| General introduction |
Background of this guide
In 2014, the Netherlands recognized sports medicine as a medical specialty. This recognition was followed by that of the Dutch Sports Association. This guide is officially supported and is very similar to that of the UK Institute of Health. The choice of Achilles tendinopathy was due to the frequency of occurrence in clinical practice, and it has an important impact on patients. On the other hand, there are many scientific works on the matter.
Achilles tendon injury is a common problem, both in active athletes and inactive individuals.
In athletes it may be caused by external overload, and in inactive individuals, relative overload may be caused by a very low basal capacity. In Dutch general practice, symptoms due to Achilles tendon problems occur in 2-3/1,000 adult patients. Runners have a 52% chance (cumulative incidence) of suffering an Achilles tendon injury in their lifetime.
The exact pathophysiology of Achilles tendinopathy is still unknown; It is believed to have a multifactorial origin. A better understanding of risk factors can help develop more effective preventive interventions.
The diagnosis of Achilles tendinopathy is usually made on the basis of clinical findings. The criteria for diagnosis are not sufficiently described. The role of imaging in diagnosis has also not been agreed upon. On the other hand, there are a number of (systemic) conditions that must be taken into account in patients with pain in the Achilles tendon region. It is important for healthcare providers to recognize these diseases, as it greatly influences treatment and prognosis.
Imaging is frequently used in patients with Achilles tendon symptoms. X-rays, ultrasounds and MRIs play a prominent role. Furthermore, imaging can have negative effects through radiation risks, misinterpretation by healthcare providers (leading to unnecessary additional imaging and interventions) while having negative consequences on patients (confusion). , catastrophizing, fear with avoidance of movement and low expectations of recovery). The additional value and potential negative consequences that the use of imaging has for healthcare providers and patients is important.
The initial treatment of Achilles tendinopathy is non-surgical.
If nonsurgical treatment fails, surgical intervention should be considered. In current clinical practice, therapeutic options are often variable and suboptimal. There are also no clear guidelines on load management during sports.
Achilles tendinopathy appears to have a poor long-term prognosis. In clinical practice, it is desirable to be able to predict which patient recovers and who will continue to experience chronic symptoms, for which it is important to know the prognostic factors. Finally, it is also important to prevent the recurrence of symptoms. Treatment should be done according to guidelines and evidence.
The objectives of this guide include: risk factors, diagnosis, imaging, treatment, prognosis and prevention of Achilles tendinopathy. The guide provides guidance on how to manage diagnostic and treatment issues in both primary and secondary care.
The conclusions in this guide indicate the level of evidence. The recommendations are aimed at optimal care and are based on the results of scientific research and the considerations of the working group that participated in the development of the guide, in which the patient’s perspective plays an important role.
Ultimately, this should lead to the overall goal, which is to reduce pain and improve function and activity level, optimizing care. Initially, efforts were made to work with 4 subcategories of Achilles tendinopathy, mostly based on recent scientific reports. The location and duration of Achilles tendinopathy played a prominent role in this subclassification.
- It is called reactive tendinopathy when the duration of symptoms is <6 weeks.
- The term chronic tendinopathy is used for conditions that last ≥3 months.
During the development process, the paucity of scientific publications on Achilles tendinopathy and the inconsistency of definitions of reactive Achilles tendinopathy became clear. The working group also disagreed on the definition, so it was decided not to subclassify based on the duration of symptoms. Subclassification based on the location of the condition was maintained in the guideline.
Insertional tendinopathy was defined as the presentation of symptoms located no more than 2 cm from the insertion of the Achilles tendon into the calcaneus. This tendinopathy can occur at the level of the calcaneus (Haglund morphology) and/or as retrocalcaneal bursitis. It was called midportion tendinopathy when it is located more than 2 cm above the tendon insertion and, according to current consensus, this refers to an isolated tendinopathy of the middle part of the Achilles tendon. The distinction between these two subclassifications is justified, because there appears to be a difference in prognosis in patients undergoing non-surgical treatment.
In contrast to the 2007 Dutch guideline, this guideline included both active and sedentary patients. It also includes patients with an identified cause of tendinopathy, for example, enthesitis due to rheumatic disease or xanthoma of the tendon, resulting from hypercholesterolemia. However, the main clinical issues in the guideline will not be covered specifically for these rare patient groups.
