What are the treatment options for chronic mid-portion Achilles tendinopathy in a professional soccer player?

From the Guidelines

Treatment for chronic mid-portion Achilles tendinopathy in a professional soccer player should begin with a comprehensive conservative approach, including relative rest, eccentric strengthening, and pain management, before considering invasive options. The initial treatment includes relative rest with activity modification to reduce loading on the tendon while maintaining fitness through cross-training activities like swimming or cycling. A structured eccentric exercise program is essential, typically involving heel drops performed twice daily (3 sets of 15 repetitions) for 12 weeks, as supported by evidence from 1. These exercises should be done both with straight and bent knees to target different portions of the tendon.

Some key considerations in the treatment plan include:

• Relative rest and reduced activity to prevent further damage and promote healing and pain relief, as recommended by 1
• Eccentric strengthening as an effective treatment that may reverse degenerative changes, as noted in 1
• Cryotherapy for acute relief of tendinopathy pain, with repeated applications of melting ice water through a wet towel for 10-minute periods being most effective, as stated in 1
• NSAIDs for short-term pain relief, but with no effect on long-term outcomes, as indicated by 1

Physical therapy modalities such as extracorporeal shockwave therapy (ESWT), low-level laser therapy, and therapeutic ultrasound can complement the exercise program. Pain management may include NSAIDs like ibuprofen (400-600mg three times daily) for short periods, though long-term use should be avoided, as cautioned by 1. For persistent cases, peritendinous injections might be considered, with platelet-rich plasma (PRP) showing some promise, though evidence remains mixed. Proper footwear with adequate support and possibly orthotic inserts to correct biomechanical issues are important, as highlighted in 1. If conservative measures fail after 3-6 months, surgical options including minimally invasive techniques or open procedures may be necessary, as discussed in 1, though these require significant rehabilitation periods of 3-6 months before return to play. Throughout treatment, addressing contributing factors such as training errors, muscle imbalances, and flexibility deficits is crucial for preventing recurrence and ensuring successful return to professional soccer.

From the Research

Treatment Options for Chronic Mid-Portion Achilles Tendinopathy

The treatment options for chronic mid-portion Achilles tendinopathy in a professional soccer player include:

• Conservative management options such as:
  • Eccentric (lengthening) exercises 2, 3
  • Extracorporeal shockwave therapy (ESWT) 2, 3
  • Topical nitroglycerin 2
  • Low level laser therapy 2
  • Orthoses, splints or injections (e.g. corticosteroids, hyperosmolar dextrose, polidocanol, platelet-rich plasma) 2
• Surgical options, which are typically considered for a minority of patients who do not respond to conservative management 2, 3
• Denervating the Achilles tendon by release of the paratenon, which has been shown to provide pain relief in the majority of patients 4
• Platelet Rich Plasma (PRP) injections, which have shown promising results in some studies, but require further research to confirm their efficacy 5

Key Considerations

• The treatment of midportion Achilles tendinopathy should be individualized and based on the specific needs and circumstances of the patient 6, 3
• A combination of treatment modalities may be more effective than a single approach 2, 3
• The use of PRP injections is still a topic of debate, and further research is needed to fully understand their potential benefits and limitations 5