Conservative Treatment of Chronic Achilles Tendinopathy: A Systematic Review

Photobiomodulation Controls the Expression of Lipoxin Receptors, Promoting the Resolution of the Inflammatory Process in an Experimental Tendinitis Model

Tendinopathies are a significant global health issue due to their detrimental effects on mobility and quality of life. Pharmacological treatments, although widely used for pain management, often demonstrate limited efficacy. Photobiomodulation therapy (PBM) has emerged as a potential adjunctive treatment due to its capacity to modulate inflammation and alleviate pain. Nevertheless, further research is required to elucidate its mechanisms of action, particularly concerning the resolution of the inflammatory process. This study aimed to evaluate the effects of PBM on inflammation control in an experimental tendinitis model by analyzing inflammatory infiltrate, myeloperoxidase (MPO) activity, the expression of inflammatory and resolution markers (TNF-α, TGF-β, COX-2, and ALX), and protein levels of PGE2 and COX-2 in rat Achilles tendons with type I collagen-induced tendinitis. Male Wistar rats were randomized into five groups: healthy control (CTL), untreated tendinitis (NT), PBM-treated tendinitis (830 nm; 3 J; 30 mW; 64 J/cm²), or tendinitis treated with sodium diclofenac (DIC; 1 mg/kg IM). After 2 or 12 h, tissues and blood were collected for biochemical and histological analysis. The NT group exhibited increased inflammatory infiltrate, MPO activity (p < 0.001), COX-2, TNF-α (p < 0.001), and PGE2 expression (p < 0.01) but lacked ALX receptor upregulation. PBM and DIC treatments significantly reduced inflammatory infiltrate and MPO activity (PBM: p < 0.001; DIC: p < 0.01). PBM enhanced ALX and TGF-β expression (p < 0.001) and maintenance of COX-2 similar to the NT group, suggesting lipoxin involvement in inflammation resolution. These findings highlight PBM as a promising therapy for tendinopathies by targeting both inflammatory and resolution pathways.

Review of Ankle and Foot Tendon Transfers, Emphasizing Indications, Anatomy, and Imaging Appearances

Ankle and foot tendon transfer involves moving a tendon from its anatomic location to another location to reinforce a weakened muscle-tendon unit. An ideal donor tendon should have appropriate strength, excursion, phase, and tensioning. Imaging plays an important role in treatment selection and pre- and postoperative evaluation. Radiographs enable assessment of hardware position, bone tunnels, and foot alignment. Weight-bearing views or CT provides a more precise evaluation of alignment, potentially uncovering flexible deformities. MRI depicts the status of the donor and transfer sites and both bone and soft-tissue complications. There are three common indications for a tendon transfer. The first is reinforcement or replacement of a diseased tendon. Flexor digitorum longus to posterior tibial tendon (PTT) transfer is a popular method to address PTT dysfunction. Flexor hallucis longus to Achilles tendon (AT) transfer is used to address a tendinotic or partially torn AT. The second indication is restoration of bone alignment. Anterior transfer of the PTT or peroneus longus (PL) is a treatment option for footdrop. The choice depends on whether peroneal neuropathy is partial or complete. Options for varus deformities are anterior tibial tendon (ATT) transfer, split transfers (ATT or PTT), and PL to peroneus brevis (PB) transfer. The final indication is correction of lateral ankle or subtalar joint instability. Current techniques involve PB looping (Watson-Jones, Lee, Castaing), rerouting (Evans), or both (Chrisman-Snook). These have been abandoned in favor of other anatomic procedures, although some are still being performed and will likely still be encountered by the radiologist. ©RSNA, 2025 Supplemental material is available for this article.

UK defence rehabilitation review of Achilles and patellar tendinopathy conservative management: a systematic review

INTRODUCTION

Tendinopathy is a common condition affecting physically active populations, such as the military. Diagnosis is clinical, with no gold-standard tests. The role of imaging and functional assessment in subdiagnosis is an active area of research with the hope of delivering more nuanced and clinically effective management. A vast array of injectable and adjunctive therapies have been proposed with varying, and at times, conflicting evidence. Multiple methods for exercise therapy exist, but increasingly tendinopathy is recognised as a heterogeneous condition not suited to a one-size-fits-all approach. The aim was to complete a systematic review, to appraise the recent evidence for conservative management of Achilles and patellar tendinopathy.

