Overuse Tendinopathy: Assessment and Intervention Strategies for the Achilles Tendon
by Mark Boles, SPT
Background:
The development of this project stems from many years ago while working towards my B.S. in exercise physiology. During this time I developed great interest in the physiological changes that occur within muscles when eccentrically loaded. My interest continued to grow throughout my studies in physical therapy school as I learned the potential benefits of eccentric loading in the treatment of tendinopathy. During my clinical rotations I was fortunate to witness firsthand the benefits that I had spent numerous hours analyzing on paper. However, towards the end of one of my rotations while evaluating a patient with Achilles tendinopathy, my strong belief in the effectiveness of eccentric loading was questioned. This patient mentioned that she knew several individuals with impairments similar to hers who had immediate relief when given a corticosteroid injection. She was curious about my opinion on corticosteroid treatment and questioned why she shouldn’t just go to a physician to obtain one of these “magical” injections. Admittedly, at the time I did not have a sound answer. This encounter led me to the development of a clinical question that served as the focus of my Critically Appraised Topic (CAT):
“In adults with Achilles tendinopathy, do gastroc/soleus eccentric exercises or corticosteroid injections have better outcomes in decreasing pain?”
After the completion of my CAT I began pondering ideas for my capstone project. I knew I wanted to somehow use the research I had synthesized during the creation of my CAT, yet I felt that my clinical question was too narrow to develop into a capstone. Instead of focusing solely on eccentric exercises and corticosteroid injections, I decided to create my capstone on Achilles tendinopathy in general. Specifically, my project is intended to help current clinicians gain an in depth understanding about the causes and risk factors of this pathology, as well as the most effective treatments.
Overview:
Overuse tendinopathy is a clinical syndrome characterized by local tissue damage in the form of cellular degeneration leading to a complaint of pain, swelling, and impaired performance.4,10,11,12 The term tendinopathy is basically used clinically to encompass four different histological pathologies: tendinosis, tendinitis, paratendinitis, and paratendinitis with tendinosis.4 Tendinosis, the chronic degeneration of tendon without clinical or histological signs of inflammation, is the most common pathology of tendon conditions.12 Tendinopathy is commonly seen in runners or athletes who participate in sports that requires a lot of running, often when suddenly increasing duration, intensity or frequency of training. It is also very common in sedentary and older individuals who suddenly increase their activity level.
In exception of true tendinitis or insertional tendinopathy, both of which are relatively uncommon, all midportion Achilles tendinopathies are treated using a similar approach. Current literature suggests that eccentric loading exercises are the most effective conservative treatment for Achilles tendinopathy. Eccentric overload training results in a direct histological effect on the injured tendon that results in a reduction in stiffness and better functioning.42 However, the reasoning behind this is still unclear. Other effective treatments for overuse Achilles tendinopathy include orthotics to control excessive pronation,7,16,30 heel lift,16 triceps surae stretching,16 cross friction massage,7 iontophoresis,16 low-level laser therapy,33,34 extracorporeal shockwave therapy,19,21 a gradual return to activity,7 and correction of training errors,41 such as a forefoot strike pattern in running.
The Project:
I created a PowerPoint Presentation that I will be giving to the clinical staff at Wake Forest Baptist Medical Center’s Outpatient Orthopedics/Sports clinic during my final clinical rotation. I also created a Foot Screen that I will give to the clinical staff at this site in hopes of promoting an efficient and organized examination of patients with various foot and lower quarter pathologies. Here is a link to all of my References.
Evaluation:
I have created a brief Survey that will be given to those who attend my presentation. This survey will encompass feedback regarding both the PowerPoint presentation and the foot screen that I will be handing out.
Self-Assessment:
The development of this capstone project has been such an enriching experience. As with any project of this magnitude, my capstone project had its fair share of ups and downs. In the initial phases of creating this capstone I was unsure of what specific topic I wanted to study. Once I finally decided I wanted to research Achilles tendinopathy I quickly realized that there was going to be an enormous amount of literature for me to appraise. This aspect of the project was easily the most time consuming and the most difficult to manage concurrently with other third year requirements. My strategy for overcoming this difficulty was working ahead in other classes when I could in order to allow larger chunks of time to focus on my literature review.
