Ep 214: What's new in treating Achilles tendinopathy? with Dr Ruth Chimenti

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

[00:00:22] We love our clinical practice guidelines here and today we have another one to give you. This one from 2024 titled Achilles pain, stiffness and muscle power deficits mid portion Achilles tendinopathy revision 2024 by Ruth L. Chimenti et al. And we are actually very lucky to have Dr. Ruth L. Chimenti here on the podcast today to talk about the CPG. Dr. Chimenti is an assistant professor in the Department of Physical Therapy and Rehabilitation Science at the University of Iowa.

[00:00:49] She received her clinical degree from Washington University in St. Louis and her PhD from the University of Rochester in New York. Her work focuses on the evaluation of underlying mechanisms that contribute to pain and disability in foot and ankle musculoskeletal conditions, as well as the development of treatment strategies that are tailored to individual needs to optimize clinical outcomes. My name is Dan Chapman, owner of Summit Physical Therapy and Performance in Baltimore, Maryland. And I'm Chelsea Kuman, a physical therapist and athletic trainer at Stanford University Athletics.

[00:01:19] So, Ruth, thank you so much for joining us today. I love everything Achilles tendon. So thanks for having me on to be able to promote and talk more about the guidelines. Listen, we love a nerd. We love nerding it up. First, can you just please define what is mid-portion Achilles tendinopathy? Let's start there. In the CPG, we went with the definition that was proposed by Dutch multidisciplinary guideline by DeVos et al. And so for that, there are four criteria.

[00:01:49] So one is that you have pain that's localized to the mid-portion of the Achilles tendon. And so that's like between the insertion and the muscle and the junction between the tendon and the muscles proximal. And, or they say like two to six centimeters above the insertion. So if you want, if you want to get like detailed in that way. And then you also have pain that's provoked by activities that load the tendon.

[00:02:15] Like if you think about walking and running, like those sorts of things are going to aggravate your pain. Often people are tender to palpation. So if you squeeze that area where they might have like a little bit of a bulge or swelling, they're often sort of with that. And then there's also thickening of the tendon as well, but that can be absent in about a quarter of people. Okay. So we know what we're dealing with now. Got it all defined. We should just dive right into it. What are we looking at in terms of updates from our prior CPG?

[00:02:45] We were really focused on this one in terms of trying to just update the intervention piece. So we reviewed some other aspects as well in a non-systematic review. And so it was really just the systematic review was on the intervention. So we had about 30 more articles that we pulled in to update the clinical practice guidelines.

[00:03:09] And so the shifts that we're seeing in the clinical practice guidelines are really just more of an update in terms of reinforcing, like exercise has always been a number one treatment for Achilles tenopathy. And then also education. There's some articles that came out on education as well that gave a little bit more information about, you know, types of education and formats for education that you could put in. I feel like this is like the current trend.

[00:03:39] I feel like in a lot of our takeaways from our, whether it's a CPG or it's related to a body part or it's related to a specific injury, just probably load it is a good way to start. So what were the biggest things you saw going off of that? I'm giving a spoiler alert for the exercise prescription stuff. Yeah. I love it. Because there's always like, if you look through, it's as PTs, we have so much literature out there.

[00:04:07] Like, and it's not, this isn't just in Achilles to the notopathy, as you mentioned, it's like all things. It's like, oh, is it, if you do this exercise or this exercise, what's better? If you do this or this, what's better? And it's like, as long as you're loading it in an appropriate way, I think that there are ways that you could mess up and do it wrong. But generally, if you have two good exercise programs and you're pitting one versus the other, they're both going to be good.

[00:04:31] And so we had, so like the shift from the initial CPG, that recommendation said that you should do eccentric exercise. So, I mean, that was a shift. Like exercise is a really effective treatment for Achilles to the notopathy. Then in 2018, the update was, well, maybe it's not just eccentric exercise. You can use other types of exercise. And as the, more evidence has come through to say, yes. And it's not just eccentric or heavy cell load. There are also like progressive tendon loading exercise programs.

[00:05:01] You can do isometrics and kind of pulling in these different, really, as you compare across, it's just reinforcing that idea that there's no one ideal way to do exercise for Achilles to the notopathy, except that you do want it to be at a level that's as high as tolerated. Is this inclusive of, I've seen in many years past, the pain monitoring model has been used a lot, like up to a four or five out of 10.

[00:05:27] When you say as high as tolerated, is that moving away from the pain monitoring model? Or is it just kind of inclusive of that as well as other ways of looking at it? So there are different beliefs in terms of like strategies for how do you progress somebody. Is it based on the max that they can tolerate in terms of their pain level?

[00:05:51] Or is it based on the max that they can tolerate when you think about like a one repetition max? In general, the idea is that the tendon needs load and in order for it to be effective. And so you wouldn't want them to be like sitting and doing theraband exercises for Achilles tendon pain. Okay, so the biggest things were exercise and then education.

