Troublesome Tendinopathy!
The Case
A 54-year-old healthy female presents for posterior left ankle pain. Pain has been present for the past 1 month and is exacerbated by walking. She notes a stiff, 6/10 pain with an occasional "catching" sensation while ambulating, but denies any "pop" or prior trauma. She has tried scheduled ibuprofen without relief. She is particularly concerned because she "hasn't been able to run for weeks" and was hoping there would be a better solution. She notes mild swelling around the left ankle compared to the right, but no erythema or warmth. Denies any history of fevers. She is not experiencing numbness or weakness. No history of recent travel.
Physical exam demonstrates:
· Mild tenderness to palpation over the Achilles tendon with mild posterior edema
· Normal left calf and negative Thompson test
· Nontender medial and lateral malleoli and left foot exam is normal
· She has a normal gait but reports pain with weight-bearing
Plain radiographs of the left ankle are normal.
The “Lingo”
While frequently interchanged, there are important distinctions in terminology that may help guide treatment.
Tendonitis: Like many other terms ending in -itis, indicates acute inflammation of a tendon, and is frequently misused!
Tendinosis: Clinical term for the underlying structural degenerative changes which incite chronic changes in a tendon (Maffulli 1998).
Tendinopathy: Accurate terminology! Better represents the true nature of the histopathologic changes seen on examination of tendon biopsies. The tissue demonstrates chronic scarring and failure to heal, rather than acute inflammatory changes. Results from an overuse injury following repeated microtrauma.
The Look
Physical exam reveals pain to palpation over the tendon. Mild to moderate swelling may be associated. The tendon may feel thickened to palpation.
Histologic evidence suggests that this is not a primary inflammatory condition, but there may be neurogenic upregulation present which can account for the pain response in chronic tendinosis.
The Cause
Commonly considered to be an overuse injury, associated with repeated microtrauma causing small tears and scarring from poor repair.
However, some debate of causation remains:
In a literature review of Achilles tendinopathy (Kvist 1991), the etiology across several studies was examined, in which there appeared to be a strong association with running, although subsequent studies did not demonstrate a direct causation.
The well-established risk of tendon rupture associated with fluoroquinolone antibiotics also correlates with an increased risk of developing tendinopathy.
The Imaging
Plain radiographs have little benefit in examining tendinosis but may be considered to exclude underlying bony abnormalities.
Both US and MRI are reasonable imaging alternatives and have demonstrated modest accuracy in predicting clinical outcome. However, US has a high false positive rate due to high sensitivity and it is operator-dependent, while MRI also lacks perfect sensitivity and specificity and can fail to correlate with clinical symptoms and surgical biopsy results.
Either imaging result should be evaluated in the context of the clinical picture. Ultimately, tendinosis is a clinical diagnosis.
The Fix
NSAIDs:
While frequently prescribed for treatment, tendinosis is not a primary inflammatory condition and, therefore, may have a low response rate. In the setting of acute pain however, NSAIDs can be helpful.
Eccentric Training:
Maximal response has thus far been demonstrated with eccentric training versus concentric training (Kader 2002).
Examples of eccentric training include calf stretch and heel drop exercises
Night splints may also be a helpful adjunct to eccentric training. (Alfredson 2007)
Corticosteroids:
Controversial therapy as several studies cite an incidence of decreased pain in the acute setting with injections, but no long term benefits and there is a theoretical risk of tendon rupture based upon case studies and animal models.
Alternative Therapies:
Other therapies include topical glyceryl trinitrate, dry needling, shock wave therapy, and acupuncture, although these interventions have an unclear effectiveness (Khan 2015).
Surgical Intervention:
If conservative measures fail after 6 months, then surgical intervention may be considered.
Summary of ED Management of Tendinopathy
It is important to rule out tendon rupture or underlying bony abnormality which may require orthopedic consultation.
Consider ultrasound to look for tendon thickening or hypoechoic areas which may support a diagnosis of tendinosis. However, outpatient MRI is a more widely used imaging modality.
Focus on analgesia and activity modification; avoid prescribing long-term NSAIDs for chronic tendinosis.
Refer patients to physical therapy for an eccentric training program which appears to have the best evidence for long-term improvement and reversal of underlying pathology.
Faculty Reviewer: Dr. Feden
References:
Alfredson, H., & Cook, J., (2007, April). A treatment algorithm for managing Achilles tendinopathy: New treatment options. Retrieved November 23, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658946/
Alfredson, H., Thorsen, K., & Lorentzon, R. (1999). In situ microdialysis in tendon tissue: High levels of glutamate, but not prostaglandin E2 in chronic Achilles tendon pain. Retrieved November 23, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/10639657
Astrom, M., & Westlin, N. (1992, December). No effect of piroxicam on achilles tendinopathy. A randomized study of 70 patients. Retrieved November 23, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/1471511
Kader, D., Saxena, A., Movin, T., & Maffulli, N. (2002). Achilles tendinopathy: Some aspects of basic science and clinical management. Retrieved November 23, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724537/pdf/v036p00239.pdf
Khan, K., & Scott, A., (2015, May 11). Overview of overuse (chronic) tendinopathy. RetrievedNovember 23, 2015, from http://www.uptodate.com/contents/overview-of-overuse-chronic-tendinopathy?source=search_result
Kvist, M. (1991). Achilles tendon injuries in athletes. Retrieved November 23, 2015, from http://www.ncbi.nlm.nih.gov/pubmed?term=1897886&holding=riurihlib_fft&myncbishare=lifespan
Maffulli, N., Khan, K., & Puddu, G. (1998, November/December). Overuse tendon conditions: Time to change a confusing terminology. Retrieved November 23, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/9848596
Paavola, M., Paakkala, T., Kannus, P., & Jarvinen, M. (2000, November). Long-term prognosis of patients with achilles tendinopathy. An observational 8-year follow-up study. Retrieved March 23, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/11032217
Rolf, C., & Movin, T. (1997, September). Etiology, histopathology, and outcome of surgery in achillodynia. Retrieved November 23, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/9310767