "haglund" bone which suggests a compressive force for important candidate.

    I have never tried grading the tendon appearance as this study does but perhaps there is some merit. Also as I mentioned the presence of neovasularisation might be worth adding to measures.

    Are you replacing your MR with US for tendon joint and ligament imaging more these days?

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com



    cheers

    Martin
     
  9. Kent

    Kent Active Member

    Achilles Insertional Calcific Tendinopathy (AICT) is a completely different beast to mid-portion tendinopathy as Steve mentioned. I tell my students this is an injury of compression. The distal portion of the tendon is compressed against the posterior calcaneus (usually a Haglund's deformity). I used to hate treating these until I understood to idea of compression. When you see these things on ultrasound, the pathology is on the ventral side of the distal tendon, where is compresses against the calcaneus. This is how I treat these conservatively:

    1. Heel lifts - these patients must have heel lifts in their shoes or added on externally.
    2. Never go barefoot - keep a pair of tongs (flip-flops) with a raised heel next to the bed so when the patient gets out of bed in the morning they put these on straight away and avoid going into dorsiflexion (which causes the compression).
    3. Graded eccentric loading exercises on FLAT GROUND (not off the back of a step) - start with only a few repititions and gardually build up. Do both straight leg and bent leg when the patient can tolerate it.
    4. Load management - I allow the patients to manage their own training load. They can do anything so long as the pain doesn't go above 4/10 or get worse the next day. Some tendon load is good, so long as you keep the pain below 4/10.
    5. Stop all calf stretching - this increases compression. Get deep tissue massage to help any tightness.
    6. Manage any bursitis component as required (ice, NSAIDs etc).

    By following this protocol I have had a lot more success treating these patients conservatively, with very few requiring surgery now. If patients still do get better with the above protocol we normally proceed to one or more of the following:

    1. Prolotherapy injections
    2. Autologous blood injections
    3. Corticosteroid injection if bursitis is a major component (rarely it is though, this is an insertional tendon pathology)
    4. Shock wave therapy

    Hope this gives some assistance in treating your patients with AICT.
     
  10. Mart

    Mart Well-Known Member

    Hi Kent

    Your conservative treatment plan seems appropriate if unproven. How do you feel about the underlying premise of the study in question which attempts to use a grading system to predict when conservative approach might statistically futile?

    I think that a weakness in Nicholson et al is that it talks about surgical cohort being those with "failure to respond" but respond "to what" is not close to explicit

    Designing a study though which controls the many possible variables for what conservative care amounts to woule be tough. In addition to the actual modalities used there are also confpounding issues eg: usefully quantifying the level of day level tendon stress of subjects due to activity and measuring compliance to treatment plan etc

    I guess one reason there is such a deficit of high grade studies in these areas is that they are really difficult (or impossible) to design for this kind of question. It is far more practical do a restrospective analysis than set up a RCT.

    Does anyone feel though that Nicholson et al have shown us anyhting useful by doing this?

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com








     
  11. David Singleton

    David Singleton Active Member

    Hi Kent,
    I just put a patient on the treatment regime you described in the previous post. First time I have read the importance of avoiding calf stretching. I will be reviewing this patient in about 6 weeks and will let you know how the treatment went. Thanks again for sharing this.
    Dave
     
  12. gnitram900

    gnitram900 Active Member

    Hi David,

    Just wondering how things turned out with your patient last year after you followed the suggested conservative protocol for in this thread.

    I have a running mate who is a beginner long distance runner, who is suffering from morning pain/stiffness on the lateral posterior aspect of his calc. He has no symptoms when running, but it is troubled by the morning occurence as it has become more and more persistent over the past 2 years, and neither is it affected by having run or not on the previous day.

    I have implemented a regime of eccentric conditioning starting off with just body weight, but after reading this thread, I am considering whether it would be better that he switch to flat surface, ie. not lowering heel off the step. There is no sign of bursitis and no obvious Haglunds.

