What is the Achilles tendon?
The Achilles tendon is the meeting of the two tendons arising from the muscles in the posterior aspect of the lower leg's posterior compartment. Muscles, gastrocnemius and soleus arise from the posterior surface of the tibia, and blend together to form the thick tendon. The achilles tendon inserts onto the back of the calcaneus just distal to the posterior-superior calcaneal tuberosity.
The achilles tendon is made up of synovial cells (paratendon), smooth muscle cells, endothelial cells and fibrochondrocytes. The largest component of the structure of the achilles tendon is the extracellular matrix which is comprised of tenoblasts and tenocytes, which lie between the collagen fibres all the way along the axis of the tendon. Type 1 collagen and elastin make up the non-extracellular component of the tendon.
As the tendon descends to its attachment point on the calcaneus, there is a rotation of the tendon which allows fibres on the medial side to reside posteriorly, as well as fibres on the posterior to move more laterally (around 90 degrees spiralling occurs).
The main blood supply to the achilles tendon enters the tendon via the thin, single layer of cells which make up the paratendon. Unlike other tendons, the achilles tendon is not encased in a tendon sheath. Instead, this highly vascularised tissue delivers the majority of the blood supply, with the rest arising from the calcaneo-tendinous and musculo-tendinous.
The main nerve supply of the tendon comes from three main branches located in the vicinity of the tendon. There are cutaneous, muscular and pertendinous nerve fibres which mostly terminate on the outer layers of the tendon. Nerves are a mixture of mechanoreceptive nerves, autonomic (sympathetic and parasympathetic) and un-myelinated nerve endings (conveying sensations of pain).
The achilles tendon functions in a similar way to most other tendons, in that it effectively acts to transmit force from the muscle to the bone. The achilles tendon also acts to absorb ground reaction forces which aid to limit damage to the muscular segment of this tripartite complex.
Largely the tendons are able to withstand forces which cause deformation of the elastic fibres up to about 4% - beyond 8% there is enough stretch to cause trauma to the tendon fascicles. The amount of load a tendon is able to withstand is proportional to the thickness of the tendon. A normal running gait will meant the achilles tendon is loaded by up to 12 times one's body weight.
What is Achilles tendinopathy, tendonitis and tendinitis?
The terms tendinosis, tendinopathy, tendinitis and tendonitis are often confused, which makes it difficult when trying to research the terms. The term tendinopathy is generally accepted to be an overall summary of the pathology at play, encompassing tendonitis, tendinitis and tendinosis. Largely a more specific description can be applied after histopathological examination; this should highlight the degree of degeneration (tendinosis) or inflammation (tendinopathy) which is resulting in the patient's heel pain. The paratendon can also be a source of degenerative or inflammatory changes.
In recent years the occurrence of Achilles tendinopathy has risen - largely due to the increased incidence of people taking part in recreational activities and competitive sports. Although common in other sports (such as football, athletics and racquet sports), Achilles tendinopathy is roughly 10 times more likely in runners vs age matched controls. The condition may also affect people who do not take part in intense sporting activity, so the sedentary population are also at risk.
Clinically the will patient tend to experience pain in the achilles tendon, often at the beginning or end of the training session. A nodule may often be present and may signify an element of degeneration according to some clinicians. Confirmation of achilles tendinopathy can be largely clinical but often radiological investigation is needed to quantify the level of deterioration of the achilles tendon.
What other treatments are available for Achilles tendinopathy?
Largely in the early phases, achilles tendinopathy can be managed conservatively by looking at various factors - both intrinsic and extrinsic - which affect the tendon. The majority of conservative measures focus on foot mal-alignments (podiatry may be of some benefit for achilles tendinopathy) and muscles Imbalances (physiotherapy for achilles tendinopathy).
- Modifying activities of daily living can make a significant difference in the early management of achilles tendinopathy. Reducing activities that are known to aggravate symptoms may be all that is needed in the early stages of the condition. However, complete rest of an injured tendon can be detrimental due to the activation of tenocytes which lead to the release of matrix metallo proteinase (MMP) causing further degradation and permeability of the paratendon to permeating blood veseels.
- Cold therapy has a benefit in the early stages as it slows down the inflammatory reaction in the tendon as well as having an analgesic effect on the afferent nerve fibres/receptors/endings.
