Send letter to journal:
Re: Time to rush? Timing is a crucial issue in elite athletes suffering from Achilles tendinopathy

Dear Editor

We read with great interest the randomized-controlled trial performed by Mayer and coworkers focussing a four-week treatment interval for running athletes suffering Achilles mid-portion tendinopathy. Time is of critical importance in rehabilitation of all sport-related injuries as pointed out by the authors and we fully agree with them. Given a professional soccer player suffering mid-portion Achilles tendinopathy, he most likely will prefer the treatment options which will reduce his pain and improve his function as early as possible. A 12-week-therapeutic regimen such as proposed for eccentric training therefore has certain limitations given the time to spent in this perspective, since at the beginning one cannot be sure whether the athlete will respond or not following the three months. Surgical procedures therefore seem attractive in this perspective since a single procedure might cure the athlete with tendinopathy. Nonathletic patients with Achilles tendinopathy yield worse results following open surgery for Achilles tendinopathy than athletes [7]. In this perspective, the initial report on 11 patients (mean age 41 years) undergoing ultrasound-guided electrocoagulation of the mid-portion Achilles tendon appears very interesting with good results even at 6-months follow-up in 10 patients [3].

Sclerosing therapy as proposed by the Alfredson group from Umea is another current option in tendinopathy with reasonable results at 2-year follow-up [6]. However, since at mean three injections of polidocanol are suggested to be performed under colour Doppler-control with 6-8-week intervals in between, at least 12-16 weeks have to be calculated for this treatment option to assess the full response of a given athlete with mid-portion Achilles tendinopathy. Interestingly, some patients even respond not earlier than following 6 weeks following initial sclerosing therapy [2], a time point which is beyond the four weeks tested in the recent study by Mayer. It would be interesting to speculate, and by far better to know, how the running athletes treated with either combined physiotherapy including eccentric training, proprioceptive training and cryotherapy and deep friction massage or those with insoles will behave in the 2nd and 3rd month following therapy in contrast to the control group.

Interestingly, Alfredson reported that following polidocanol sclerosing therapy there is initially (during 1–3 weeks) an increased intratendinous vascularity, which might be a response to the colour Doppler based sclerosing therapy, which can be encountered following the first three weeks of eccentric training as well [1]. They stated: “In successfully treated patients, we have found that after both eccentric training and sclerosing injections, there is already at day 1 after instituted treatment an increased vascularity in the region with structural tendon changes and neovessels. In the majority of tendons, this increased vascularity remains during 2–3 weeks and then in the successfully treated cases, gradually decreases.”

Unfortunately given the small number of patients (n=31) in the randomized trial by Mayer, only the combined application of deep friction massages at the midsubstance of the Achilles tendon, local pulsed ultrasound (1.5W/cm2), ice application and sensory motor training with 3 sets of 15 repetitions of balance and stabilization exercises on a stability pad and eccentric exercises (loading of the calf muscles by lowering the heel standing with the forefoot on stairs, drop-jumps and counter-movement-jumps) has been tested. It would be at least in our view by far more interesting to elucidate the impact of prioprioceptive training in addition to eccentric training alone, since in the literature we could not identify such a comparison. It is worthwhile to speculate that besides its injury preventing effect proprioceptive training on balance pads might have an effect in Achilles tendinopathy.

Furthermore, we do not know whether or not all the different modalities of treatment might counteract and limit themselves in the effect sizes since we do not know the effect size of each treatment alone besides the eccentric training. Another critical issue in the treatment group is the cryotherapy: How long was it applied and how often (intermittent or single shot), since intermittent cryotherapy for 3x10min has been demonstrated to decrease mid-portion Achilles tendon capillary blood flow significantly by 65% [4], which might at least in part be effective in Achilles tendinopathy.

Mayer did not perform any ultrasound, colour Doppler or MRI at all in their 4-week trial, so we can only speculate on the structural response in the given running athletes with mid-portion tendinopathy quoting Karim Khan: “12-month clinical outcome cannot be predicted using ultrasound. Power and color Doppler sonography did not improve performance [5]. ” The recent published comparison in patellar tendinopathy found the combination of grey-scale and colour Doppler Sonography to be more accurate than magnetic resonance imaging in confirming clinically diagnosed patellar tendinopathy [8].

Based on these recent findings and given the long rehabilitation times in tendon disorders at the Achilles level, we believe that substantial changes in tendon structure and function will at least take 8-12 weeks to be sustained, since Achilles tendon rupture is to be prevented as the worst case scenario in athletes suffering Achilles tendinopathy.

References

(1) Alfredson H, Ohberg L. Increased intratendinous vascularity in the early period after sclerosing injection treatment in Achilles tendinosis: a healing response? Knee Surg Sports Traumatol Arthrosc 2006;14(4):399-401.

(2) Alfredson H. Personal communication, 2007, Jan 30 via email.

(3) Boesen MI, Torp-Pedersen S, Koenig MJ, Christensen R, Langberg H, Holmich P, Nielsen MB, Bliddal H. Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study. Br J Sports Med 2006;40(9):761-6.

(4) Knobloch K, Grasemann R, Spies M, Vogt PM. Intermittent KoldBlue® cryotherapy of 3x10min changes mid-portion Achilles tendon microcirculation. Br J Sports Med 2006, Nov 30 (Epub).

(5) Khan KM, Foster BB, Robinson J, Cheong Y, Louis L, Maclean L et al. Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br J Sports Med 2003;37:149-153

(6) Lind B, Ohberg L, Alfredson H. Sclerosing polidocanol injections in mid-portion Achilles tendinosis: remaining good clinical results and decreased tendon thickness at 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 2006;14(12):1327-32.

(7) Maffulli N, Testa V, Capasso G, Oliva F, Sullo A, Benazzo F, Regine R, King JB. Surgery for chronic Achilles tendinopathy yields worse results in nonathletic patients. Clin J Sports Med 2006;16(2):123-8.

(8) Warden SJ, Kiss ZS, Malara FA, Oui AB, Cook JL, Crossley KM. Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy. Am J Sports Med 2007, Jan 29 (Epub).