Ep 208: REVISITED: Getting your tendinopathy diagnosis and treatment right, with Dr Robert-Jan de Vos

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Clare Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today.

[00:00:23] As 2024 wraps up and the JOSPT Insights team are taking a few weeks break, we're taking the opportunity to revisit a few of the episodes that were definite fan favourites in 2024.

[00:00:34] The topics are just as relevant today as they were when the episodes first aired.

[00:00:39] Before today's episode begins though, a big thanks to everyone who's listened, shared episodes with colleagues, offered feedback and requested guests in 2024.

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[00:01:03] To my wonderful co-hosts, Drs. Chelsea Koeman and Dan Chapman, your interviews are going from strength to strength.

[00:01:10] It's such a joy to work with you both to bring JOSPT Insights to our listeners each week.

[00:01:16] Listeners, you'll hear us back with new JOSPT Insights episodes in your feed in January.

[00:01:21] Until then, our very best holiday wishes to you and those you love.

[00:01:25] And here's today's episode.

[00:01:28] Thank you for joining us on JOSPT Insights.

[00:01:30] This week, we are diving deep into the world of Achilles tendinopathy.

[00:01:34] Joining us is Dr. Robert-Jean DeVos, sports physician and associate professor working at Erasmus Medical Center in Rotterdam, the Netherlands.

[00:01:41] He coordinates an academic tendon clinic and the main focus of his research line is to improve management of tendinopathies.

[00:01:47] Among his many, many, many publications, recently he was first author on the Dutch multidisciplinary guidelines on Achilles tendinopathy.

[00:01:55] That came out in the British Journal of Sports Medicine in 2021.

[00:01:58] Definitely make sure to check the show notes on this episode because we cover a lot of different references.

[00:02:03] But we'll make sure to put those in the show notes for you.

[00:02:06] My name is Dan Chapman.

[00:02:08] I'm a US-based physical therapist and owner of Chapman PT in Baltimore, Maryland.

[00:02:12] Dr. DeVos, thank you so much for joining us on JOSPT Insights.

[00:02:16] I am very much looking forward to a comprehensive dive into optimal management for Achilles tendinopathy.

[00:02:22] There was a clinical practice guideline that came out relatively recently that you were a part of.

[00:02:27] For those who may not be familiar with it, can you just tell us a little bit about that?

[00:02:30] Yeah, thank you.

[00:02:32] Thank you also for inviting me.

[00:02:34] Yeah, so with this guideline, we gained a lot of information.

[00:02:37] It was a Dutch multidisciplinary guideline for Achilles tendinopathy and I chaired that process.

[00:02:43] In this process, we collaborated with a lot of different disciplines like sports physicians, orthopedic surgeons, radiologists, and also rheumatologists, GPs, and physiotherapists.

[00:02:54] What we normally do as healthcare providers is when we have a question, we start to summarize the scientific evidence from the literature and also draw conclusions based on this.

[00:03:06] But in the guideline process, normally you would also take other considerations into account.

[00:03:12] So for example, patient preferences, contextual things.

[00:03:16] And based on this, you make recommendations.

[00:03:18] The listeners, if you haven't seen it, there's a massive amount of work that went into it, but it's also clarified and condensed really well.

[00:03:26] So it's very easy to get, you know, all the important and relevant clinical information quickly.

[00:03:31] Can we just talk really briefly about the physiology?

[00:03:35] Again, we're focusing on Achilles tendons here.

[00:03:37] So the physiology of the Achilles tendon, the makeup.

[00:03:39] And then from there, we'll dive into, you know, how does tendon pain kind of present in the clinic?

[00:03:45] Tendons are composed of mainly collagen fibers that are arranged in a parallel direction.

[00:03:53] So in parallel bundles.

[00:03:55] What's very specific for tendons is that, that collagen fibers are very highly organized and the tissue has limited blood supply compared to muscles, for example.

[00:04:05] And tendons are also less metabolically active and especially in the core of the tendon.

[00:04:12] Therefore also have a slower healing than muscles.

[00:04:16] There's a lot of interesting work from the research group of Michael Kerr from Copenhagen.

[00:04:21] And if people are interested to read more about physiology, I would definitely refer them to their work.

[00:04:28] For someone that comes in with Achilles tendon pain into the clinic, what do they typically present like?