[00:06:16] Do you mind giving us just a couple of pieces of like what you found in the research was helpful in regards to education? Is there like a category? Is there a way to do it that would be helpful for most people? I would say that I feel like this is like the least helpful information. It's like just like exercise. Like there's no like one way. Like there are key principles of exercise that we're talking about like, you know, in that you want to load the tendon as much as possible.

[00:06:46] And you can use different strategies to get them to that higher load depending on if you take them through a progressive tendon loading exercise. Or even if you do an eccentric exercise program, those are gradual. For education, a similar message is that you can do education. So like pain neuroscience education has been really popular recently to go through.

[00:07:10] And so we had actually done a study where we compared pain neuroscience education to just a more pathway anatomic, just providing education about the diagnosis in general. And so what we found was no difference between the two. And so four in the guidelines when that came out too is that you could do education and it could be focused on pain neuroscience education. Or you could just use a more biomedical approach to education. And both are effective.

[00:07:38] I think it really depends on the person who is in front of you. And if you think that they have more of a psychosocial aspects that are contributing to their pain, obviously you need to address like those psychosocial pieces and have that come in. But I think it can be person specific as long as it's evidence based. And then also for the format of providing education, it can be our study.

[00:08:03] And another study was also showing that you could provide the education remotely over telehealth or you could do it in person or you could do a mix of the two. They all work. And so I think that what's nice is that we get a little bit more guidance in terms of key principles to include in the education. I think, you know, in general people want to know about, you know, what is the diagnosis just as we start out today? What are the common symptoms?

[00:08:33] What are the treatment options that I have available to me? What's my prognosis? And talking through our rationale for doing exercise. And I think that those are key pieces of the education to include. But again, you have flexibility in terms of how to implement it. I love that. You can hear some guidelines, but also like you just got to do it and make it to the person in front of you. And it's going to be helpful.

[00:08:59] This was mainly looking at exercise and education or the interventions, excuse me, that we pulled for this one. But you also, there were some updates on some assessment pieces in there. Did you want to touch on those? Some outcome scores and things like that? So the gold standard for evaluating keyless synopathy using an outcome measure is the Visa A.

[00:09:22] And if you look in the literature, that's really what all the studies have used in the past. And also I think in the guideline we also talked about FAM, which I like. And then the LEFS is also in there. So those have been used. There have been some new surveys that have just recently come out that I think offer some promise.

[00:09:46] So the Visa A, one of the potential cons of that outcome measure is that it can have a cap. So if you are not an athlete, you have like a max score of like 60. Whereas, and so that can lead to kind of like a ceiling effect as you're trying to, if you have a goal of trying to get someone back, you know, you can't, you might not be able to see as big of an improvement in a non-athlete using that outcome score.

[00:10:14] And so the Visa A sedentary was developed, which is basically a way of adapting the gold standard into a way that won't have that ceiling effect for non-athletes. Another measure that came out that I really like as well is the Tendons A. And it is a way to, it's nice. It has like kind of subdomains in terms of one section looks at pain, one looks at stiffness, one looks at function.

[00:10:42] And the Tendons A also, the last section on function incorporates movement evoked pain. And so where it takes people, you have people go through heel raises, double leg hops, single leg hops, and get their pain rating with that, which I think is just a helpful evaluation piece. And to have the pain and have the movement together and to give you a standardized way to assess that. Those two measures are relatively new.

[00:11:09] So we also didn't have enough evidence yet to be like, oh, look at these new ones that are, you know, have the validity and reliability and responsiveness. And so I anticipate that in the next CPG that we'll be able to report on that. 20-30, coming in hot. Ruth, can we talk about the language, the change in language regarding tendinopathy, tendonitis, tendinosis, and then kind of what the takeaway is in our new update?

[00:11:38] So that has been going on for a little while. I would say that the U.S., I think in particular, a lot of practitioners use the term tendinitis. It's familiar versus tendinopathy, which is kind of promoted more by people that have – so maybe I should go back a little bit. So with tendinitis, it indicates that you have inflammation that's occurring in the tendon.

[00:12:07] Tendinitis indicates that it's degeneration. And so there's kind of been a back-and-forth debate in terms of is there – because then people – because we went from tendinitis to tendinosis to say that there's not inflammation. But now people are like, well, maybe there is inflammation. And so the ICON group has come up with a consensus statement that kind of bridged clinicians and researchers together to say – come together to say, okay, we want to use the term tendinopathy, which covers both.

[00:12:34] A lot of times when we're treating patients, like we don't know necessarily exactly what is the pathophysiology of this person's tendon. And so that's the terminology that we have gone forward with for the CPG was to call it tendinopathy. No, that makes a lot of sense. You guys have an incredible decision tree in the CPG that kind of goes through, okay, let's first determine that somebody's appropriate, that they actually have this.

[00:13:01] Here's what we should look at, some key things to look at for the exam, for the interventions and all that stuff. We're going to meet Trinity, our patient today, who definitely started running way too fast for her half marathon because her sister pressured her into it. So the pain is in the mid-portion of the Achilles tendon. It's tender and palpation. It's painful with Achilles tendon loading activities. And there might be thickening. Okay, so now what are some key things that we need to remember in our exam that includes an outcome measures?

