Foot & Ankle
Achilles tendinopathy is a problem familiar to many runners and non-athletes alike.1 The combination of pain, tendon thickening and dysfunction is well recognised.2 The natural history is typically of a long protracted course with management, rather than treatment, focusing on physiotherapy. The exercises reduce symptoms and improve function in the majority of patients3 but 40% patients report ongoing pain even after five years of therapy.4
Many are keen to try any new treatments to attempt to resolve their problems. Requests for injections are frequently made in clinics. Anecdotes of alleviation and case series have been discussed at international meetings for the last five years, however, randomised controlled studies are still lacking. Gross5 recently presented the effectiveness of injections therapies in a systematic review and noted that only one study by de Jonge et al6 scored adequately on the Detsky methodological scale; being double blind, having sound inclusion and exclusion criteria, objective outcome measures and appropriate statistical analysis. The group from Rotterdam found no clinical or radiological appearance with ultrasound in those treated with PRP over placebo saline injections after one year when combined with eccentric loading exercises. ...
Kearney7 has recently shown no significant outcome in a pilot study of 20 patients with Achilles tendinopathy randomised to either PRP injections or an eccentric loading exercise programme. As a pilot no significant difference at six months was anticipated but VISA-A in the PRP group was 76 compared to 57.4. This has led to the development of a large multicentre study, hopefully supported by ARUK, to see if the enhancement of biological response is better than exercise therapy.
Roche and Calder8 presented an excellent review in the October issue of The Bone & Joint Journal noting the outcome of surgical management. New techniques which were considered include decompression of the seemingly insignificant plantaris tendon on the medial side of the Achilles insertion. The first series of proximal releases of the medial gastrocnemius has been reported.9 Mean VISA-A scores improved by 59% (non-insertional) vs. 22% (insertional) and mean AOFAS scores improved by 29% (non-insertional) vs. 15% (insertional). The improvement in the non-insertional group was statistically significant (P < 0.05).
Another new annotation is patient positioning for hindfoot and posterior ankle surgery. The vast majority of patients will be positioned prone for their procedures posing significant anaesthetic challenges. Anthony Sakellariou’s group have described placing patients in the recovery position.10 Being keen to try new techniques this has been tried and found it worked well. Those who are skeptical may wish to note that the time spent in the anaesthetic room was significantly reduced!
Mr Mike Carmont, Consultant Orthopaedic Surgeon, Princess Royal Hospital, Shropshire, UK
1. de Jonge S, van den Berg C, de Vos RJ, et al. Incidence of mid portion Achilles tendinopathy in the general population. Br J Sports Med 2011;45:1026-1028.
2. Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy. 1998;14:840-843.
3. Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. Am J Sports Med 2011;39:607-613.
4. van der Plas A, de Jonge S, de Vos RJ, et al. A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med 2012;46:214-218.
5. Gross CE, Hsu AR, Chahal J, Holmes GB Jr. Injectable treatments for non-insertional Achilles tendinosis: a systematic review. Foot Ankle Int 2013;34:619-628.
6. de Jonge S, de Vos RJ, Weir A, et al. One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med 2011;39:1623-1629.
7. Kearney RS, Parsons N, Costa ML. Achilles tendinopathy management: A pilot randomised controlled trial comparing platelet-richplasma injection with an eccentric loading programme. Bone Joint Res 2013;2:227-232.
8. Roche AJ, Calder JC. Achilles tendinopathy: a review of the current concepts of treatment. Bone Joint J 2013;95-B:1299-1307.
9. Gurdezi S, Kohls-Gatzoulis J, Solan MC. Results of proximal medial gastrocnemius release for Achilles tendinopathy. Foot Ankle Int 2013;34:1364-1369.
10. Gougoulias N, Dowe EJ, Sakellariou A. The recovery position for posterior surgery of the ankle and hindfoot. Bone Joint J 2013;95-B:1317-1319.