    Cheers,

    John Gregory
     
    Last edited: Oct 18, 2011
  13. gnitram900

    gnitram900 Active Member


    Hi Kent and fellow colleagues,
    I have been some reading about Achilles tendinopathy + conditioning exercise programme threads, and the links to studies stemming from the various threads.
    Just wondered if any one could enlighten me as to why it is not advised to do the eccentric loading programmes into AJ dorsiflexion, ie. with a ramp or off a step? I have noted this caution against the eccentric repetitions going below the flat, through comments from contributors, but so far I´ve not seen any papers which specifically deal with why it should be avoided. I am keen to learn about the difference that those extra 5-10º could have on the rehabilitation of the tendon tissue.
    Any studies related to this? e.g. does it have anything to do with calcification of the tendon insertion, making the tendon fibres less elastic?
    In any case what would be the rational for the patient to not do it?
    The only reasoning that I dare hazard, is that the premise of Alfredson´s programme is to force the tendon to the edge of the plastic deformation barrier, little by little, to stimulate remodelation healing, through mechanostimulation of tenocytes, in an otherwise metabolically devoid zone. Whereas at the insertion site, you have a zone with a more rich blood supply, so there is no need to induce a mechanical stimulus to healing through an over-exertion of the tissue. And indeed due to the anatomy of the tendon, the eccentric contraction, could lead to each time more compression on the tendon, between skin/retrocalc bursa/Haglunds? So in such cases, yes! Strengthen the Achilles tendon, yes do increase its flexibility, but very gradually, and….. remove the compression force (ie. cut out the heel counter-or a portion of it) plus the rest from the conservative tx. possibilities…. NSAIDs, icing, shock wave tx, frictional massage, injection therapy, heel raises and address pathomechanics.
    John
     
    Last edited: Oct 20, 2011
  14. Mart

    Mart Well-Known Member

    As already mentioned; if there is Haglund deformity (posterior superior calcaneal tuberosity prominence) then there is likely to be increased bone to tendon compression and if pre-exisiting insertional tendo-calcaneus tendonosis present then increased injury above 0 degrees dorsiflexion.

    Cheers
    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  15. gnitram900

    gnitram900 Active Member

    Thanks for the explanation it sums in better words what I was thinking, so I am happy with that.

    cheers!
     
  16. Kent

    Kent Active Member

    Ditto what Martin said re compression. Stopping the compression goes a long way to reducing the pain.

    Here's a link to the paper by Jonsson et al published in BJSM. PM me if you want the pdf.
     
  17. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Prognostic Value of Achilles Tendon Doppler Sonography in Asymptomatic Runners
    Medicine & Science in Sports & Exercise: February 2012 - Volume 44 - Issue 2 - p 199–205
     
  18. Katiebruce

    Katiebruce Member

    Have just had a patient in who is being given. Cryofos therapy by physio for mid portion Achilles tendinosis. Never heard of it before and not much on net. Anyone experience of it please? Katie
     
  19. drsarbes

    drsarbes Well-Known Member

    Someone reinvented the ice cube!
    I think it's useful for frosting a beer mug.
    Steve
     
  20. Ian Drakard

    Ian Drakard Active Member

    Never heard of it either. Just googled it and can't quite see the rationale for using it on achilles tendinosis (other than I have a machine that was expensive so I'd better use it ;) )

    I like Steve's idea though :drinks
     
  21. Katiebruce

    Katiebruce Member

    Thanks for your replies. Nice to know tthis is not some new wonder treatment I've missed. I think desperation can convince patients that if it's new it works. Katie
     
  22. alessandro costa

    alessandro costa Active Member

    in calcific insertional Achilles tendon enthesopathy what do you think about shockwawe therapy instead of surgery? do they work? there is something else that can help. thank you, Alessandro :craig:
     
  23. Admin2

    Admin2 Administrator Staff Member

    See the studies here: Eccentric loading vs shockwave for achilles tendonitis
     
  24. alessandro costa

    alessandro costa Active Member

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