Rest and ice are considered first-line therapy for acute Achilles tendonopathy (strength of recommendation [SOR]: C, expert opinion), as is nonsteroidal anti- inflammatory drugs (NSAIDs) (SOR: B, systematic review). Chronic noninsertional Achilles tendonopathy should be treated with eccentric calf-muscle training (ECMT) (SOR: B, 3 randomized controlled trials [RCTs])

Glaser, Troy

Poddar, Sourav

Tweed, Elizabeth M.

University of Missouri: MOspace

CLINICAL INQUIRIES From the Family Physicians Inquiries Network VOL 57, NO 4 / APRIL 2008 261www.jfponline.com  What’s the best way to treat Achilles tendonopathy?Rest and ice are considered fi rst-line therapy for acute Achilles tendonopathy (strength of recommendation [SOR]: C, expert opinion), as is nonsteroidal anti-infl ammatory drugs (NSAIDs) (SOR: B, systematic review).  Chronic noninsertional Achilles tendonopathy should be treated with eccentric calf-muscle training (ECMT) (SOR: B, 3 randomized controlled trials [RCTs]). Continuing an activity such as running, while monitoring pain, is as effective as resting while enrolled in an eccentric strengthening program (SOR: B, 1 RCT). If conservative management fails, surgery may help (SOR: C, case series).  Treat tendonopathy one step at a time I’ve found stepwise treatment of Achilles tendonopathy to be the most useful approach for my patients. Initially, I recommend NSAIDs, stretching, and decreasing the offending activity. If the patient hasn’t improved in 2 weeks, I refer him for physical therapy with a focus on fl exibility and eccentric strengthening. I recommend applying ice for 20 minutes after each therapy or exercise session and 2 or 3 more times a day.  If the patient doesn’t improve in another 2 to 3 weeks, I have him (or her) wear a cam walking boot (fracture boot) constantly, except when bathing, for 2 to 6 weeks. The boot maintains the ankle in a neutral position, facilitating the rest required for healing. I’ve found that most patients can avoid surgery by wearing the boot until they are free of pain for a week (but no longer than 6 weeks) and then undergoing aggressive physical therapy to strengthen the ankle.  Charles W. Webb, DOOregon Health and Science University, Portland, Ore❚ Evidence summaryWhile patients may refer to this condi-tion as “Achilles tendonitis,” the phrase is actually a misnomer. That’s because in tendonitis, the infl ammation is lim-ited to the surrounding structures, but doesn’t involve the tendon itself. Acute symptoms respond to NSAIDsA Cochrane review of treatments for acute Achilles tendonopathy included 9 randomized trials with a total of 697 pa-tients. Two RCTs showed evidence that NSAIDs alleviate acute symptoms. In 1 trial of 212 patients who received an oral NSAID or placebo for 14 days, signifi -cantly fewer patients in the placebo group achieved a good or excellent symptom re-lief (relative risk [RR]=0.42; 95% confi -dence interval [CI], 0.21-0.86). A second RCT of 243 patients compared treatment Clinical commentaryEvidence-based answerFAST TRACKEccentric calf-muscle training is effective for chronic, noninsertional Achilles tendonopathy Troy Glaser, DO, Sourav Poddar, MD, and Beth Tweed, MLISDepartment of Family Medicine, University of Colorado Health Sciences Center, Denver261_JFP0408   261 3/19/08   9:33:20 AMCopyright® Dowden Health Media  For personal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.FAST TRACKCLINICAL INQUIRIES262 VOL 57, NO 4 / APRIL 2008  THE JOURNAL OF FAMILY PRACTICEwith a topical NSAID to placebo for 21 days; signifi cantly fewer participants who took placebo returned to their pre-injury level of activity (RR=0.78; 95% CI, 0.63-0.95). Low-dose heparin injec-tion, heel pads, topical laser therapy, and peritendinous steroid injection produced no signifi cant decrease in pain compared with placebo.1Eccentric calf-muscle training helps chronic tendonopathyECMT is an effective intervention for chronic noninsertional Achilles ten-donopathy. An observational study of ECMT in 78 patients (101 tendons total) with chronic noninsertional Achilles ten-donopathy found that 89% were back to their preinjury activity level after a 12-week regimen of ECMT, as indicated by signifi cantly lower scores on a 100-point visual analog scale (67 at baseline vs 10.2 at 12 weeks; P<0.001).2An RCT compared ECMT or repeti-tive shock wave therapy to a “wait-and-see” control group (25 patients in each group). After 4 months, both the ECMT and shock wave therapy groups reported a signifi cant decrease in pain compared with controls (P< 0.001; mean difference in 10-point pain score, 2.4; 95% CI, 1.3-3.5). Sixty percent of participants in the ECMT group reported complete recov-ery or signifi cant improvement (P<0.001; number needed to treat [NNT] = 3; mean difference in 6-point Likert scale = –1.6; 95% CI, −2.4 to 0.8).3 During an ECMT program, patients may be able to continue activity without exacerbating Achilles tendonopathy. An RCT of 38 patients compared rest with eccentric training and continued activ-ity and eccentric training for 12 weeks to 6 months using a pain-monitored model. Both groups showed similar improvement in pain and function when measured with the Swedish version of the Achilles assess-ment questionnaire (VISA-A-S 100-point scale: 0 = worst function, 100 = completely recovered). The baseline mean VISA-A-S scores were 57 for both groups; the mean scores after 12 months were 85 for the ex-ercise group and 91 for the rest group.4Another option: The AirHeel braceAn AirHeel brace may be a viable alter-native to ECMT, especially if the