This guide is not intended for patients <18 years of age. Achilles tendon symptoms in <18 years of age are usually caused by extra-articular osteochondroses (Morbus Sever or Sever’s disease).
The current clinical difficulties and the measurement of the main outcomes have been identified in collaboration with patients with a confirmed diagnosis of Achilles tendinopathy. Initially, a panel of patients (n = 9) was formed, and information was collected on what difficulties they had experienced in practice.
In this analysis, 6 practical problems were prioritized, which were developed in 6 modules:
1. There is not enough knowledge about the causes of Achilles tendinopathy and what can be done to prevent it.
2. The diagnostic criteria for Achilles tendinopathy are not sufficiently known.
3. The role of imaging in Achilles tendinopathy is unclear.
4. There is not enough knowledge about the natural course and what is the optimal treatment.
5. Lack of knowledge about long-term prognosis.
6. Lack of knowledge about preventing symptom recurrence after recovery from Achilles tendinopathy.
A national survey was then launched in collaboration with the Netherlands Patients’ Federation. (Netherlands Patient Federation). Ninety-seven patients with Achilles tendinopathy responded to this digital questionnaire. A total of 85 (88%) described their therapeutic goals. The most common goals were: participation in sports without mentioning pain status (36%), sports participation without pain (27%), functioning in activities of daily living (ADL) without pain (22%), reduction in pain without more specifications and, restoration of ADL function, without specific mention.
A similar process was undertaken at a recent international consensus meeting with the overall goal of determining key tendinopathy outcome measures for healthcare providers (n = 29) and patients with tendinopathy at different locations (n = 32). At this consensus meeting, domains related to pain level and burden and participation emerged as patient-relevant outcome measures.
Based on this patient feedback, this guideline defines the validated, disease-specific Victorian Institute of Sports Assessment-Achilles (VISA-A) score, rate of return to sport, satisfaction of the patient and subjective recovery.
The VISA-A questionnaire consists of questions covering 3 domains: pain during ADLs, during functional tests, and (sports) activities. A score of 100 is optimal and represents a fully loadable Achilles tendon without symptoms, 0 points represents a very low load capacity of the Achilles tendon, with severe symptoms. The pace of return to sports activities and subjective recovery should always be reported by the patient, without further specifying the type of scale used in the guide.
The guide contains 6 separate modules.
| Module 1 |
Risk factors and primary prevention of Achilles tendinopathy
- Reference question
Who is at higher risk of developing Achilles tendinopathy and how can it be prevented?
This question is broad and includes other questions:
1. What modifiable and non-modifiable factors increase the risk of Achilles tendinopathy?
2. Which primary prevention strategy is most effective for Achilles tendinopathy?
Problem
The onset of Achilles tendinopathy is generally related to aging and overuse . Furthermore, biomechanical and genetic factors, specific health problems, medication use, and imaging abnormalities are thought to be associated with the development of Achilles tendinopathy.
Currently there is insufficient knowledge about modifiable and non-modifiable risk factors. This is important because it can lead to (preventive) interventions. Primary prevention aims to prevent an initial episode, especially in athletes. By applying prevention in specific populations at high risk for Achilles tendinopathy, symptoms and long-term incidence could be reduced. There is not enough knowledge about the effectiveness of primary prevention strategies.
recommendations
Achilles tendinopathy of the middle and insertional portion
Inform people with a history of lower limb tendinopathy that they are about to activate or increase training load, which will also increase the risk of Achilles tendinopathy. > Gradual training, taking into account the type, frequency, size and intensity of training. > Calf muscle strengthening exercises > Wear enough warm clothing during winter training. In the context of the importance of preventing Achilles tendinopathy, advise people to avoid the use of fluoroquinolones if alternative antibiotics are available and the clinical picture allows. |
| Module 2 |
Diagnosis of Achilles tendinopathy
Reference question
How is Achilles tendinopathy diagnosed?
This question includes the following two questions:
1. What are the criteria for diagnosing Achilles tendinopathy?
2. What are the differential diagnoses of posterior ankle pain to consider and what underlying pathology might be related to Achilles tendinopathy?
Problem
Achilles tendinopathy is often diagnosed on the basis of clinical findings, with differential diagnoses taking into account pain suggestive of Achilles tendinopathy. Images can help
recommendations
Achilles tendinopathy of the middle and insertional portion.
