Achilles Tendon Pathologies & Treatment with BioFlex Laser Therapy System

Author: David Kunashko, DC

Source: Meditech International Inc.

The Achilles tendon and connecting triceps surae musculature (medial and lateral heads of gastrocnemius and soleus) are anatomical structures frequently injured as a result of stressful, high level physical activities. The injuries sustained often require medical intervention and when they become chronic, can lead to considerable economic loss. Injuries of the Achilles tendon may occur at any age, however, most commonly present in the 20 to 50 age group.

Anatomy

The Achilles tendon is the largest tendon in the body and is formed by the aponeurosis of the heads of the medial and lateral gastrocnemius and the soleus muscle. The tendon inserts into the postero-superior aspect of the calcaneal tuberosity with the retrocalcaneal bursa lying anteriorly. The plantaris tendon also travels medial to the Achilles tendon and inserts into the calcaneus.

The Achilles tendon is covered by a double-layered sheath of synovial cells termed the paratenon or peritenon. The inner layer of the paratenon lies adjacent to the tendon itself and the outer layer is confluent with the subcutaneous tissue and the mesotendon. The blood supply to the Achilles tendon is derived mainly from the mesotendon and to a lesser degree from the muscle mass and from the bony insertion. Overall, blood flow is distributed evenly throughout the tendon with the exception of decreased flow at the calcaneal insertion. While there is a relative reduction both in blood flow frequency and total area of blood in the mid-tendon region, recent dynamic studies conclude that this hypovascular zone (often referred to as the watershed area) is not the main cause of tendon pathologies; nevertheless, the evidence may be conflicted.

week4img1 Etiology

Achilles tendon and related injuries include tendonitis, tendinosis, tenosynovitis, partial and complete ruptures and tennis leg (musculotendinous rupture). Achilles tendinopathies are typically the direct result of excessive repetitive tendon strain. During strenuous exercise, the tendon is loaded up to 10 times the person’s weight. Certain systemic factors may also contribute to Achilles tendonopathies including: steroids (local injection and systemic use), quinolones, chronic renal failure, rheumatoid arthritis, systemic lupus erythematosus, collagen deficiencies, diabetes mellitus and blood group O patients. Achilles tendonitis is an acute tendon inflammation that develops insidiously after changes in activity, the utilization of inappropriate footwear and poor running/ training surfaces with an incidence in runners and joggers of up to 18%. It occurs more frequently in association with certain deformities including pes cavus, tibia vara and heel and forefoot varus. The recovery time is generally 2-6 weeks.

Achilles tendinosis is the most frequent pathology and is generally considered an overuse condition. Episodes of multiple microtrauma result in the tendon no longer having the ability to heal and a mechanical breakdown of the tendon without the presence of acute inflammation results. Histological alterations include fibre disorientation, mucoid replacement of fibres, increased weaker type III collagen, collagen degeneration, increased cellularity and neovascularization. The increase in type III collagen and decrease in normal type I collagen results in an increased susceptibility of tendon rupture.

Achilles tenosynovitis occurs in the peritenon of the tendon with an etiolology and pathophysiology similar to that of tendinosis. The end result is fibrosis and scarring that restricts movement of the tendon within the pseudo-sheath. It occurs with greater incidence near the tendon insertion and may occur concomitantly or directly as the result of tendinosis.

Achilles tendon rupture occurs most frequently in middle age during the performance of recreational sports Achilles Tendon Pathologies & Treatment with BioFlex Laser Therapy System David Kunashko, DC.

Tennis leg involves a musculotendinous junction disruption of the medial head of the gastrocnemius due to a forceful push-off of the foot, occurring most commonly in middle aged recreational athletes, during activities such as hill running, jumping, tennis, basketball and volleyball. This injury is more prevalent in athletes with a history of recurrent calf strain and is associated with an audible “pop” and the feeling of being kicked or struck from behind.

Physical Examination

Achilles tendon rupture is associated with a palpable defect in the tendon 2-4 cm superior to the calcaneal insertion with the affected foot resting in slight dorsiflexion. If the tendon is completely ruptured, the Thompson sign may be present, such that squeezing the calf in a patient lying prone with passive knee flexion results in the absence of foot movement. A partial tear is often misdiagnosed as a strain or minor tendon injury and a diagnostic ultrasound or MRI should be considered in order to establish a definitive diagnosis.

Achilles tendinosis presents with an edematous and thickened tendon that is painful on palpation. The patient typically describes constant pain or discomfort and crepitus during plantar and dorsiflexion. Due to the chronic nature of this disorder, an MRI is useful to visualize the degenerative changes present in the tendon.

Achilles tendinosis presents with an edematous and thickened tendon that is painful on palpation. The patient typically describes constant pain or discomfort and crepitus during plantar and dorsiflexion. Due to the chronic nature of this disorder, an MRI is useful to visualize the degenerative changes present in the tendon.

Tennis leg presents with acute tenderness at the medial musculotendinous junction of the gastrocnemius, accompanied by local edema that may spread to the ankle and foot. A visible and palpable muscle defect is noticeable as the edema decreases. The Achilles tendon should be intact and pain is generated with passive dorsiflexion and resisted plantar-flexion. An MRI or diagnostic ultrasound is useful to determine the degree of injury.