[00:04:34] And what's the diagnostic criteria that that clinicians should be looking out for?

[00:04:38] But if we look for like diagnostic studies, we didn't find really adequate studies.

[00:04:43] There's also a problem that that's like a self-fulfilling prophecy, because on one hand, it's a clinical diagnosis.

[00:04:50] And on the other hand, you do not really have a gold standard.

[00:04:54] So therefore, we decided to extract diagnostic criteria that have been used in randomized controlled trials in this field.

[00:05:02] So in other words, we identified what clinical and research experts in this field consider as important diagnostic criteria.

[00:05:10] And it seemed that pain on palpation, localized swelling and pain associated with activity were considered most frequently used criteria.

[00:05:20] And thankfully, the Achilles tendon is pretty easy to get to and it's pretty easy to see.

[00:05:25] It's pretty easy to palpate.

[00:05:26] When someone does fit that diagnostic criteria, what else should clinicians kind of have on their mind as things to rule out to make sure that we're not just assuming that this is an Achilles tendon issue?

[00:05:40] And then actually missing the boat?

[00:05:42] Yeah.

[00:05:43] So I think when considering a differential diagnosis, it's first of all important to make a distinction between insertional and mid-portion Achilles tendonopathy.

[00:05:53] So the working group of the guideline defined an insertional Achilles tendonopathy as symptoms localized within the first two centimeter of the attachment of the Achilles tendon to the calcaneus.

[00:06:05] Above that two centimeter or above the proximal border of the calcaneus, we call it a mid-portion Achilles tendonopathy.

[00:06:14] And these two separate entities will result in different treatment options, but also needs other consideration of other differential diagnosis.

[00:06:23] And this is quite an extensive list.

[00:06:26] This has also been published in the guideline and also in several textbooks, you can see this large list.

[00:06:32] But I think it's good to focus on some of the common diagnoses that are easily missed or are coexisting or should not be missed.

[00:06:41] For the insertional Achilles tendonopathy, well, for example, there may be an associated prominence of the calcaneus, which we refer to as Haecland morphology, or an associated retrocalcaneal bursitis.

[00:06:55] These are often thought to be associated with due to an increased compression force during ankle dorsal flexion.

[00:07:04] To date, it is unknown whether these entities need other treatments.

[00:07:08] In my experience, they do not.

[00:07:11] And if you try not to focus too much on these entities as a healthcare provider, but treat it according, well, the basic principles, which we touch on later, there will be many patients with a good response.

[00:07:24] So it's really questionable whether these features are of importance.

[00:07:28] When the diagnosis of Achilles tendonopathy is made, there might be still some other underlying pathologies or diseases which may have consequences for the general health of a patient.

[00:07:42] And one of them is anthicitis as part of a rheumatological disorder.

[00:07:47] Paul Kirwan designed the SCREENDOM acronym with specific signs that makes this diagnosis more likely.

[00:07:55] Then you need to think about psoriasis, inflammatory bowel diseases, eye infections, relatives with a rheumatological disorder.

[00:08:05] These kinds of things should make you suspicious of more anthicitis, and that really needs different treatments.

[00:08:12] And if we're going to look at the mid-portion Achilles tendonopathy, I think there are two differential diagnostic options that I would like to mention.

[00:08:20] And one is the acute onset of pain in the Achilles region, with also an abnormal Carl Suisse test, the Thompson test, should make you suspicious of an acute Achilles tendon rupture.

[00:08:33] And this is still a diagnosis that is missed by patients and healthcare providers, and that results in an eclectic rupture.

[00:08:41] And I think we should prevent that.

[00:08:44] One other diagnosis that might be confused for Achilles tendonopathy is a posterior ankle impingement syndrome.

[00:08:51] And in this case, there's a compression of the structures posterior to the ankle joint during terminal plantar flexion.

[00:09:00] And patients with pain in the Achilles region that increases during passive plantar flexion are unlikely to have Achilles tendonopathy.

[00:09:09] So I think also that's one to keep in mind.

[00:09:12] That is such a good list because I think Achilles tendonopathy in and of itself is very, very common.

[00:09:18] And if you're working, especially in a busy outpatient clinic, it can be very easy to just say, oh, I've seen this pattern before.

[00:09:25] We have another Achilles tendonopathy.