Diagnose midportion Achilles tendinopathy based on the presence of all of the following findings: 1. Symptoms located 2-7 cm proximal to the tendon insertion. 2. Painful middle portion of the Achilles tendon during loading (sports). 3. Local thickening of the middle portion of the Achilles tendon (this may be absent in cases with short-term symptoms). 4. Pain on local palpation of the middle portion of the tendon. Diagnose Achilles tendon insertion tendinopathy based on the presence of all of the following findings: 1. . Symptoms located in the region of tendon insertion (2 cm from the insertion of the Achilles tendon). 2. Region of the insertion of the Achilles tendon painful with loading (sports). 3. Local thickening of the Achilles tendon insertion (this may be absent in cases with short-term symptoms). 4. Pain on local palpation of the insertion of the Achilles tendon. No additional imaging studies are needed if the case presents all 4 diagnostic criteria. Consider additional imaging (calcaneal X-ray, Achilles tendon ultrasound, or ankle MRI) if: > The symptoms do not fit the 4 diagnostic criteria. > The symptoms match the 4 diagnostic criteria, but the evolution is unexpected or the symptoms change during follow-up. > Surgery is being considered. Refer to a sports doctor or orthopedic surgeon if: > Diagnostic doubt persists. > There is an unexpected course or change of symptoms during follow-up. Refer to a rheumatologist if: > There is insertional tendinopathy of the Achilles tendon or a diagnosis of spondylarthritis or suspicion of this condition (chronic low back pain that started before age 45 or psoriasis). Refer to a general practitioner if: > In the presence of mid-portion Achilles tendinopathy, proven or suspected familial hypercholesterolemia, cardiovascular diseases in those under 60 years of age and/or presence of a lipoid arch before the age of 45. In patients with a clinical diagnosis of Achilles tendinopathy, consider the underlying causes and associated pathologies. |
| Module 3 |
Achilles tendinopathy images.
Reference question
What is the role of imaging in Achilles tendinopathy?
Problem
The diagnosis of Achilles tendinopathy can be made based on clinical data. Additional imaging may be used if the diagnosis is uncertain, or if the course is unexpected or symptoms change during preoperative studies. There are several imaging modalities that are used by different health professionals. Currently, there is no adequate way to recommend one image over another.
recommendations
Midportion Achilles tendinopathy
If images are necessary, consider the following modalities: > Ultrasound: it is the imaging modality of choice. > MRI if: –– Ultrasound is not available. –– There is a discrepancy between the ultrasound results and the clinical findings. –– An additional specific diagnosis is expected that cannot be detected by ultrasound. –– Surgery is being considered. |
Achilles tendon insertion tendinopathy
If images are deemed necessary, consider the following modalities: > Ultrasound: it is the imaging modality of choice > Profile radiography of the calcaneus to exclude bone abnormalities. > MRI if: –– Ultrasound is not available. –– There is a discrepancy between ultrasound results and clinical findings. –– An additional specific diagnosis is expected that cannot be detected by ultrasound. –– Surgery is being considered. |
Problem
There are several imaging techniques used in Achilles tendinopathy. Some are carried out by different health service providers. There is insufficient knowledge of what qualifications are needed to apply, evaluate, and communicate the results of an imaging modality to a patient with Achilles tendinopathy.
recommendations
Achilles tendinopathy of the middle portion.
Ensure that the performance and evaluation of additional imaging studies are performed by highly qualified professionals. When indicating images, take into account the following competencies: > The professional who refers to obtain images (or perform them) is capable of critically considering the added value of the imaging technique. The use of the technique must be clinically important to the patient. > The professional who performs and evaluates the imaging must have sufficient information and experience, the product of continuing medical training and education. > The professional who communicates the imaging results must have sufficient knowledge of the clinical picture and the relationship between the imaging results and the outcome in Achilles tendinopathy. |
What are the characteristic findings of Achilles tendinopathy?