I am overall pleased with the products I have created and with the learning experience I gained through this process. From eccentrics versus steroids all the way to the broad topic of Achilles tendinopathy, I feel that I have learned an incredible amount of information. Additionally, I believe that my presentation and foot screen will be beneficial to the clinicians that I present to, as well as to those who stop by and read through the information I have provided on this site.
Acknowledgements:
I would like to give a big thank you to my advisor, Mike Gross, for his input in devising an appropriate and beneficial topic. Furthermore, his passion for teaching the lower quarter in the Musculoskeletal II course was contagious and sparked my interest in the foot and ankle. I would also like to give many thanks to my committee members, Mike McMorris and Jennifer Thomas, for their guidance and invaluable feedback throughout the development of this project. I truly appreciate the time that was dedicated in helping to make this a success. Additionally, I would like to recognize and thank Prue Plummer who was instrumental in supervising and facilitating the creation of my Critically Appraised Topic throughout the Evidence-Based Practice II course.
Last but not least, thank YOU for visiting my capstone web page! Please do not hesitate to provide comments below or contact me at mark_boles@med.unc.edu if you have any questions or feedback regarding my capstone.
7 Responses to “Overuse Tendinopathy: Assessment and Intervention Strategies for the Achilles Tendon”
Mark Boles
Chris,
I’m glad you were able to find my capstone useful and I really appreciate your kind words. I can tell you took some time delving into my PowerPoint with your mention of things that I have documented in the ‘notes’ section. In attempts to keep my slides from being too wordy, I took advantage of these notes sections to give those reviewing the PowerPoint an idea of what I will be talking about and how the presentation will flow. I am especially delighted to hear that you liked the layout of the foot screen. This took probably more time than it should have for me to figure out how I wanted it to flow and how to format the document, so I am happy that you found it helpful. I encourage you or anyone else visiting my capstone site to feel free to print it out and use it in the clinic.
It has been an absolute adventure these last three years and I’m glad we made it to where we are now! I know you’ve got big goals for your career and I am certain you will turn them into realities. Never lose your work ethic and stay the course; you will do big things. I say on August 1, 2025 we take a trip to California and watch the Price Is Right live…de-bop-badeee!
High five,
– Mark
Mark Boles
Laura,
Thank you so much for you post and your compliments. I also appreciate you sharing the story about your teammate. I’m very glad she was finally able to return to running despite undergoing surgery and a long postoperative rehabilitation period. Her results were quite impressive! To answer your question: yes, this is a common surgical procedure for treatment of Achilles tendinopathy. It is hard to tell from my PowerPoint but it sounds like she had a similar surgery that I was attempting to portray. The picture on that slide depicts a tendon that is not cut so this could be misleading. I used this picture just to show healthy versus unhealthy tendon. Let me know if you think it would be beneficial to use another picture. But yes, a common surgical approach is to actually cut the tendon where it has become thickened or has developed nodules. Once cut, they remove any adhesions and degenerative substances that have formed within the tendon. This is thought to help restore vascularity to the tissue to allow healing. Also, understanding that overuse tendinopathy is not an inflammatory condition, I believe this controlled trauma to the tendon via surgery aids in restarting the normal inflammatory process to promote healing. If your teammate’s tendinopathy was an insertional issue there may have been calcific deposits or exostosis also removed. Overall, the outcomes with surgery are generally good to excellent from what I have found. There, of course, are always a proportion of people who don’t respond as well to surgery as others, but most people have good outcomes and return to full participation in sport with appropriate postoperative rehabilitation. This is especially true for younger individuals who have surgery. I, however, will always advocate that conservative treatment with a physical therapist is paramount simply because the literature demonstrates good outcomes for most people. If conservative treatment fails then surgery is a viable option.
Thanks again for checking out my capstone and for your great question! If you have any other questions don’t hesitate to ask.