- Ultrasound can be used in the acute phase to help reduce swelling and improve healing.
- Laser has also been shown to be beneficial for management of acute and chronic tendinopathy.
- Deep frictions massage can be used in more chronic cases to help increase blood flow and reorgnaisation of collagen fibres, accompanied with stretching.
- Commonly eccentric muscle training is used to reduce pain in chronic achilles tendinopathy, as well as increase the tensile strength of the musculo-tendinous complex.
- Heel lifts are commonly used for the ‘off-loading’ of the achilles tendon during acute phases.
- Several studies have looked at the role of drugs and injection therapy and concluded there is little evidence for the use of pertendinous and intratendinous corticosteroid injection therapy.
- Surgery is an option for more severe cases but the long-term complications and outcome measures are still in question.
- Shockwave therapy provides an alternative to surgery and, in most cases of tendinopathy, will result in a satisfactory outcome.
How is shockwave therapy applied to the area?
Shockwave therapy for Achilles tendinopathy is applied following a set protocol. The clinician will carry out a thorough case history taking which isolates the area that is painful and begins to understand the clinical history behind the condition. It is important to make sure that the condition being treated is actually an Achilles tendinopathy and, as such, is treatable with shockwave therapy.
- Largely the study of exactly what happens during shockwave therapy is the topic of many research projects. Some proposed mechanisms so far that has good evidence include;
- Direct stimulation of healing (increased TGF-b1, IGF-1, increased GAG’s)
- Direct suppression effects on nociceptors
- Hyper-stimulation (blocking the gait control mechanism)
- Increased NO expression
- Increase PCNA (proliferating cell nuclear antigen), collagen type 1 and collagen type 3
During the examination period a tender point where the pain is maximal will be located, upon which a water-based medium will be applied. This aids the transmission of the impulses into the desired area.
The probe will then be placed over the desired area and then treatment for your Achilles tendinopathy will begin. At first the clinician will ensure the discomfort is kept to a minimum. After a while, as the impulses increase, little pain is experienced. However, more often than not, there is some pain felt over the area of application. After treatment you should feel very little pain and this may last for a few days. After then an aching sensation can occur. After subsequent treatments there will be a definite improvement in symptoms leading to reduction in the original pain felt.
How long will shockwave therapy take to work?
Generally most applications of shockwave for Achilles tendinopathy and most conditions will resolve within 3-4 sessions of approximately 30 minutes treatment. Naturally, this can depend on the exact presentation of the condition. Making sure you see someone quickly to have the condition diagnosed can reduce the number of sessions needed.
It is vital that you continue to work with a physical therapist to maintain the exercise regime you should already be carrying out for Achilles tendinopathy, prior to consulting for shockwave treatment. This will involve balancing exercises, strength exercises and a good eccentric loading programme depending on your stage of Achilles tendinopathy.
What is the evidence for shockwave therapy and achilles tendon pain/achilles tendinopathy?
There is growing evidence for the use of shockwave therapy in the management of achilles tendinopathy. Largely the area of non-operative management of achilles tendinopathy has been poorly studied. One area that is of increasing interest is the use of shockwave therapy for the conservative management of achilles tendinopathy.
A recent paper has highlighted the previously gold standard eccentric loading programmes having inferior results to shockwave therapy at 4 months follow up. It is very promising that there are alternatives available which are proving better than what we have been prescribing previously (Rompe 2008).
Where can I get shockwave therapy for this condition?
You are able to get shockwave therapy at a few specialist clinics in the UK. There are a growing number of clinics providing this specialist form of treatment. It is beneficial to make certain the type of machine they use is a swiss dolor clast machine as this is the only one that has been tested to high level in research papers.
At Perfect Balance Clinic we often see people with different types of Tendinopathy who have tried other forms of treatment. For us, Shockwave therapy has been the one form of treatment that has consistently delivered results for Achilles Tendinopathy.
How long will shockwave treatments last for?
If everything goes to plan with your shockwave therapy for Achilles tendinopathy then the treatment should make a significant contribution to reducing the pain and improving the function of your Achilles tendinopathy. In most cases the shockwave will get rid of the patellar tendinitis.