Problem
Multiple imaging findings have been described that may be present in Achilles tendinopathy. However, it is unknown which are the most common signs compared to an asymptomatic population. Currently there is a lack of diagnostic criteria for obtaining images.
recommendations
Midportion Achilles tendinopathy
When an ultrasound or MRI is indicated in a patient with a clinical diagnosis of Achilles tendinopathy, the following parameters should be reported at a minimum: > Increase in the thickness of the Achilles tendon (anteroposterior diameter). > Altered structure of the Achilles tendon (altered echogenicity on ultrasound and altered signal intensity on MRI). > Presence of vascularization parameters (peritendinous or intratendinous). |
Insertional Achilles tendinopathy
For X-rays of the calcaneus in clinically diagnosed insertional Achilles tendinopathy, report the following characteristics at a minimum: > Calcifications located at the insertion of the Achilles tendon. When using ultrasound or MRI in clinically diagnosed insertional Achilles tendinopathy, report the following parameters at a minimum: > Increase in the thickness of the Achilles tendon (anteroposterior diameter). > Altered structure of the Achilles tendon (altered echogenicity on ultrasound and altered signal intensity on MRI). > Presence of vascularization parameters (peritendinous or intratendinous). |
Prognostic factors
What imaging findings have prognostic value in Achilles tendinopathy?
Problem
Whether imaging findings have prognostic value is unknown and is important to consider.
recommendations
Do not perform imaging in both medial and insertional Achilles tendinopathy. Inform the patient of the reason.
| Module 4 |
Achilles tendinopathy treatment
Reference question
What is the effectiveness of current treatments?
This question includes the following six submodules
1. What measurement instruments are most appropriate for monitoring a treatment effect?
2. What is the effect of the wait and see policy ?
3. Which non-surgical treatment is most effective?
4. Is non-surgical treatment more effective than surgical treatment?
5. What factors influence the effects of treatment?
6. What advice (self-management and patient education) to provide to the patient regarding lifestyle, work, and sports?
Measurement tools
What measuring instruments are most suitable for monitoring? therapeutic?
Problem
There are many possible outcome measures to evaluate Achilles tendinopathy, making it very difficult to compare the results of different therapeutic modalities. Therefore, it is important to have consensus on the outcome measures to be used. Outcome measures should be considered relevant to both patients and professionals, and also to encompass a ’core outcome set’.
recommendations
Achilles tendinopathy of the middle and insertional portion
Consider using the VISA-A questionnaire to evaluate the course of Achilles tendinopathy. Do not order imaging to monitor response to treatment and/or predict the course of tendinopathy symptoms. |
Wait and see policy
What is the effect of wait and see on Achilles tendinopathy?
Problem
Initial advice is usually to adjust or temporarily stop the (sports) load that likely caused the injury, and wait and see. Little is known about the natural course of Achilles tendinopathy, so it is difficult to answer the question about wait and see.
recommendations
Inform patients with chronic mid- and insertional Achilles tendinopathy that applying the wait-and-see policy will not provide short-term improvement, or that the improvement will be limited.
Non-surgical treatment options
What non-surgical treatment is most effective?
Problem
Non-surgical treatments are usually the first option and can be divided into several categories. Its effectiveness can be evaluated using different control groups. For this reason, the following categories of procedures were defined: wait-and-see policy, placebo treatment, exercises, orthoses, shock wave therapy, medication, acupuncture, injections and multimodal treatments.
The national survey of patients showed that the majority receive multiple treatments from these categories. This translates into significant healthcare consumption, mainly due to the lack of knowledge about the comparative effectiveness of the different therapeutic options.
recommendations
Achilles tendinopathy of the middle and insertional portion
Advise active treatment. Treatment must be done by a professional who is sufficiently qualified (medical or paramedical care). Discuss initial therapeutic options with the patient, regarding: > Advice: 1. Explanation about the condition. 2. Explanation about the forecast. 3. Education about pain and treatment of psychological factors. > Tips on charging: 1. Temporary cessation of (sports) activities that cause pain. 2. Temporary replacement of provocative (sports) or non-provocative activities ((non-sports activities). 3. Gradual increase in the load of (sports) activities. 4. Use a pain scale to monitor the level of complaints related to (sports) activities and adjust them based on the pain scale. Indicate progressive exercises to strengthen the calf muscles for at least 12 weeks, which must be adapted to each patient. Consider the role of: motivation, time constraints, pain monitoring and availability of facilities and resources. For insertional Achilles tendinopathy, the initial exercises should be done on a flat surface. If after 3 months of patient education, temporary structural exercises, and following loading advice, there is still no improvement, discuss other therapeutic options. Discuss concerns about the additional effect as well as the advantages and disadvantages of any additional treatment. If patient education and loading advice are ineffective, consider the following options, in addition to continuing exercise: > Extracorporeal shock waves. > Tips on combining the load together with continuation of the exercises: > Extracorporeal shock waves. > Other passive modalities (night splint, inlays, collagen supplements, application of ultrasound and friction massages, laser therapy and phototherapy). > Injections (with polidocanol, lidocaine, autologous blood, plasma enriched with platelets, stromal vascular fraction, hyaluronic acid, prolotherapy or high volume injection) and, acupuncture (or intratendinous puncture). Caution with the following additional therapeutic options: > Non-steroidal anti-inflammatories > Corticosteroids. |
Surgical treatment options
Is surgery more effective than non-surgical treatment?