METHODS

A multidisciplinary team from across defence rehabilitation searched PubMed for literature dating from May 2017 to July 2023. Four key areas were searched: diagnosis and outcome measures, medical, exercise and adjuncts.

RESULTS

A total of 840 articles were identified. Articles were screened using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Following screening and abstract review, a total of 143 were included for full review. Due to the breadth of literature and large heterogeneity of studies, meta-analysis of results was not feasible. Articles were assessed against the Oxford Centre for Evidence Based Medicine criteria.

CONCLUSIONS

The literature review found the strongest evidence for exercise-based rehabilitation as first-line treatment, with limited evidence for medical interventions and adjuncts. The primacy of stand-alone loading modalities is challenged by developing literature supporting a progressive tendon loading exercise protocol (PTLE). PTLE represents a framework where various exercise modalities are prescribed based on the individual's capacity and function. Novel interventions should be practised with caution and not conducted as monotherapy.

Advancements in Therapeutic Approaches for Degenerative Tendinopathy: Evaluating Efficacy and Challenges

Degenerative tendinopathy results from the accumulation of minor injuries following unsuccessful tendon repair during acute tendon injuries. The process of tendon repair is prolonged and varies between individuals, making it susceptible to reinjury. Moreover, treating chronic tendinopathy often requires expensive and extensive rehabilitation, along with a variety of combined therapies to facilitate recovery. This condition significantly affects the quality of life of affected individuals, underscoring the urgent need for more efficient and cost-effective treatment options. Although traditional treatments have improved significantly and are being used as substitutes for surgical interventions, the findings have been inconsistent and conflicting. This review aims to clarify these issues by exploring the strengths and limitations of current treatments as well as recent innovations in managing various forms of degenerative tendinopathy.

Comparability of the Effectiveness of Different Types of Exercise in the Treatment of Achilles Tendinopathy: A Systematic Review

Achilles tendinopathy (AT) is a common condition both in athletes and the general population. The purpose of this study is to highlight the most effective form of exercise in managing pain-related symptoms and functional capacity as well as in a return to life activities, ensuring the quality of life of patients with AT, and creating a protocol to be used in rehabilitation. We conducted a systematic review of the published literature in Pubmed, Scopus, Science Direct, and PEDro for Randomised Controlled Trials concerning interventions that were based exclusively on exercise and delivered in patients 18-65 years old, athletes and non-athletes. An amount of 5235 research articles generated from our search. Five met our inclusion criteria and were included in the review. Research evidence supports the effectiveness of a progressive loading eccentric exercise program based on Alfredson's protocol, which could be modified in intensity and pace to fit the needs of each patient with AT. Future research may focus on the optimal dosage and load of exercise in eccentric training and confirm the effectiveness of other type of exercise, such as a combination of eccentric-concentric training or heavy slow resistance exercise. Pilates could be applied as an alternative, useful, and friendly tool in the rehabilitation of AT.

Functional biomaterials for tendon/ligament repair and regeneration

With an increase in life expectancy and the popularity of high-intensity exercise, the frequency of tendon and ligament injuries has also increased. Owing to the specificity of its tissue, the rapid restoration of injured tendons and ligaments is challenging for treatment. This review summarizes the latest progress in cells, biomaterials, active molecules and construction technology in treating tendon/ligament injuries. The characteristics of supports made of different materials and the development and application of different manufacturing methods are discussed. The development of natural polymers, synthetic polymers and composite materials has boosted the use of scaffolds. In addition, the development of electrospinning and hydrogel technology has diversified the production and treatment of materials. First, this article briefly introduces the structure, function and biological characteristics of tendons/ligaments. Then, it summarizes the advantages and disadvantages of different materials, such as natural polymer scaffolds, synthetic polymer scaffolds, composite scaffolds and extracellular matrix (ECM)-derived biological scaffolds, in the application of tendon/ligament regeneration. We then discuss the latest applications of electrospun fiber scaffolds and hydrogels in regeneration engineering. Finally, we discuss the current problems and future directions in the development of biomaterials for restoring damaged tendons and ligaments.

