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Achilles tendinopathy

Definition
Achilles tendinopathy is a non-rupture injury of the Achilles tendon characterized by pain, swelling, and reduced performance, with symptoms often exacerbated by physical activity.
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Pathophysiology
The pathophysiology of Achilles tendinopathy involves a continuum from reactive tendinopathy, where tenocytes proliferate and protein production increases, leading to tendon thickening, to tendon disrepair with further increase in tenocytes and protein production and focal collagen fiber disruption, and finally to degenerative tendinopathy involving cell death, large areas of collagen disorganization, and areas filled with vessels and nerves.
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Epidemiology
The incidence of mid-portion Achilles tendinopathy in the US is estimated at 235 per 100,000 person-years in the general population aged 21-60 years. Annually, 7-9% of runners experience Achilles tendinopathy.
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Disease course
Clinically, patients with Achilles tendinopathy present with symptoms localized 2-7 cm proximal to the Achilles tendon insertion, painful Achilles tendon midportion on loading, local thickening of the Achilles tendon midportion, and pain on local palpation of the Achilles tendon midportion.
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Prognosis and risk of recurrence
The prognosis of Achilles tendinopathy can vary widely among individuals, but generally, the condition is manageable with appropriate treatment.
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Key sources
The following summarized guidelines for the evaluation and management of achilles tendinopathy are prepared by our editorial team based on guidelines from the Dutch Multidisciplinary Guideline (DMG 2021), the American Physical Therapy Association (APTA 2018), and the American College of Rheumatology (ACR 2018).
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Guidelines

1.Screening and diagnosis

Diagnosis: diagnose midportion Achilles tendinopathy based on the presence of all the following findings:
symptoms localized 2-7 cm proximal to the Achilles tendon insertion
painful Achilles tendon midportion on (sports) loading
local thickening of the Achilles tendon midportion (may be absent in cases with short symptom duration)
pain on local palpation of the Achilles tendon midportion
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  • Differential diagnosis

2.Diagnostic investigations

History and physical examination: consider using a subjective report of pain located 2-6 cm proximal to the Achilles tendon insertion that began gradually and pain with palpation of the midportion of the tendon, in addition to the arc sign and Royal London Hospital test, for the diagnosis of midportion Achilles tendinopathy.
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  • Diagnostic imaging

3.Medical management

Nonsteroidal anti-inflammatory drugs: be cautious when using NSAIDs in patients with Achilles tendinopathy.
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4.Nonpharmacologic interventions

Exercise: as per DMG 2021 guidelines, advise progressive calf muscle strengthening exercises for at least 12 weeks in patients with Achilles tendinopathy. Ensure the form of exercise therapy is suitable for the individual patient. Take into consideration the role of motivation, time constraints, pain monitoring, and availability of facilities and resources. Consider advising performing exercises initially on a flat surface in patients with insertional Achilles tendinopathy.
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  • Footwear and ankle support

  • Manual therapy

  • Acupuncture

  • Collagen supplements

5.Therapeutic procedures

Injection therapy: consider offering injection therapies (polidocanol, lidocaine, autologous blood, platelet-rich plasma, stromal vascular fraction, hyaluronic acid, prolotherapy, or high-volume injection) in case of insufficient effectiveness of patient education and loading advice in combination with continued exercise therapy. Be cautious when using corticosteroid injections.
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  • Iontophoresis

  • Laser and light therapy

  • Extracorporeal shockwave therapy

6.Surgical interventions

Indications for surgery: consider performing surgery only in patients not recovering after at least 6 months of active treatment. Discuss the expected effectiveness of surgical intervention compared with active non-surgical treatments and the potential surgical complications.
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7.Patient education

General counseling: as per DMG 2021 guidelines, discuss the initial active treatment options together with the patient. Assess specific patient characteristics (such as activity level and the presence of comorbidities) to personalize treatment.
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8.Preventative measures

Avoidance of fluoroquinolone: consider advising the avoidance of fluoroquinolone antibiotics if alternative antibiotics are available and the clinical picture allows in the context of the importance of preventing Achilles tendinopathy.
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  • Secondary prevention

9.Follow-up and surveillance

Indications for specialist referral: consider referring patients to a sports medicine physician or an orthopedic surgeon if there is continued uncertainty about the diagnosis or there is an unexpected course or change of symptoms during follow-up.
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  • Assessment of treatment response