Initial

The initial treatment goal is to decrease pain and to reduce inflammation when it is present. It should be noted that the cohort of patients with the diagnosis of Achilles tendinopathy modulate pain centrally, in addition to peripherally, and this may add a degree of complexity to their analgesic management. Therefore rest from aggravating activities is critical. Icing (20 minutes, two or three times daily) and nonsteroidal anti-inflammatory drugs or analgesics can be used for pain and inflammation. A wide range of novel treatments from repetitive low-energy shock wave treatment, sclerosing agents, and topical nitroglycerin to low-level laser therapy have been attempted with varying degrees of mixed results in small studies. Given the non-inflammatory histopathology and need for healing and tissue repair, this stands to reason that it may be one of the more rational diagnoses for PRP (platelet-rich plasma) therapy as part of a comprehensive program. At one point, Hylan GF-20 seemed promising, but a recent study has suggested it is to be avoided. These results suggest that Hylan GF-20 may have a sclerosing or pro-inflammatory role and can be combined with PRP.

Warm-up before any weight-bearing activity and cooling with ice afterward is still empirically recommended. Good functional results can usually be achieved in most cases at 3 months with nonoperative treatment in compliant patients with mild to moderate tendon separation. In light of the growing body of evidence of serum lipid abnormality association with Achilles tendinopathy, it stands to reason that these underlying lipid abnormalities should be addressed. As with any overweight patient, the treatment program should include lifestyle changes linked to a sustainable weight loss, such as dietary consultation.

Rehabilitation

The rehabilitative process focuses on biologic improvement of the damaged tendon and peritenon and restoration of function, rather than the comfort efforts of the initial treatment phase. Rehabilitation is best initiated in a structured physical therapy program followed by home therapeutic exercise. Non-weight-bearing status and axillary crutches may have a role in the acute phase of treatment, with return to weight bearing as tolerated. A short leg cast or splint in 10 to 15 degrees of plantar flexion may also have a short-term role in acute phase treatment. Counterforce bracing is often helpful and may enable ADL activity level if fitted appropriately. A simple heel lift (1⁄8 to 1⁄2 inch) has been definitively shown to reduce Achilles tendon load. This mechanism by which benefit occurs is hypothesized to be redistribution of load from the medial to lateral triceps surae, but the exact mechanism by which heel lifts help is poorly understood. Passive modalities including therapeutic ultrasound, iontophoresis, and phonophoresis often enhance compliance and enable the rehabilitation program. Electrical stimulation should be considered contraindicated in the face of the overuse etiology and counter-physiologic motor unit recruitment of muscle fibers and is likely to only pull the tendon farther apart, potentially converting a partial to a complete tear.

Therapeutic exercise needs to be directed toward the complete kinetic chain because strength, endurance, and flexibility deficits are common, and most lower extremity sports activities occur as patterned motor engrams. Strength, proprioceptive, and endurance testing usually aids in uncovering relative weaknesses and monitoring the rehabilitation progress. Controlled eccentric exercise may be of benefit throughout the strength-building phase of rehabilitation and avoids additional tendon separation.

Control of abusive force loads can be accomplished by counterforce bracing of the Achilles tendon or orthotics to minimize abnormal foot posture. Gradual, controlled return to running may be initiated through running in water programs. As with any lower extremity injury, general fitness may be maintained by use of upper body land programs such as arm ergometry, resistance training, and water programs dedicated to the entire body. Return to sport or running is transitional, including plyometric and eccentric exercises. Full return generally requires normal strength, endurance, and flexibility. However, there is some evidence that even after 5-minute static stretching, there is no change in stiffness of the tendon. It also seems to even be true that the tendon does not stretch or become more pliable one hour after a full marathon, which calls into question any association between stretching or exercise and stiffness of the Achilles tendon itself. Repeated injury is not uncommon. Return to normal activity, generally in 6 to 12 weeks, depends on level of participation (professional athlete versus weekend warrior), severity of the injury, and general medical and athletic condition.

Procedures

Exogenous glucocorticoid injection is contraindicated, as cellular death and tendon weakness with potential progression to tendon rupture are significant concerns. Although there may be a developing role for Hylan G-F 20, the context is changing. Likewise, extracorporeal shockwave therapy may work by theoretically removing damaged matrix constituents; pulsed ultrasound, indium-gallium-aluminum-phosphide diode laser irradiation, and substance P injection in an animal tenotomy model have all been studied and shown varying degrees of potential. Hyperbaric oxygen may have a slightly more promising role.

Technology

No new technology in treatment of the Achilles tendon exists per se. However, with the increased availably and use of diagnostic and guidance ultrasound, earlier and more accurate tear data would be an expected trend in clinical practice. Use of PRP, while not exactly a new treatment protocol, has seen an increase of use in small nonacademic settings.

Surgery

Rehabilitation failure may invite surgical intervention with a goal of problem resolution versus acceptance of the malady and alteration of activity level. Optimal surgical management strategy is controversial, but the relative avascularity of the region makes wound healing complications and deep infection ever-present threats. Recently, it has been shown that operative approaches should consider the vulnerability of the peroneal artery to surgical trauma in that region of the tendon. The concepts of surgery include removal of symptomatic peritendinitis tissue and resection of the abnormal tendinosis tissue in the body of the Achilles tendon with subsequent repair of the remaining adjacent normal tendon. This is usually accomplished with standard sutures or wires; however, fibrin sealant has been used, and at least on the surface, this may seem a more biologic approach. Surgical options consist of open, mini-open, or percutaneous repair. Surgery outcomes are better if all pathologic tissue is removed, reanastomosis is performed, and appropriate postoperative rehabilitation is implemented. The postoperative goals of neovascularization, reduction of atrophy, fibroblastic infiltration, and collagen production and the restoration of strength, endurance, and flexibility are best served by early mobilization.

In cases of suspected tendon rupture, a surgical consultation is warranted. Endoscopic techniques have evolved alongside open and mini-open approaches, but with comparable re-rupture rates. The percutaneous repair seems to be a better option for elite athletes with a greater likelihood of return to sport activities, but it has an increased complication rate. There are differences of opinion as to whether the percutaneous technique should be performed at all in lieu of a limited open technique. Insertional Achilles tendinopathy has different surgical approaches that may involve flexor hallucis longus tendon augmentation in the elderly, but they do not seem to add anything for cases in active individuals.