With some tendon surgery there is a 75% success rate at 18 months, with shockwave for the same condition it has been shown that up to 80% of patients who have received the shockwave therapy at 18 months have a good to excellent result. Shockwave is better than surgery for certain tendinopathy and more research is being done with this in mind.
Shockwave therapy has proven to be better than surgery and better than the current non-operative measures used for management of resistant achilles tendinopathy.
- Alfredson H, Cook J. Pain in the Achilles region. In: Brukner P, Khan K, editors. Clinical Sports Medicine. 3rd ed. Sydney: McGraw-Hill; 2006. p 590-611.
- Alfredson, H., & Lorentzon, R. (2000). Chronic Achilles tendinosis: recommenda- tions for treatment and prevention. Sports Medicine, 29, 135e146.
- Alfredson, H., Pietilä, T., Jonsson, P., & Lorentzon, R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine, 26, 360e366.
- Allison, S. J., & Nazarian, L. N. (2010). Musculoskeletal ultrasound: evaluation of ankle tendons and ligaments. American Journal of Roentgenology, 194, W514.
- Bianchi, S., Delmi, M., & Molini, L. (2010). Ultrasound of peroneal tendons. Seminars in Musculoskeletal Radiology, 14, 292e306.
- Brunner, J., Anderson, J., O’Malley, M., Bohne, W., Deland, J., & Kennedy, J. (2005). Physician and patient based outcomes following surgical resection of Haglund’s deformity. Acta Orthopaedica Belgica, 71, 718e723.
- Chen, S. K., Lu, C. C., Chou, P. H., Guo, L. Y., & Wu, W. L. (2009). Patellar tendon ruptures in weight lifters after local steroid injections. Archives of Orthopaedic and Trauma Surgery, 129, 369e372.
- Chung, B., & Wiley, J. P. (2002). Extracorporeal shockwave therapy: a review. Sports Medicine, 32, 851e865.
- Cohen, D. B., Kawamura, S., Ehteshami, J. R., & Rodeo, S. A. (2006). Indomethacin and celecoxib impair rotator cuff tendon-to-bone healing. American Journal of Sports Medicine, 34, 362e369.
- Costa, M. L., Shepstone, L., Donell, S. T., & Thomas, T. L. (2005). Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial. Clinical Orthopaedics and Related Research, 440, 199e204.
- Fridman, R., Cain, J. D., Weil, L., Jr., & Weil, L., Sr. (2008). Extracorporeal shockwave therapy for the treatment of Achilles tendinopathies: a prospec- tive study. Journal of the American Podiatric Medical Association, 98, 466e468.
- Gill SS, Gelbke MK, Mattson SL, Anderson MW, Hurwitz SR. Fluoroscopically guided low-volume peritendinous corticosteroid injection for Achilles tendinopathy. A safety study. J Bone Joint Surg Am. 2004;86:802-6.
- Hsu, C. J., Wang, D. Y., Tseng, K. F., Fong, Y. C., Hsu, H. C., & Jim, Y. F. (2008). Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder. Journal of Shoulder and Elbow Surgery, 17, 55e59.
- Hugate R, Pennypacker J, Saunders M, Juliano P. The effects of intra- tendinous and retrocalcaneal intrabursal injections of corticosteroid on the bio- mechanical properties of rabbit Achilles tendons. J Bone Joint Surg Am. 2004;86:794-801.
- Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991;73:1507-25.
- Magnussen, R. A., Dunn, W. R., & Thomson, A. B. (2009). Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clinical Journal of Sport Medicine, 19, 54e64.
- Magra, M., & Maffulli, N. (2006). Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe. Clinical Journal of Sport Medicine, 16, 1e3.
- Maquirriain J. Endoscopic Achilles tenodesis: a surgical alternative for chronic insertional tendinopathy. Knee Surg Sports Traumatol Arthrosc. 2007;15: 940-3.
- Metcalfe, D., Achten, J., & Costa, M. L. (2009). Glucocorticoid injections in lesions of the achilles tendon. Foot and Ankle International, 30, 661e665.
- Mouzopoulos, G., Stamatakos, M., Mouzopoulos, D., & Tzurbakis, M. (2007). Extra- corporeal shock wave treatment for shoulder calcific tendonitis: a systematic review. Skeletal Radiology, 36, 803e811.
- Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med. 2005;15:370-5.
- Pan, P. J., Chou, C. L., Chiou, H. J., Ma, H. L., Lee, H. C., & Chan, R. C. (2003). Extra- corporeal shock wave therapy for chronic calcific tendinitis of the shoulders: a functional and sonographic study. Archives of Physical Medicine and Rehabili- tation, 84, 988e993.
- Rasmussen, S., Christensen, M., Mathiesen, I., & Simonson, O. (2008). Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy. Acta Orthopaedica, 79, 249e256.
- Read, M. T. (1999). Safe relief of rest pain that eases with activity in achillodynia by intrabursal or peritendinous steroid injection: the rupture rate was not increased by these steroid injections. British Journal of Sports Medicine, 33, 134e135.
- Rompe JD, Decking J, Schoellner C, Theis C. Repetitive low-energy shock wave treatment for chronic lateral epicondylitis in tennis players. Am J Sports Med. 2004;32:734-43.
- Rompe JD, Meurer A, Nafe B, Hofmann A, Gerdesmeyer L. Repetitive low- energy shock wave application without local anesthesia is more efficient than repetitive low-energy shock wave application with local anesthesia in the treatment of chronic plantar fasciitis. J Orthop Res. 2005;23:931-41.
- Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg Am. 2002;84:335-41.
- Rompe, J. D., Furia, J., & Maffulli, N. (2008). Eccentric loading compared with shock wave therapy for chronic insertional Achilles tendinopathy. Journal of Bone and Joint Surgery, 90, 52e61, American Volume.
- Rompe, J. D., Kirkpatrick, C. J., Küllmer, K., Schwitalle, M., & Krischek, O. (1998). Dose-related effects of shock waves on rabbit tendo Achillis. A sonographic and histological study. Journal of Bone and Joint Surgery, 80, 546e552, British Volume.
- Rompe, J. D., Nafe, B., Furia, J., & Maffulli, N. (2007). Eccentric loading, shock wave treatment or a wait-and-see policy for tendinopathy of the main body of the tendo Achilles: a randomized controlled trial. American Journal of Sports Medicine, 35, 374e383.
- Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am. 2005;87:187-202.
- Trebinjac, S., Mujic-Skikic, E., Ninkovic, M., & Karaikovic, E. (2005). Extracorporeal shock wave therapy in orthopaedic diseases. Bosnian Journal of Basic Medical Sciences, 5, 27e32.
- Tsai WC, Hsu CC, Chen CP, Chen MJ, Lin MS, Pang JH. Ibuprofen inhibition of tendon cell migration and down-regulation of paxillin expression. J Orthop Res. 2006;24:551-8.
- Uhthoff, H. K., & Loehr, J. W. (1997). Calcific tendinopathy of the rotator cuff: pathogenesis, diagnosis, and management. Journal of the American Academy of Orthopaedic Surgeons, 5, 183e191.
- van Leeuwen, M. T., Zwerver, J., & van den Akker-Scheek, I. (2009). Extracorporeal shockwave therapy for patellar tendinopathy: a review of the literature. British Journal of Sports Medicine, 43, 163e168.
- Vulpiani, M. C., Trischitta, D., Trovato, P., Vetrano, M., & Ferretti, A. (2009). Extra- corporeal shockwave therapy (ESWT) in Achilles tendinopathy. A long-term follow-up observational study. Journal of Sports Medicine and Physical Fitness, 49, 171e176.
- Wagner E, Gould JS, Kneidel M, Fleisig GS, Fowler R. Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis. Foot Ankle Int. 2006;27:677-84.
- Wang JHC, Iosifidis MI, Fu FH. Biomechanical basis for tendinopathy. Clin Orthop Relat Res. 2006;443:320-32.
- Wang, C. J., Ko, J. Y., Chan, Y. S., Weng, L. H., & Hsu, S. L. (2007). Extracorporeal shockwave for chronic patellar tendinopathy. American Journal of Sports Medi- cine, 35, 972e978.
- Woodley, B. L., Newsham-West, R. J., & Baxter, G. D. (2007). Chronic tendinopathy: effectiveness of eccentric exercise. British Journal of Sports Medicine, 41, 188e198.