Prevalence of Achilles tendinopathy in physical exercise: A systematic review and meta-analysis

This comprehensive systematic review and meta-analysis assessed the prevalence of Achilles tendinopathy (AT) in physical exercise (PE). Specifically, we estimate the overall risk of AT in physical exercise and compare sport-specific estimates of AT risk. PubMed, Web of Science, Cochrane Library, and SPORTDiscus were searched before the 1^st of October 2021. Random-effects, subgroup analysis, sensitivity analysis and meta-regressions were conducted, involving 16 publications. This meta-analysis found that the overall prevalence of AT was 0.06 (95%CI, 0.04–0.07). The prevalence of Achilles tendon rupture was 0.03 (95%CI, 0.02–0.05). Subgroup analysis showed that the prevalence of AT increased with age, the highest among the group aged over 45 (0.08; 95%CI, 0.04–0.11), and the lowest among the group under 18 years old (0.02; 95%CI, 0.01–0.03). The gymnastics and ball games had the highest prevalence of AT, at (0.17; 95%CI, 0.14–0.20) and (0.06; 95%CI, 0.02–0.11), respectively. The prevalence of AT in athletes (0.06; 95%CI, 0.04–0.08) was higher than that of amateur exercisers (0.04; 95%CI, 0.02–0.06) and there was no difference in the prevalence of AT between males and females. There are differences in the prevalence of AT in different ages, sport events and characteristics of participants. This systematic review and meta-analysis suggested that it was necessary to pay more attention to AT in people who were older or engaged in gymnastics.

Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice

Tendinopathy is labeled by many authors as a troublesome, common pathology, present in up to 30% medical care consultations involving musculoskeletal conditions. Despite the lasting interest for addressing tendon pathology, current researchers agree that even the exact definition of the term tendinopathy is unclear. Tendinopathy is currently diagnosed as a clinical hypothesis based on the patient symptoms and physical context. One of the main goals of current clinical management is to personalize treatment approaches to adapt them to the many different needs of the population. Tendons are complex structures that unite muscles and bones with two main objectives: to transmit forces and storage and release energy. Regarding the tensile properties of the tendons, several authors argued that tendons have higher tensile strength compared with muscles, however, are considered less flexible. Tendinopathy is an accepted term which is used to indicated a variety of tissue conditions that appear in injured tendons and describes a non-rupture damage in the tendon or paratendon, which is intensified with mechanical loading Even when the pathoetiology of tendinopathy is unclear, there is a wide array of treatments available to treat and manage tendinopathy. Although tendinitis usually debuts with an inflammatory response, the majority of chronic tendinopathies do not present inflammation and so the choosing of treatment should vary depending on severity, compliance, pain and duration of symptoms. The purpose of this article is to review and provide an overview about the currently research of the tendon diagnosis, management and etiology.

The analgesic effect of joint mobilization and manipulation in tendinopathy: a narrative review

Objective: To summarize the available literature with regards to the potential analgesic effect and mechanism of joint mobilization and manipulation in tendinopathy. Results: The effect of these techniques in rotator cuff tendinopathy and lateral elbow tendinopathy, applied alone, compared to a placebo intervention or along with other interventions has been reported in some randomized controlled trials which have been scrutinized in systematic reviews. Due to the small randomized controlled trials and other methodological limitations of the evidence base, including short-term follow-ups, small sample size and lack of homogenous samples further studies are needed. Literature in other tendinopathies such as medial elbow tendinopathy, de Quervain's disease and Achilles tendinopathy is limited since the analgesic effect of these techniques has been identified in few case series and reports. Therefore, the low methodological quality renders caution in the generalization of findings in clinical practice. Studies on the analgesic mechanism of these techniques highlight the activation of the descending inhibitory pain mechanism and sympathoexcitation although this area needs further investigation. Conclusion: Study suggests that joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.

