Foot and Ankle- Achilles Tendinopathy and Associated Conditions Flashcards
What is the prevalence of Achilles tendinopathy?
- MOST frequently reported overuse injury
What population is Achilles tendinopathy MOST common in?
- recreational/competitive activities
- training> competition
- 30-50 year olds
What percentage of runners end up with Achilles tendinopathy?
~10-20%
What are risk factors/etiologies for Achilles tendinopathy?
- Limited calf flexibility that may lead to tendinopathy origins
- calf weakness that may lead to overuse/ under supply
- biological males and family hx
- excessive EV/pronation
- Abnormal tendon structure / prior injury
- older age
- obesity
- systemic dz with persistent inflammation and poor blood supply
Why can excessive EV / pronation lead to Achilles tendinopathy?
- may lead to tendipathy origins due to achilles attaching more to medial portion of calcaneus
- Overuse may occur with impaired LQ control
What can impaired LQ control with excessive EV / pronation lead to?
- hip neuromuscular deficits
- balance deficits
What is excessive pronation?
- earlier, extended and/or excessive combination of DF, EV and abduction
How can pronation become excessive if hypermobility/instability is present?
More commonly:
- tibfib or talocrural hypermobility/instability
- impaired LQ control, top-down influence
Less commonly
- subtalar or medial knee hypermobility
How can pronation become excessive if adjacent joint hypomobility is present?
- limited talocrural DF may lead to midfoot and forefoot excessively EV and abd
- limited knee ext may lead to excessive ankle DF
- HIP WONT COMPENSATE, hip is IR when knee and talus both ER at heel/toe off
What can excessive pronation be associated with in the foot? leg and ankle? Knee and hip?
LQ conditions
- Foot: plantar fascitiis, tarsal tunnel, Morton’s, OA, hallux valgus
- Leg and ankle: Achilles tendinopathy, Sever’s, MTSS
- knee and hip: see prior notes
Why is older age a risk factor for Achilles tendinopathy?
more plastic, less elastic = more tension (tendinopathy origins)
What else should we consider when thinking about the etiology of Achilles tendinopathy?
- training errors
- environmental factors
- improper shoes
Why is obesity a risk factor for Achilles tendinopathy?
- OVERUSE, increased demand due to excess weight
What is an example of a systemic disease with persistent inflammation and poor blood supply that can contribute to Achilles tendinopathy?
- DIABETES
What structure is involved with Achilles tendinopathy?
Achilles tendon
What are the pathomechanics of Achilles tendinopathy?
- repetitive lengthening with compression from limited DF and/or excessive EV
- Collagen fibril thinning/disorganization and fibroblast death
- Thickened tendon
- Ineffective force transfer
- Impaired motor control
What can cause the non-collagen matrix to fill in with Achilles tendinopathy?
- altered fluid movement leads to overheating
- Increased nitric acid with persistent inflammation
CELLULAR CHANGES
What can cause the tendon to thicken yet weaken with Achilles tendinopathy?
- increase of non-collagen matrix
- fat deposition
What are some functional questionnaires for Achilles tendinopathy?
- Victorian Institute of Sport Assessment
- Foot and Ankle Ability Measure
- LEFS
What are symptoms of Achilles tendinopathy?
- Gradual onset that limits WBing activity
- Localized pain and stiffness
When does the localized pain and stiffness occur with Achilles tendinopathy?
- Particularly after inactivity
- Lessens with mild bout of activity
- Increase with moderate to severe activity
What are signs we will find in observation of Achilles tendinopathy?
- Achilles thickening
- possible impaired LQ control and/or excessive pronation
What will we find with ROM with Achilles tendinopathy?
- Possible pain and limitation with DF
What will we find with resisted/MMT with Achilles tendinopathy?
- possible pain with PF, may be weak
- possible hip and knee weakness
What will we find in accessory motion with Achilles tendinopathy?
- possible talar hypomobility for DF
What are some special tests for Achilles tendinopathy?
- Arc sign (high spec)
- Royal london test (high spec)
- Single leg heel raise
- Single leg hip
- Muscle length (gastroc)
What does the single leg heel raise help us determine with Achilles tendinopathy?
- On a flat surface vs. incline - Plantaris and insertional injury if more pain on incline
- For PF endurance: less reps vs. uninvolved side
What are we looking for with the single leg hop test for Achilles tendinopathy?
- less reps or pain vs. uninvolved side
What muscle length are we concerned about with Achilles tendinopathy?
shortened gastrocs
What are signs with palpation with Achilles tendinopathy?
- TTP 2-6 cm proximal to insertion; area of less blood supply
- Achilles crepitis
What does it indicate if the more medial Achilles is painful with palpation?
- the plantaris is involved
What is NOT indicated for Achilles tendinopathy?