patient can’t tolerate eccentric muscle training because of pain. The brace was designed for Achilles tendonopathy and posterior heel pain. It applies intermittent compres-sion to minimize swelling and promote circulation. An RCT evaluated 100 patients with chronic noninsertional Achilles tendonop-athy who were treated with ECMT, an AirHeel Brace, or a combination of the 2 for 12 weeks. At 1-year follow-up, all 3 groups showed a signifi cant reduction in pain measured by a 10-point visual analog scale (ECMT 30%, brace 27%, combina-tion 53%; P<0.0001). All the groups also showed signifi cantly improved function as measured by an American Orthopaedic Foot and Ankle Society Score (10%, 10%, and 30%, respectively; P<0.001). No An AirHeel brace may be an option if a patient can’t tolerate eccentric muscle training because of painContinue to exercise?ILLUSTRATION © 2008 JOHN M. DAUGHERTY / PHOTO RESEARCHERS, INCPatients with chronic noninsertionalAchilles tendonopathy may be able to continue activity during eccentriccalf-muscle training without exacerbatingthe tendonopathy, according to an RCT of 38 patients that compared rest with eccentric training and continued activity with eccentric training.  SHOWN HERE: MEDIAL FOOT AND ANKLE WITHOUT INJURY.262_JFP0408   262 3/19/08   9:33:25 AM VOL 57, NO 4 / APRIL 2008 263www.jfponline.comsignifi cant differences in outcomes were found across the treatment groups, and 90% of participants reached their prein-jury activity level after 1 year.4 Shock wave therapy and topical glyceryl trinitrateThe role of repetitive shock wave therapy and topical glyceryl trinitrate in the treat-ment of chronic noninsertional Achilles tendonopathy is less clear. In a double-blinded RCT of 49 patients, shock wave therapy did not produce better outcomes than placebo.5 However, a prospective cohort study of 68 patients found that patients who received shock wave therapy had sig-nifi cantly lower mean visual analog scale scores for pain compared with controls after 1 month (P<0.001), 3 months (P<0.001), and 12 months (P<0.001) of treatment.6 In a double-blinded RCT of 65 patients, more patients treated with topical glyceryl trinitrate therapy were asymptomatic during activities of daily living at 6 months compared with pla-cebo (P<0.001).7 Both shock wave therapy and topical glyceryl trinitrate may have a signifi cant role to play in treating chronic noninser-tional Achilles tendonopathy, but more studies are needed to support their use. Surgery appears to work better for athletesSurgery is an option for patients with chronic noninsertional Achilles ten-donopathy who have failed conservative measures and a 3- to 6-month rehabili-tation program. In a systematic review of 26 studies of patients managed surgi-cally, the mean success rate (full return to preinjury activity level) was 77%. However, a negative correlation was ob-served between the reported success rate and the overall methods score, a rating of the quality of studies (r = 0.53; P<0.01). Only 5 of the studies reviewed were pro-spective cohort studies; the remaining 21 were retrospective cohort studies and case studies.8 Athletes responded signifi cantly better to surgery than nonathletic pa-tients, returning to full activity in 4.5 months compared with 7.1 months for nonathletes (P<0.03). Fewer ath-letes had surgical complications (9% compared with 19% of nonathletes).9 More studies are needed to clarify the role of surgery in managing Achilles tendonopathy.RecommendationsThe American College of Foot and An-kle Surgeons recommends initial man-agement by reducing pressure around the affected area combined with heel lifts, orthotics, NSAID therapy, and physical therapy. Immobilization may be used on a case-by-case basis. Local steroid injections aren’t recommended. Patients with resistant tendonopathy should be referred to a foot and ankle surgeon.10 ■ References 1.  McLaughlan G, Handoll H.  Interventions for treat-ing acute and chronic Achilles tendonitis. Cochrane Database Syst Rev. 2001;(2):CD000232.  2.  Fahlstrom M, Jonsson P, Lorentzon R, et al. Chron-ic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Ar-throsc. 2003;11:327-333.   3.  Rompe J, Nafe B, Furia J, et al. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis. Am J Sports Med. 2007;35:374-383.   4.  Silbernagel K, Thomee R, Eriksson B, et al. Contin-ued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendi-nopathy. Am J Sports Med. 2007;35:897-906.   5.  Costa M, Shepstone L, Donnell S, et al. Shock wave therapy for chronic Achilles tendon pain. Clin Orthop. 2005;440:199-204.   6.  Furia J.  High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles ten-dinopathy. Am J Sports Med. 2006;34:733-740.  7.  Paoloni J, Appleyard R, Nelson J, et al. Topical glyceryl trinitrate treatment of chronic noninser-tional Achilles tendinopathy. J Bone Joint Surg Am. 2004;86:916-922.   8.  Tallon C, Coleman B, Khan K, et al. Outcome of surgery for chronic Achilles tendinopathy. Am J Sports Med. 2001;29:315-320.  9.  Maffuli N, Testa V, Capasso G, et al. Surgery for chronic Achilles tendinopathy yields worse re-sults in nonathletic patients. Clin J Sport Med. 2006;16:123-128.   10.  Thomas J, Christensen J, Kravitz S, et al. The di-agnosis and treatment of heel pain. J Foot Ankle Surg. 2001;40:329-337. Achilles tendonopathyFAST TRACKAthletes appear to respond better to surgery, demonstrating quicker recovery than nonathletes263_JFP0408   263 3/19/08   9:33:31 AM

What's the best way to treat Achilles tendonopathy?

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