The effect of lumbar spine manipulation on pain and disability in Achilles tendinopathy. A case report

BACKGROUND/PURPOSE

Cervical and thoracic spine manipulation has been found to reduce tendon pain and disability in lateral epicondylalgia and rotator cuff tendinopathy. Based on these findings, the application of lumbar spine manipulation may also provide similar improvements in Achilles tendinopathy (AT). Therefore, the purpose of this study was to evaluate the effect of lumbar spine manipulation on pain and disability in a patient experiencing AT.

CASE DESCRIPTION

A 44 years old male ex-football player presented with a 20-year history of persistent Achilles tendon pain (ATP) consistent with AT diagnosis. The patient attended 12 treatment sessions receiving a high-velocity, low amplitude lumbar spine manipulation. Outcome measures were collected at baseline, 2 weeks, 4 weeks, 3 months and 6 months and included pain in visual analogue scale, the American Orthopedic Foot and Ankle Score, the 36-Item Short Form Health Survey and the Victorian Institute of Sport Assessment-Achilles questionnaire. Pressure pain threshold was also assessed using an electronic pressure algometer.

OUTCOMES

Improvement in all outcome measures was noted 6-months post intervention. Outcome measures indicated substantial improvements in both the patient's pain and disability. The patient was able to perform activities of daily living without difficulties, suggesting higher level of function and quality of life at 6-months post initial evaluation.

CONCLUSION

These findings have demonstrated the positive effects of lumbar spine manipulation on ATP and disability. Further studies, specifically clinical trials investigating the effect of lumbar spine manipulation or combining this technique with exercises and functional activities are suggested.

Functional Outcome at Short and Middle Term of the Extracorporeal Shockwave Therapy Treatment in Lateral Epicondylitis: A Case-Series Study

Lateral epicondylitis (LE) of the humerus is a chronic degeneration of wrist extensor tendons at their attachments to the lateral epicondyle of the humerus. There is not a common consensus on a specific therapeutic algorithm, but Extracorporeal Shockwave Therapy (ESWT) is widely used. The purpose of this study is to evaluate the clinical benefits of low dose ESWT in LE-affected patients in short and medium follow-up. Between January 2015 and December 2017, 60 patients (38 male, mean age 52.2 ± 10.1 years, the duration of the disease was 3.6 ± 1.3 months) were clinically evaluated using visual analog scale (VAS) and Patient Rated Tennis Elbow Evaluation Test (PRTEE-I) scores before treatment, at one, three, six and 12 months after treatment. According to the VAS and PRTEE-I scoring systems, all patients achieved an improvement of pain and functional outcome comparing the baseline results with one, six and 12 months values. Low dose ESWT is a safe and effective treatment of LE in the short and middle term. In elderly subjects, patients with a long disease history, or those with occupational and sportive risk factors, a longer persistence of the symptomatology could be observed.

Extracorporeal Shockwave Therapy Treatment in Upper Limb Diseases: A Systematic Review

Background: Rotator cuff tendinopathy (RCT), subacromial impingement (SAIS), and medial (MEP) and lateral (LEP) epicondylitis are the most common causes of upper limb pain caused by microtrauma and degeneration. There are several therapeutic choices to manage these disorders: extracorporeal shockwave therapy (ESWT) has become a valuable option.

METHODS

A systematic review of two electronic medical databases was performed by two independent authors, using the following inclusion criteria: RCT, SAIS, MEP, and LEP, ESWT therapy without surgical treatment, with symptoms duration more than 2 months, and at least 6 months of follow-up. Studies of any level of evidence, reporting clinical results, and dealing with ESWT therapy and RCT, SAIS, MEP, and LEP were included.

RESULTS

A total of 822 articles were found. At the end of the first screening, following the previously described selection criteria, we selected 186 articles eligible for full-text reading. Ultimately, after full-text reading, and reference list check, we selected 26 articles following previously written criteria.

CONCLUSIONS

ESWT is a safe and effective treatment of soft tissue diseases of the upper limbs. Even in the minority cases when unsatisfied results were recorded, high energy shockwaves were nevertheless suggested in prevision of surgical treatment.