Best wishes,
– Mark
Mark Boles
Andy,
This is an excellent question and one that set me up for the answer I have been waiting three years to use: “it depends!” For starters, I am having trouble creating a hypothetical situation in my mind in which a corticosteroid injection would be indicated as a first-line treatment. This is because corticosteroid injections are known to have deleterious effects on collagenous structures, causing them to become weaker than they already are. Furthermore, there is a dearth of evidence showing their worth in ‘healing’ the pathology. I think it is fair to say that corticosteroids are typically used to treat inflammation; however, one must remember that chronic overuse tendinopathy is not an inflammatory condition and there are no signs of inflammatory cells in or around the tissue. Usually corticosteroids are given in combination with an analgesic agent, and I think the analgesic often relieves the pain more than the steroid. I would like to direct you to Laura’s post on my capstone site regarding her teammate on the track team. I think it is worthwhile to point out how she did not have great outcomes with her corticosteroid injections. This was a relatively common finding in my research. Corticosteroid injections seem to be hit or miss with patients in regards to pain relief, and if they do relieve pain, research indicates that it is generally just a short-term solution. I believe this is something therapists should think about if asked our opinion of them. Now, lets say her teammate actually DID have significant or total pain relief with an injection. I am willing to bet that it wouldn’t have been very long until she was back to full participation in running. What I think often happens with this population is the athlete receives an injection, misinterprets their pain relief as the pathology being healed, and quickly begins full participation in their sport on a tendon that is still injured. Continuation of sport under these conditions is likely to lead to further injury and breakdown of the tissue structure. The reason I believe this happens more often than not is because I have heard this story in the clinic, I have heard it from numerous friends, and admittedly, I was also one of these athletes in high school who sought any way to get back on the field (you know…to play real, REAL football). But I do think there are scenarios in which it might be worthwhile to give corticosteroids a shot (see what I did there?). For example, it may be indicated for patients who are still in significant pain after attempting conservative management, such as physical therapy, and strongly oppose having surgery. Nonetheless, having an injection is something that should be the decision of the patient after they have been educated on the many side effects, the importance of not overloading the further weakened tendon, and the fact that this will likely just be a short-term fix.
Again, great question and I’m glad you asked. Looking forward to seeing you around Baptist hospital!
Cheers
– Mark
Chris Ball
Mark,
First off i want to say, Deeeeeeeee… de-bop-badeeeeee de-bop ba-de bop ba debop ba-dee…… de-bop-badeee.
Secondly, you did an excellent job with your capstone. This is a great example of presenting clinical information and promoting translatable knowledge that can be immediately tangible as to enhance everyday clinical practice within the outpatient orthopedic setting. All your efforts in developing your foot/ankle screen is very evident and I thought that your choice of list-style format will facilitate better and more efficent point of care documentation while also keeping good patient-client interaction during the assessment. Additionally, the plethora of special tests and measures to utilize along with the multitude of factors to consider which could contribute to the onset or attenuation of pathologies at the foot and ankle such as Achilles Tendonopathy can be very overwhelming especially for green therapists like yourself and I. As such, your template that also included foot/ankle osteology and lower-quarter dermatomes will ensure that my lower-quarter screen will have greater consistency as well as thoroughness for each patient I see in the future.
Proaxis physical therapy is very much involved in the treatment and rehabilitation of runners in the area so your capstone was extremely valuable in covering possible implications of Achilles injuries with rehabilitation concerning evaluation, diagnosis and treatment of achilles tendinopathy. Additionally I thought it was good you provide objective measures and outcome measures such as SLS, single limb toe raises, and highlight the decreasing size of affected tendon area as a measure of decreasing pain to justify the need of continuing rehab due to improvement with PT treatment. Some evaluative components you highlight will also be helpful in my clinical practice that included:
• Ability to recognize early tendonopaty with patient slight offloading of the affected tendon and excessive pronation and measure
• Methodology in size of affected area measurement
o TTP 2-7 cm proximal to calcaneus wish squeezing the tendon btwn thumb and index finger
• Overview of the “Arc Sign”
• Vasculatures which supply of Achilles tendon and patient consideration with LE edema, intermittent claudication or lymphedema
• Subjective questions such as “is it too bad to walk”
o How often during the day, how soon after you wakeup walk run
You note many interesting and important clinical points that are very relevant to the general outpatient orthopedic setting. These included many behaviors and maladaptive health behaviors that we should ask about or take note of in assessment and throughout the continuum of the patient-clinician interactions such as nicotine, caffeine, and obesity amongst others. These play large roles in the formation of the injury/condition as well as could be attenuating the pathology or impairing the healing response. I thought it was interesting and important you identify that the majority of those who incur Achilles tendon rupture report no prior signs or symptoms of tendonitis and that you highlighted the importance of avoiding misuse of the tendon inflammation nomenclature as to prevent underestimation of the conditions significance. In the orthopedic setting the hard headed athlete and their at times, overbearing parent are the ones we will have to make continual efforts to impart this wisdom.
