Review Question - QID 214139

The first-line treatment of Achilles tendinopathy is eccentric strengthening exercises.

Achilles tendinopathy is inflammation and thickening of the Achilles tendon that most commonly occurs in middle-aged men. It results from the poor blood supply 2-6cm from its insertion and repetitive micro-tears of the tendon. Patients will often have a thickening of their Achilles tendons on examination and symptoms will be worse with activity, specifically running. MRI will show intrasubstance intermediate signal intensity. Treatment is initially with eccentric strengthening exercises. If this fails, operative treatment includes open excision of degenerative tissue with tendon tubularization and FHL tendon transfer if >50% of the tendon is excised.

Reddy et al reviewed chronic disorders of the Achilles tendon. They recommend the use of ultrasound and MRI for the evaluation of the tendon. A thorough discussion of paratenonitis, tendinosis, paratenonitis with tendinosis, retrocalcaneal bursitis, and insertional tendinosis. Initial treatment for Achilles tendonitis is physical therapy. If this fails they recommend surgical debridement of the degenerated tissue with a possible FHL tendon transfer.

Magnussen, Dunn, and Thomson performed a systematic review of RCTs on the nonoperative treatment of Achilles tendinopathy. They found that eccentric exercises have the most evidence in the treatment of midportion Achilles tendinopathy. Other nonoperative treatment modalities with less evidence of efficacy included extracorporeal shockwave therapy, concentric exercises, and night splints.

Illustration A demonstrates a sagittal T2 MRI of the ankle with fusiform swelling of the Achilles tendon with intrasubstance intermediate signal intensity consistent with Achilles tendinopathy.

Incorrect answers:
Answer 1: Baxter's nerve compression is initially treated with stretching, physical therapy, and anti-inflammatory medications.
Answer 2: Calcaneal stress fractures are often first treated with nonweightbearing and activity modification.
Answer 4: Tears of the ATFL are initially treated with physical therapy and proprioceptive training
Answer 5: Syndemotic sprains are treated with nonweightbearing in a cast or CAM boot until pain-free.