Laser Therapy Treatment

Achilles tendon pathologies respond dramatically to low intensity laser therapy (LILT) for a number of reasons. Acute inflammation associated with tendonitis, rupture and musculotendinous disruption has been observed to be rapidly modulated with the use of LILT. Bjordal et al. concluded the inflammatory marker PGE-2 levels were significantly decreased as was pressure pain threshold after the application of LILT (i.e. the analgesic effect).

Numerous scientific research papers have also concluded that LILT produces significant clinical benefit for chronic tendon pathologies, including tendinosis and tenosynovitis. Oliverira et al. concluded that LILT improves collagen fibre organization within the Achilles tendon while Lidiane et al. deduced that LILT reduces histological abnormalities, collagen concentration and oxidative stress. Furthermore, Stergioulas et al. observed that LILT in conjunction with eccentric exercise, accelerates the clinical recovery of chronic Achilles tendinopathy.

Case Profile 1

Diagnosis 70% partial rupture of the right medial musculotendinous junction of the gastrocnemius with tendinosis.

History

  • 46-year old male
  • Acute forced dorsiflexion injury while playing basketball
  • Duration of symptoms – 4 months
  • Diagnostic ultrasound was positive for 70% rupture and considered to be inoperable
  • Slight antalgia during gait with moderate decreased muscle function
  • Physical Examination

Moderate edema along length of tendon

  • Palpable muscle defect of the medial gastrocnemius
  • 5cm by 3cm area of scar tissue formation at the musculotendinous junction
  • Moderate pain on palpation of proximal muscle and musculotendinous junction of medial gastrocnemius
  • Negative Thompson test with decreased foot movement compared to unaffected leg
  • Positive heel lift test

Status On Completion of Treatment:

  • 90% reduction of tendon edema and scar tissue formation
  • Negative heel lift test
  • Normal gait pattern re-established
  • Improvement of motor strength by 75%

Treatment

Application of arrays and probes to medial gastrocnemius, musculotendinous junction and Achilles tendon.

14 treatments at the Meditech Clinic, 12 with home unit, massage treatments and eccentric exercises over a period of 10 weeks.

Discussion

This patient presented at Meditech with a chronic musculotendinous tear resulting in accompanying tendinosis. Previous reported therapeutic intervention included physiotherapy and bracing; these aggravated symptoms with minimal positive change. Chief complaint initially consisted of stiffness, pain and edema with significant loss of function. Laser Therapy was provided at the Meditech Clinic and with a home unit concurrent with massage therapy and eccentric strengthening exercises. The patient also initiated low weight-bearing exercise with significant improvement of motor strength. It was noted that the late intervention resulted in associated tendinosis; earlier intervention using LILT would have promoted collagen synthesis and alignment, reduced fibrosis and scar tissue formation and earlier resolution.

Case Profile 2

Diagnosis Bilateral Achilles tendonitis

History:

  • 53-year old female
  • Presented with pain in both heels and difficulty walking
  • 9/10 on VAS
  • Duration of symptoms – periodic recurrence over 4 years
  • Several ankle sprains in the past
  • Utilized analgesics, massage, physiotherapy, chiropractic and cortisone injections without significant benefit

Physical Examination

  • Marked thickening and tenderness of Achilles tendons, more pronounced on the right
  • Difficulty standing on toes

Progress

  • Symptoms substantially diminished after initial treatment
  • Able to stand on toes without difficulty
  • Tendon thickness and pain reduced substantially after 4 treatments
  • Able to walk with normal gait pattern after 12 treatments

Treatment

  • Application of arrays and probes to calcaneal region and Achilles tendons
  • Laser Therapy treatments were initiated on 3 consecutive days and then to 2-3 sessions per week
  • Weekly treatments were continued subsequently until remodeling and strengthening of the tendon was complete

Discussion

This patient presented at Meditech with bilateral Achilles tendonitis. Previous therapeutic interventions had provided minimal positive effect with regard to function and symptom relief. The original complaint was stiffness and pain with significant loss of function. Laser Therapy was initiated at the Meditech Clinic along with eccentric strengthening exercises. The patient completed a course of treatment with complete resolution of all symptoms and functional levels totally retsored.

CONCLUSIONS

Achilles tendon pathologies are debilitating musculoskeletal disorders that are often misdiagnosed and treated inproperly. Acute inflammatory tendonitis and traumatic injuries along with chronic tendinosis, require a correct diagnosis and early appropriate therapeutic intervention. Unlike traditional therapeutic treatments, Laser Therapy produces immediate clinical benefits with regard to the pathologies encountered, including reduction of the degree of inflammation along with PGE-2 levels and progressive collagen fibre organization. It should be noted that calcification of the Achilles tendon is a frequent complication; in our experience, the application of Laser Therapy invariably results in complete dissolution of the calcium deposits.

Clearly Laser Therapy should be the preferred therapeutic approach, in dealing with the multiple Achilles Tendon pathologies that occur.

References Available Upon Request

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