REST
What is the BEST pt ed for Achilles tendinopathy?
- Optimal stress is BEST within appropriate pain levels, which is mild pain during and up to 24 hours after
What other topics should we educate the patient on with Achilles tendinopathy?
- weight management
- shoe wear
- timeline
What is the timeline/prognosis with Achilles tendinopathy?
- ~80% improvement within 8-12 weeks once right treatment begins, doesnt include “calming it down”
What modality is useful for pain and function with Achilles tendinopathy?
- IONTO with dexamethasone
What should we know about LASER for Achilles tendinopathy?
- contradictory evidence
What should we know about shockwave therapy for Achilles tendinopathy?
- support for more pain relief with ADLs when added to 4 weeks of exercise
- NO indication on structure changes or return to sport
What should we know about bracing for Achilles tendinopathy?
- neoprene sleeves on involved muscles are anecdotal
- night splint - NOT beneficial and NO support, stretches the tendon and repeats causative stress
What should we know about taping along the tendon with Achilles tendinopathy?
- taping, including kinesiotape, along the tendon to reduce pain is anecdotal and conflicting
What should we know about arch taping and foot orthotics for Achilles tendinopathy?
limited evidence
- arch taping may help predict orthotic benefit
- shock absorbing orthotic decreased rate of injury
What should we know about a heel lift for Achilles tendinopathy?
- mixed support
- BOTH SHOES
What should we know about dry needling for Achilles tendinopathy?
- helpful for pain when ADDED to exercise, but questionable otherwise
What should we know about STM for Achilles tendinopathy?
- MOSLY anecdotal
- ASTYM helpful for motion when ADDED to exercise
What should we know about gentle stretching for Achilles tendinopathy?
- Weak but some recent support on pain
- May be contraindicated due to higher tension / compression on tendon
What are JMs used for with Achilles tendinopathy?
- mobility and function
What are the primary purposes with MET for Achilles tendinopathy?
tendon proliferation and stabilization (hip and lumbar)
What is the MET perscription for Achilles tendinopathy?
Tendinosis prescription
- Isometric loading without compression from lengthening
- Isotonic loading without compression from lengthening
- Isotonic loading with compression from lengthening
- Isometric loading in weight bearing
- Plyometric loading
What is there best evidence of with MET for Achilles tendinopathy?
varied muscle actions
- eccentrics only - Alfredson protocol ( 6-10 sec eccentrics)
- lower compliance rates with eccentric training
- heavy and slow concentric/eccentrics
- isometrics
What are the ultimate parameters for MET for Achilles tendinopathy?
3 sets of 10-15 reps
- 3 sec phases of muscle actions
- heavy load but NOT during inflammatory phase
Why would we do heel raises with the knee extended and flexed with Achilles tendinopathy?
- Extended for the gastroc
- flexed for the soleus
- want to target both
When do we progress MET resistance and activity with Achilles tendinopathy? such as?
≥ mild symptoms
- add weight in hand or with a loaded backpack
- leg press or heel raise machine
- sitting or standing heel raises
How often should we be doing the MET for Achilles tendinopathy?
- at least 2x/week and keep up 6-12 weeks
- recommended every other day
- may need more recovery time between heavy loading in a non-athletic or older patient, possibly 72 hours
- once symptoms return to normal pain levels, repeat exercises
What is the recurrence rate of Achilles tendinopathy?
- 27%
What is the success rate like with Achilles tendinopathy?
- MOSTLY normalized tendon structure and thickness
- improved mechanical properties as well as cortical function
- ~12 week recovery
~80% of those with Achilles tendinopathy are recovered in how many months?
3-5 months of progressive loading at a 5 year follow up
What are the success rates for eccentric exercises for athletes with Achilles tendinopathy?
82-100% mid-portion tendinopathy in athletes
What is the success rate for eccentric exercises for Achilles tendinopathy in sedentary individuals?
60%
What is the success rate for eccentric exercises for insertional tendinopathy?
- ≤ 32%
How many have mild pain remain with Achilles tendinopathy?
- 20-45%
What should we know about mid-portion injections with Achilles tendinopathy?
- insufficient evidence for cortisone
- emerging evidence for high volume sclerotherapy (prolotherapy)
What should we know about insertional injections for Achilles tendinopathy?
guided cortisone effective for pain and function
- alternative option for lack of success with MET
What population is a guided cortisone injection recommended for with Achilles tendinopathy?
- non-athletic population
What can also be done with Achilles tendinopathy as a MD rx?
- achilles debridement
- remove plantaris
What is another term for calcaneal apophysitis?
Sever’s disease
What is the prevalence of calcaneal apophysitis?
- 9-12 years of age
- biological males > female
What is the etiology of calcaneal apophysitis?
- growth with high activity
What is the structure involved and pathomechanics of calcaneal apophysitis?