Problem
When nonsurgical treatment is unsuccessful, consider surgery, with the goal of reducing symptoms, which can be achieved by removing fibrotic adhesions, excising degenerative nodules, and/or making longitudinal incisions to induce a recovery response in the extracellular matrix. Little is known about the comparative effectiveness between both types of treatment.
recommendations
Achilles tendinopathy of the middle and insertional portion.
| Consider surgery only in patients who do not recover after at least 6 months of active treatment. |
What factors affect the effectiveness of treatment
Problem
With the emergence of so-called "Big Data" , personalized attention becomes important. This information can be obtained from electronic medical records, DNA profiles and eHealth applications in the field of Achilles tendinopathy, but not much is known about the factors that influence the treatment effect or prognosis. Consider surgery only in patients who do not recover after at least 6 months of active treatment. Discuss the expected effectiveness of surgical intervention compared to non-surgical treatment and the risk of surgical complications.
recommendations
Achilles tendinopathy of the middle and insertional portion.
| Evaluate the specific characteristics of the patient (activity level and presence of comorbidities) to personalize treatment, but without using this information to make a prognosis. Share with the patient the decision about the best therapeutic option. |
Advice on lifestyle and workload and sports
Problem
Patients with Achilles tendinopathy often report pain and are not able to exercise without pain. Patients usually ask about the expected nature and course, and how they can contribute positively or negatively to recovery. Differing opinions from healthcare providers often create confusion and uncertainty for patients. To avoid this, it is important that professionals have sufficient knowledge to correctly instruct patients about lifestyle and workload and sports, for a better recovery.
| Module 5 |
Long-Term Prognosis of Achilles Tendinopathy
Reference question
What is the long-term prognosis for people with Achilles tendinopathy?
This question includes the following 3 questions
1. What percentage of patients with Achilles tendinopathy have persistent symptoms for more than 1 year?
2. What percentage of patients with Achilles tendinopathy return to their original athletic level for more than 1 year?
3. What factors affect the long-term prognosis (more than 1 year).
Problem
Achilles tendinopathy treatment is not always successful. Recovery can be slow and take months or years.
There is insufficient knowledge about the exact prognosis. This applies to both the intensity of the symptoms and the possibility of returning to a desired sporting level, without pain. Knowledge about prognosis is important to provide the patient with realistic expectations, taking into account prognostic factors.
recommendations
Achilles tendinopathy of the middle and insertional portion.
• Inform patients of the long-term consequences of Achilles tendinopathy. • Most patients recover, but there is a possibility that symptoms may persist long term (at least up to 10 years; 23-37% of patients have persistent symptoms, despite treatment). • Most athletes with this tendinopathy return to sports (85%). It is unknown if they do so with the original performance and if they do so completely asymptomatic. • Report the inability to make a prognosis, since the long-term prognostic factors are unknown. |
| Module 6 |
Preventing Achilles Tendinopathy Recurrence
Reference question
How to prevent recurrent symptoms in patients who have recovered from Achilles tendinopathy?
Problem
Since a history of lower extremity tendinopathy is the best-known risk factor for Achilles tendinopathy, recurrence of symptoms is possible. Little is known about the effectiveness of targeted prevention strategies.
recommendations
Achilles tendinopathy of the middle and insertional portion
Discuss the need to dedicate sufficient time to active treatment before starting provocative (sports) loading. As a rule, a return to complete freedom from symptoms (sports) is only possible after a few months of active treatment, at least. Returning to sports within a few days is associated with a greater likelihood of recurrence. Discuss with the patient the pace of return to sports. Ensure a gradual build-up of (sports) load after recovery or after a longer period of relative inactivity. Continue calf muscle exercises after symptomatic recovery. |
