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Achilles tendinitis — Clinical Guidelines

Overview

Achilles tendinopathy encompasses pain and functional impairment in the Achilles tendon, typically categorized into insertional and noninsertional types, often resulting from chronic stress and abnormal collagen fiber arrangement 7.

Diagnosis

Clinical Presentation: Pain, stiffness, and reduced muscle power in the affected limb 1.

Imaging: Ultrasound is crucial for identifying pathological changes in the tendon and surrounding soft tissues, including retrocalcaneal bursae 2 7.

Grading: No specific grading system universally adopted; clinical severity often assessed based on symptoms and functional limitations 1.

Management

First-Line Treatments:

- Eccentric Strengthening Exercises: Recommended as a primary intervention 4. - Physical Therapy: Including manual therapy and targeted exercises to improve flexibility and strength 1.

Adjunctive Treatments:

- Viscoelastic Heel Inserts: May alleviate symptoms in some patients 9. - Ultrasound Therapy: Not extensively detailed in abstracts but often used adjunctively 7.

Special Populations

Dancers: Management should consider unique biomechanical demands; evidence-based approaches are recommended to avoid unproven treatment modalities 6.

HLA-B27 Associated Cases: Longstanding bilateral Achilles tendinitis may indicate underlying HLA-B27-associated disease processes requiring careful monitoring 8.

Key Recommendations

Implement Eccentric Strengthening Protocols for midportion Achilles tendinopathy to improve pain and function (Evidence: Strong 4).

Utilize Ultrasound Imaging for accurate diagnosis and monitoring of Achilles tendinopathy progression and treatment efficacy (Evidence: Moderate 2 7).

Consider Patient-Specific Modalities such as viscoelastic heel inserts for symptomatic relief, particularly in those with heel strike-related symptoms (Evidence: Weak 9).

Monitor HLA-B27 Positive Patients with chronic Achilles tendinitis for potential systemic associations (Evidence: Expert opinion 8).

Tailor Rehabilitation Programs for dancers to address specific biomechanical stresses without relying on unproven treatments (Evidence: Expert opinion 6).

References

1 Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision - 2024. The Journal of orthopaedic and sports physical therapy 2024. link 2 Ricci V, Cocco G, Mezian K, Chang KV, Tamborrini G, Naňka O et al.. Histo-Anatomy and Sonographic Examination for the Retrocalcaneal Bursal Complex: EURO-MUSCULUS/USPRM Approach. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine 2024. link 3 Smerilli G, Cipolletta E, Destro Castaniti GM, Pieroni G, Sartini G, Cenci A et al.. Ultrasound assessment of Achilles enthesitis: a dedicated training program. Reumatismo 2024. link 4 Murphy M, Travers M, Gibson W. Is heavy eccentric calf training superior to wait-and-see, sham rehabilitation, traditional physiotherapy and other exercise interventions for pain and function in mid-portion Achilles tendinopathy?. Systematic reviews 2018. link 5 Rahim M, El Khoury LY, Raleigh SM, Ribbans WJ, Posthumus M, Collins M et al.. Human Genetic Variation, Sport and Exercise Medicine, and Achilles Tendinopathy: Role for Angiogenesis-Associated Genes. Omics : a journal of integrative biology 2016. link 6 Maffulli N, Longo UG, Denaro V. Achilles Tendinopathy in Dancers. Journal of dance medicine & science : official publication of the International Association for Dance Medicine & Science 2012. link 7 McShane JM, Ostick B, McCabe F. Noninsertional Achilles tendinopathy: pathology and management. Current sports medicine reports 2007. link 8 Haberhauer G, Wandner G, Dax K. Longstanding isolated bilateral Achilles tendinitis. Zeitschrift fur Rheumatologie 1990. link 9 MacLellan GE, Vyvyan B. Management of pain beneath the heel and Achilles tendonitis with visco-elastic heel inserts. British journal of sports medicine 1981. link 10 Sharma SV. A modified method of Achilles tendon lengthening. International surgery 1978. link 11 Clancy WG, Neidhart D, Brand RL. Achilles tendonitis in runners: a report of five cases. The American journal of sports medicine 1976. link

Achilles tendinitis