- leg bone growth exceeds PF lengthening
- increased tendon tension
- growth plate is the weak spot as opposed to tendon in the adult
- mostly inflammation
What are complications with calcaneal apophysitis?
- avulsion and/or premature closure
what are risk factors for calcaneal apophysitis?
- long or year-round sports
- poor fitting shoes that lack heel cushion
- training errors
- shortened PFs
- foot dysfunction such as pes planus or cavus
What is the onset of calcaneal apophysitis?
- gradual onset of heel pain with overuse
- 60% bilateral
- a pop can indicate an avulsion
What are some signs with observation of calcaneal apophysitis?
- poor shoe support/cushion
- foot dysfunction such as excessive pronation or supination
- impaired LQ control
What are some signs with ROM of calcaneal apophysitis?
- limited DF leading to greater tensile forces on growth plate
What are some signs with resisted/MMT of calcaneal apophysitis?
- possibly weak and painful PFs
- weak DF
What are some special tests for calcaneal apophysitis?
- squeeze test on heel
- sever’s sign - pain with heel raise
- muscle length: shortened gastroc
What are we looking for with palpation with calcaneal apophysitis?
- TTP over “cap” of calcaneus
What pt ed should we do with calcaneal apophysitis?
- soreness rule
- load management such as active rest or rest days
- movement cues for LQ mechanics
What PT rx should we do for calcaneal apophysitis?
- pt ed
- POLICED
- “u” shaped foam upside down on achilles with ankle sleeve
- Restore DF ROM/ accessory motion
- Hamstring stetching
- Orthotics
How can we restore DF ROM and accessory motion with calcaneal apophysitis?
- JM and STM
What should we be careful with calcaneal apophysitis?
- prolonged calf stretches
Why do we do hamstring stretching with calcaneal apophysitis?
- due to fascial connections with gastroc
What orthotics are useful with calcaneal apophysitis?
- arch suport for excessive pronation
- heel lifts > arch supports
What should we know about heel lifts for calcaneal apophysitis?
- more effective at 2 months
- equally effective at 12 months
- gel heel cups with a lift work BEST
- BOTH SHOES
What is MET for with calcaneal apophysitis?
- any impaired LQ control
- caution with muscle/tendon attached to growth plate to avoid greater overuse
What is the prognosis with calcaneal apophysitis?
- 75% resolved at 1 month and 95% at 3 months
- can be a recurrent and/or persistent problem
When does the growth plate close with calcaneal apophysitis?
= around 14 years
What is the prevalence of Achilles rupture?
- MOST common in biological men ages 20-50
Where does the Achilles typically rupture?
- typically ruptures 3-4 cm proximally to the calcaneal insertion
- may or may not be associated with previous tendinopathy
What is the etiology of Achilles rupture?
- acutely and typically during a sudden eccentric activity
- gradual with tendinosis
What are symptoms of an Achilles rupture?
- sudden onset of severe pain with trauma
- sounds and feels like you’ve been shot in your calf
- significant limitations in PF and weakness, if any use
- unable to walk well if at all
What are signs of an Achilles rupture in observation?
- ecchymosis and swelling
- asymmetrical and antalgic gait at BEST, likely unable
What is a sign of an Achilles rupture in ROM?
- limited if any PF
What will we find in our resisted/MMT with Achilles rupture?
- weak and painful PF
What are some special tests for Achilles rupture?
- Matle’s (20-30 degrees PF)
- Thompson’s (insufficient research) (squeeze)
What will we find with palpation with Achilles rupture?
- gap in tendon
What is the PT rx for Achilles rupture?
- POLICED
- like Achilles tendinopathy
- follow MD protocol
What is the consensus on a protocol for Achilles rupture?
NO consensus
What should we know about early rehab vs immobilization with Achilles rupture?
- early functional rehab and WB does NOT increase re-rupture rate vs cast immobilization
What should we do with Achilles rupture patients early?
Early mobilization and WB with orthoses
At week 0-2 of Achilles rupture, what is our ROM?
none
At week 0-12 of Achilles rupture, what is our orthosis doing?
fixed at 30˚ PF
What is our WB status at 0-2 weeks with a Achilles rupture?
NWB
What is our ROM on weeks 3-6 of Achilles rupture?
- up to 30 degrees DF, free PF
What is our orthosis doing at weeks 3-6 of a Achilles rupture?
30 degrees PF, 0 DF
What is our WB status 2 weeks after a Achilles rupture?
FWB
What is our ROM limitations from week 7 on after an Achilles rupture?
-unlimited
What is our orthosis doing at week 7 after an Achilles rupture?
- NONE
What should we know about prognosis of an achilles rupture?
- Many professional athletes dont return to prior levels
- 1/3 of NBA and NFL players dont RTP at all
