In published efficacy studies on Achilles tendinopathy (AT) exercise alone results in improvement in 60-90% of the cases. However, this high success rate cannot be expected in usual clinical practice. We prospectively investigated the effectiveness of a treatment regimen consisting of home-based exercises (concentric, eccentric, and stretching) and optional glucocorticosteroid (GCS) injections in patients with (AT) in a usual clinical setting. Patients unable to commence or progress in exercise were offered GCS, hypothesizing that the GCS would facilitate exercise. Ninety-three consecutive patients with AT referred to two outpatient rheumatology clinics were registered, and seen at five visits over a 6-month period. Exercises seemed to have a slow, but long-lasting effect with GCS having a dramatic short-term effect on symptoms. Twenty-six percent of the patients could proceed with training alone, the remainder received one to three supplementary GCS. There were significant improvements on all outcome variables over time (P ≤ 0.001). At follow-up, 42 had no more symptoms, 29 good result, 16 slightly improved, 4 unchanged, and 2 slightly worse. Overall, 94% of the patients had improved, and we thus recommend the use of GCS injections in AT patients if training alone does not lead to improvement.

BackgroundAchilles tendinopathy is a common and often long-lasting injury. We present a 10-year follow-up on a pragmatic study on Achilles tendinopathy treated with controlled exercises supplemented with corticosteroid injections if necessary in order to continue training.MethodsAll patients who completed the original study (n=93) were invited for a 10-year follow-up. 83% participated. Patients were evaluated with ultrasound scanning (n=58) and with a questionnaire (n=77) using the same outcome measures as in the primary study. The 10-year overall outcome on a 4-point scale (excellent, good, fair, poor), other treatments and adverse event and present activity level were recorded.ResultsExcellent outcome was reported in 63% and good outcome in 27%. 76% reported an activity level at 75%–100% of preinjury level. The average Victorian Institute of Sports Assessment-Achilles score for all patients was 84 (SD 19). 16% had surgery. Three ruptures occurred 5–8 years after the primary study. The improvement from entry to 6 months in the primary study was maintained until 10-year follow-up. Insertional tendinopathy did not differ from mid-substance tendinopathy in any outcome measure (short term and long term). We encountered no prognostic markers on ultrasound for the long-term outcome; however, present heterogeneity and increased flow resemble present pain. Thickened tendons seem to maintain their thickness despite improvement of symptoms.ConclusionOne to two corticosteroid injections are a safe and effective supplement to controlled exercises in the treatment of Achilles tendon pain with no signs of deterioration in the very long term. Mid-substance and insertional tendinopathies benefit equally from this treatment.

PurposeThe biarticular anatomy of the gastrocnemii is an important mechanism of knee-ankle coupling and diferential elongation may afect this function leading to weakness of the push-of phase during the gait. Achilles tendon ruptures may cause detachment of the gastrocnemius tendon from the soleus aponeurosis with subsequent diferential elongation of the individual subtendons. This study investigated the efects of such detachment by investigating tendon fusion levels of the two muscle groups, and the efect of sequential diferential elongation of the gastrocnemius on the Achilles tendon resting angle (ATRA) and to the knee-ankle coupling. Methods Conjoined tendon length (CTL) was measured in 23 cadavers. ATRA in knee extension (ATRA 0) and 90-degree knee lexion (ATRA 90) was measured with the gastrocnemius tendons (GT) intact, transected and with the gap reduced in 5-mm increments. In 15 specimens, knee-ankle coupling was examined. Results Considerable anatomical variation was present with CTL ranging from 2 to 40% of ibular length. In the intact triceps, surae ATRA 0 difered from ATRA 90 by 6 degrees (p < 0.001). Cutting the gastrocnemius caused an immediate separation of the tendon ends by 19 mm. ATRA 0 and ATRA 90 increased 8 and 4 degrees (p < 0.001), signiicantly larger increase for ATRA 0 (p < 0.001). Lengthening the gastrocnemius 10 mm altered the coupling point 10 degrees towards dorsilexion.Transixing the gastrocnemius at the level of the gap where the Achilles was sectioned, decoupled the knee-ankle coupling in all but two specimens. A moderate correlation between CTL and length of the medial gastrocnemius tendon was found. Conclusions A greater relative ATRA 0 than relative ATRA 90 indicates diferential elongation of the gastrocnemius. By elongating the gastrocnemius the knee-ankle coupling point shifts dorsally, and 20 mm elongation completely decouples the knee-ankle coupling. Independent lengthening of the gastrocnemius may explain the loss of power experienced by some patients following acute Achilles tendon rupture despite what would appear to be appropriate approximation of the ruptured tendon ends. Recognizing this occurrence is crucial when treating Achilles tendon ruptures and such patients require surgical correction in order to avoid long-term weakness of push-of strength.

No abstract