[00:09:26] But it's an important reminder that regardless of how common the presentation is, you need to do a thorough evaluation to rule out all the other things that can mimic Achilles tendonopathy before you move forward and just try to treat it.

[00:09:41] I wanted to jump back to the rheumatological comorbidities.

[00:09:45] You mentioned eye infection, psoriasis, as well as inflammatory bowel disease.

[00:09:49] So it's just important to also, you know, when someone comes in with that typical Achilles tendonopathy presentation, ask follow-up questions that are probably going to sound unrelated to the patient.

[00:10:01] But, you know, if they are showing that patterning, it's going to be really, you can make a major difference by giving them a really good referral and getting them checked out through rheumatology.

[00:10:12] That's just excellent information.

[00:10:14] So let's assume that this person does not have a rheumatological condition, does not have posterior ankle impingement, and they are actually coming in with Achilles tendonopathy.

[00:10:24] What are the best recommendations in terms of interventions?

[00:10:28] And let's maybe talk first about education.

[00:10:32] For the education, I think that's indeed really an important part of management of Achilles tendonopathy.

[00:10:39] Mainly aims to enhance the patient's self-awareness and self-efficacy.

[00:10:44] I think also good to know it's an interactive exchange of knowledge between the healthcare provider and the patient.

[00:10:52] Also in the guideline process, we mentioned three elements of education, explaining the condition to the patient,

[00:11:00] and also offering pain science education with a specific intention to psychological factors,

[00:11:07] like an expectation management or providing a prognosis to the patient.

[00:11:12] What can the patient expect?

[00:11:14] The explanation of the condition, it really depends a bit on what the preference is of the healthcare provider.

[00:11:21] But I personally normally use a more biomedical approach.

[00:11:25] So to explain to the patients that there are structural abnormalities of the tendon tissue,

[00:11:31] and that is one of the main features that can also help them understanding to know the role of exercise therapy.

[00:11:39] We know the concept of mechanotherapy.

[00:11:42] And I think in the end, we are uncertain of the specific effects of exercises,

[00:11:48] but at least I think we can help patients understanding how they can influence their tendon pain.

[00:11:54] And psychological factors do have an increasing role and increasing interest in this research field.

[00:12:02] Often when pain is more dysfunctional, it can also be influenced by modifiable factors,

[00:12:08] such as fear of movement and also inaccurate perceptions regarding the association between pain and tissue damage.

[00:12:15] And I more and more ask people about their fears or their worries.

[00:12:22] So I think that's also something you can actively ask to patients.

[00:12:27] Last part of the education is the expectation management.

[00:12:31] So I think important to also actively discuss with the patient is at which term they can experience improvement.

[00:12:41] So that will be likely somewhere in several months and not in days or weeks.

[00:12:47] And the majority of patients will recover over time.

[00:12:50] So I think around 70 to 80% is likely to recover within one year.

[00:12:58] Really long-term follow-up studies show that approximately a quarter of the patients still have symptoms,

[00:13:02] like fluctuating symptoms over time.

[00:13:05] And I think also regarding the return to sports activities, most of our patients should also be counseled about that.

[00:13:13] And most long-term follow-up studies show that approximately 50% of the patients return to their sports.

[00:13:21] But it's unclear whether this is in their preferred sports at the same level or without pain.

[00:13:28] So there are still some uncertainties in that perspective.

[00:13:32] But I think it also shows that, well, there are really quite some patients that will not return to their preferred sports activities.

[00:13:41] And a separate category of education.

[00:13:44] And in that guideline process, we really describe that separately because we think it's really important.

[00:13:51] That's the load management advice.

[00:13:53] And there we often use the pain monitoring model that was designed by Karen Silbernagel.

[00:13:59] And what gives you an idea of how much a patient can do a certain amount of pain.

[00:14:06] And often an NRS scale is used.

[00:14:09] And in that scale, they can accept a level of zero to five of pain during or after activities.

[00:14:17] And it should also, well, at least give the patient some guidance to stay active, but also not overdue.

[00:14:26] So to keep a bit more balance and try to gradually increase that load over time.

[00:14:32] I think that's so important, especially the prognosis and how long it can take.

[00:14:38] I find that if you miscalculate and you tell someone that they're going to be better in days or weeks and they're not,

[00:14:46] they start to think things are not working, they're more likely to give up and then not actually go the full course and, you know,

[00:14:54] give up too early when things actually were working.