With treatments along with eccentrics and RICE I’m glad that you mentioned addressing proximal weaknesses such as hip abductors and External rotators as well as modalities such as Iontophoresis w/ dexamethasone as means of treatment. Between your and Nick’s capstones I feel much more prepared to prevent, and optimally treat injury and pathology common to the foot and ankle as well as enhance overall functioning over the long-term.
Way to go buddy, I cant say how proud I am of you and I am personal wit and fortunate I feel to have been able to share this experience of PT school with you. Your going to be a great PT Mark and lastly…. Boles-Ball 4-life!
Much Love,
Chris
Mike Gross
Mark- Your capstone project is excellent. You did a great job on all 3 major components: CAT, Power Point, and the screening form. You are the expert on this topic now, having acquired a lot of good evidence on how to assess and intervene. You also came away with a very useful screening form. A pleasure to work with you on this. Best regards, Mike Gross
Laura Rapp
Mark,
It looks like you did an excellent job on your capstone!! Your PowerPoint is incredibly well-structured and easily flows from composition of the Achilles tendon and its mechanical behavior into how Achilles tendinopathy may develop and its classification and symptoms. I was particularly interested in your capstone topic because, as a track athlete in undergrad, I saw many of my teammates diagnosed with Achilles tendinopathy. One of the most memorable cases I was able to first-hand witness occurred in one of my good friends on my team. She was a long-distance runner and had dealt with Achilles pain for a little over a year. Nothing had helped get rid of her pain, from working with the athletic trainer to corticosteroid injections. Since she was one of the fastest runners on my team, the coaches were desperate to get rid of her pain, so she actually even tried the PRP injections you mentioned in your PowerPoint. Although the use of PRP rid her of pain for a month or two, it eventually came back in full force. However, she was originally from Ukraine, and so one summer she went home and had “unauthorized” surgery (that’s what they called it when someone had any sort of medical procedure without the approval of our coaching staff). In the surgery – based on what she told us upon her return to the U.S., the doctors did more than what you described as typical of Achilles tendinopathy surgery here, in that they actually CUT her Achilles in order to allow it to heal itself more fully. Although I am not certain as to whether or not they cut the full depth of the tendon all the way through, I do remember that she was on crutches for quite a while and had to sit out almost an entire year. However, when she DID finally start running again, she was pain free! She went on to finish number 3 in the nation the next year for the 10k at Division 1 NCAAs, and she went to the Olympics the year after that!
Therefore, I was just wondering if you came across extreme surgical interventions like that in your research or what your thoughts are on how that may affect the return of Achilles tendinopathy?
Again, great presentation! And to echo Andrew, your foot screen looks like a great tool for clinical staff in evaluating foot and lower quarter pathologies!
Thanks,
Laura
Andrew Newman
Hey Mark,
I think you’ve done a great job with your capstone piece, your enthusiasm and energy are very apparent and I’m glad that you at least spent much of your time producing work that you found both meaningful and interesting.
Your capstone spoke to me on a personal, as well as professional level in that when I played soccer (the real football) before I emigrated from the UK, I remember having to visit a physiotherapist for treatment of right Achilles tendinopathy. I remember being asked to eccentrically lower my heels over the edge of a step, as well as perform bosu ball/disc balance exercises. I was told that these exercises would help to ‘realign poor tissue orientation.’ I was advised to gingerly return to full sporting activities. Glad to say it worked!
On a separate note, I really liked your foot screen, it is something I have not seen in any other capstone, and I’d like to commend you on the detailed yet easy to utilize lay-out.
Seeing as though we are both at Wake Baptist Hospital for our final rotation, I look forward to listening to your PowerPoint presentation!
I have just the one question for you: based on your time in the clinic and the learning you’ve acquired in the program, do you think use of corticosteroid injection for tendinopathy is ever indicated based on the potential side effects and provision of just short-term pain relief?
Thanks,
Andy