From the Guidelines
The treatment algorithm for severe Achilles tendinosis identified on MRI should begin with a 3-6 month trial of conservative management before considering surgical intervention. Initial treatment includes relative rest with activity modification to avoid painful activities, particularly those involving repetitive loading. Physical therapy focusing on eccentric strengthening exercises (such as heel drops performed 3 sets of 15 repetitions twice daily for 12 weeks) forms the cornerstone of treatment, as supported by the evidence from 1, which states that eccentric strengthening is an effective treatment of tendinopathy and may reverse degenerative changes. Pain management can include NSAIDs like naproxen 500mg twice daily or ibuprofen 600mg three times daily for 1-2 weeks to control inflammation, as recommended by 1. Orthotic devices such as heel lifts (12-15mm) can reduce tendon strain, as suggested by 1. For persistent cases, extracorporeal shockwave therapy (ESWT) administered weekly for 3-5 sessions may be beneficial, as indicated by 1, which states that ESWT appears to be a safe, noninvasive, effective but expensive means of pain relief for a number of chronic tendinopathies. Ultrasound-guided injections may be considered, with platelet-rich plasma (PRP) showing better outcomes than corticosteroids, which carry a risk of tendon rupture. If conservative measures fail after 6 months, surgical options include minimally invasive techniques like percutaneous tenotomy or open procedures such as debridement with or without augmentation, as suggested by 1, which states that surgery is an effective option in carefully selected patients who have failed three to six months of conservative therapy.
Some key points to consider in the treatment of severe Achilles tendinosis include:
- The importance of relative rest and reduced activity to prevent further damage and promote healing and pain relief, as recommended by 1
- The use of eccentric strengthening exercises to promote collagen remodeling and reverse degenerative changes, as supported by the evidence from 1
- The potential benefits of orthotic devices, such as heel lifts, in reducing tendon strain, as suggested by 1
- The consideration of ESWT and ultrasound-guided injections for persistent cases, as indicated by 1
- The role of surgical options, such as percutaneous tenotomy or open procedures, for patients who have failed conservative therapy, as suggested by 1.
It's worth noting that the most recent and highest quality study, 1, provides guidelines on offloading foot ulcers in persons with diabetes, but does not directly address the treatment of severe Achilles tendinosis. However, the principles of offloading and reducing pressure on the affected area may still be applicable in the treatment of Achilles tendinosis. Overall, the treatment of severe Achilles tendinosis should prioritize a stepwise approach, beginning with conservative management and progressing to surgical options only if necessary, with the goal of minimizing morbidity, mortality, and improving quality of life.
From the Research
Treatment Algorithm for Severe Achilles Tendinosis
The treatment algorithm for severe Achilles tendinosis as diagnosed by Magnetic Resonance Imaging (MRI) involves a range of conservative and surgical options.
- The initial treatment approach typically involves conservative management, including eccentric exercises, shock wave therapy, and nitric oxide patches 2, 3.
- If symptoms do not improve with conservative treatment, peritendinous injections may be considered as an alternative option 2.
- Surgical intervention is usually required after six months of conservative treatment, especially for patients with severe tendinosis or those who have not responded to non-operative treatment 2, 4.
- The decision to proceed with surgical intervention may be guided by MRI findings, with patients having confluent areas of intrasubstance signal changes on MRI (types II and III) being less likely to respond to non-operative treatment 4.
- Recent research emphasizes the need for individualized treatment plans that address the multifaceted nature of Achilles tendinosis, combining biomechanical analysis, advanced imaging, and patient-specific factors to achieve optimal outcomes 2.
Role of MRI in Treatment Algorithm
MRI plays a crucial role in the treatment algorithm for severe Achilles tendinosis, as it can help identify patients who are unlikely to respond to non-operative treatment and may require early surgical intervention.
- MRI can be used to classify the severity of tendinosis, with types II and III tendons being more likely to require surgical intervention 4.
- MRI can also be used to monitor the morphological response to treatment interventions, including the regression of intratendinous signal abnormalities and changes in tendon volume and mean intratendinous signal 5.
- The use of MRI techniques, such as gadolinium contrast medium-enhanced T1-WI images and dynamically enhanced MRI signal, can provide valuable information on the severity of tendon changes and the effectiveness of treatment interventions 5.