[00:14:56] But we mismanage those expectations.

[00:15:00] The pain monitoring model also so helpful to give people the freedom to continue to be active with pain and not be so fearful of actually damaging their tendon or what they're doing.

[00:15:10] I think let's jump right into exercise interventions.

[00:15:13] I know there's, you know, in the past five, 10 years, there's been a lot of discussion between isotonics, isometrics, heavy concentrics, heavy eccentrics.

[00:15:21] You know, where are we when it comes to trying to actually develop a plan of care around exercise interventions for Achilles tendinopathy?

[00:15:30] There is a lot of literature on exercise therapy in tendinopathies in general.

[00:15:35] What I can say about Achilles tendinopathy is that there are no specific types of exercise interventions that are more effective.

[00:15:42] And in multiple studies, we do see that there is a large heterogeneity in acute pain response after exercises.

[00:15:50] Also in our data, we saw that some patients respond very well to isometric exercises, but we do see the same in isotonics.

[00:16:00] And I think the main take home is that we should personalize exercise therapy based on this response.

[00:16:06] And a recent systematic review also showed that implementing resting days between sessions and working with external wages is beneficial for tendinopathies in general.

[00:16:17] So these are things we can take into account.

[00:16:21] Progressive strengthening exercises for the calf muscles and Achilles tendin are considered to be core, the core treatment component for Achilles tendinopathy.

[00:16:29] And from a scientific point of view, there are many remaining questions about the optimal type, dosage and timing of exercises and also their working mechanisms.

[00:16:40] But I think it's really clear that exercise therapy results in clinically relevant improvements, which are better than wait and see approach and at least equal to other conservative treatments in the short and long term.

[00:16:53] And I think to touch on that difference between Achilles tendinopathy regarding exercise therapy.

[00:17:03] There is some low-level evidence that the exercises performed on a staircase with a full range of motion of ankle dorsal flexion does result in more pain in patients with insurgent or tendinopathy.

[00:17:17] So what we normally do is to let them perform weight-bearing exercises on a flat ground.

[00:17:24] But when we are improving in that training schedule and we see the patient is responding well, then normally we are also trying to slowly increase that ankle dorsal flexion angle and try to also let them respond well to that compression component that we also introduced them.

[00:17:47] I can see how some people might be frustrated that there's not like a, you do this thing, this is the best thing for loading.

[00:17:53] But to me, it means that we have the freedom to use whichever loading is going to work best for the patient in front of us.

[00:18:02] We know that concentric can work, eccentric can work, isometrics can work.

[00:18:06] It just depends on how the person in front of us is responding.

[00:18:11] And it sounds like if it is that insertional tendinopathy, which is within two centimeters of that calcaneal insertion, you really got to be careful about loading them into dorsiflexion.

[00:18:23] Is that fair?

[00:18:24] Yeah, and I think it really also makes the case for physiotherapists who can really personalize treatment for these patients.

[00:18:32] So I really think what you're also stating, there's not one cookbook for patients with achilles tendinopathy that we can do one specific exercise that's good for all.

[00:18:42] So I think we should really personalize it.

[00:18:45] And also, it really depends on the aim someone has.

[00:18:48] And so we do see physically inactive people with this problem as well as high-level athletes.

[00:18:54] And it really depends on what someone would like to do with this tendin in the end.

[00:19:00] And also, yeah, that will result in different type of loading exercises that we will advise.

[00:19:08] That's fine.

[00:19:09] G'day, JOSPT Insights listeners.

[00:19:11] It's Claire Ardern here.

[00:19:13] I'm jumping in your feed to let you know that next week we'll continue this excellent chat with Dr. Robert Yarn-DeVos on all things Achilles tendinopathy.

[00:19:21] Today, you've had the foundations of what to look for when diagnosing Achilles tendinopathy and some ideas on implementing that core exercise-based therapy plus managing load.

[00:19:32] Next week, we're going to jump into some of the other potential options for treating tendinopathy,

[00:19:37] including what the best evidence says about the value of injection therapies.

[00:19:42] You won't want to miss that chat.

[00:19:44] So stay tuned and make sure you're subscribed to JOSPT Insights so you don't miss an episode.

[00:19:50] We'll catch you next week.

[00:19:55] Thanks for listening to this episode of JOSPT Insights.

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