[00:13:30] You checked off already that she met all of the diagnostic criteria. So that is helpful. I think also I'd be interested to know, is it more of a gradual onset or did you suddenly or was it like a really like sudden sharp pull that you felt? And in that case, I might want to look more at like an imaging to be able to do that.

[00:13:56] So one of the updates that we had with imaging, so imaging is a little bit debated in the Achilles tendinopathy world. The recommendations are that you don't need imaging to diagnose Achilles tendinopathy. As you mentioned, like it's really just based on the symptoms. However, I think that imaging is super helpful to rule out other conditions.

[00:14:17] I'm concerned that, you know, maybe this is peritendinitis or, you know, maybe she ruptured her tendon, you know, or even just being able to show them with the ultrasound, like here's your tendon. It's all in one piece. Like, I think, you know, like I'm feeling confident that this is, you know, a typical case of Achilles tendinopathy and we can move forward with that. So, you know, so that's what I would think through in terms of going through that medical screening and examination piece on the clinician flow chart.

[00:14:44] And then the next piece on there is for the assessment. And one thing that we updated on that this year was changing that from thinking about it being acute versus chronic to looking more at the level of symptom irritability. Because a lot of times with Achilles tendinopathy, I think it was more than acute or chronic. So they've been having a, you know, they've held it before.

[00:15:14] They've been, you know, it's kind of been a low level. And then it's been aggravated by some sharp increase in activity like this person had. And so I think using that is really helpful in terms of guiding exactly what interventions you want to do.

[00:15:30] So if they are somebody that has a really high level of symptom irritability and, you know, just doing an isometrics is pushing them to their max, you know, double limb isometrics is pushing them to their max pain. That would kind of shift you towards, okay, well, maybe this person should start with some even lower, lower, lower load tendon activities.

[00:15:56] And then you might want to supplement with some passive interventions and try to help them find, you know, focus a lot on education as well to try to help them find strategies to be able to manage their tendon pain. I'm going to say that for this case, that this is probably somebody who is, has a low level of symptom irritability and is going to be able to tolerate those higher load activities.

[00:16:17] I guess one way that I could use to be able to, as for an outcome measure, I think, you know, because this is an athlete, the visa A would be appropriate to use. And then you could be able to track their level, their time of being able to get back into it. Like the visa A is actually like perfectly set up for a runner.

[00:16:38] But I also like if you were to use the tendons A, you could use that last section on function to be able to determine that would help guide like what level of symptom irritability they are. And you could see how that might shift over time. What is their range of motion? What is their pain with it? That would inform they need heel lifts. Do they want stretching? So I kind of go through that that way. And then kind of actually spending about an equal amount of time on education and exercise is probably a good balance.

[00:17:08] With the isometrics, I like it as a tool to be able to teach people a way to load the tendon with low pain. And if, you know, even if they could do start at something higher, I think it's just nice to know. Like if you flare up, if you have a huge flare up, this is an exercise that you can still be able to do in the meantime. And then she'd probably progress really quickly within like a week to doing heel raises. You could probably even teach her both to move forward and then go into the spring phase,

[00:17:35] which involves, you know, going up and down stairs and hopping and kind of transition into that would integrate well with her running. And then as she's getting back to running, still maintaining the heel raises or maybe isometrics if she has a flare up to lower so that she has a balance so that she's still getting that a good high load on her tendon.

[00:17:55] And finding alternative strategies if she can't do it with those fast dynamic activities that can be symptom provoking, that she has, you know, slower options with the heel raises or the isometrics to keep on loading.

[00:18:34] So, yeah. High benefit, high benefit, low risk. And then you can bring in those other ones if they aren't progressing at the speed that you're at. They were hoping or that you can try to address some other factors that you think are contributing to the persistence of their pain. So all in all, it sounds like we need to load, load, load the patient up to what is tolerated. And obviously that's always going to change based on where they're starting at.

[00:19:02] And then as they improve, we need to match our interventions to now what they can tolerate, right? Or if they backslide, maybe they overdo it and now they're more irritable than they were last week. We need to change those interventions and again, load them, but match them to the symptom irritability. We need to be good about patient education and counseling them about what is going on. What does improvement look like? How long you should be with conservative care before doing something more aggressive?

[00:19:28] Things like manual therapy and dry needling are kind of, we don't have enough. It looks like research to really give you a clear yes or no, but it sounds like in certain circumstances with certain patients, they can absolutely be helpful. Keel lifts got an upgrade in terms of the evidence in this update. Is there anything else that I didn't just mention there that we should make sure that is getting hammered home? I think you hit it all. That's a great summary.

[00:19:58] Well, Ruth, thank you so much for joining us today. We really appreciate it. Diving into everything you love about Achilles tendinopathy. There are some good pearls that we can take away here and take to our patients. Thank you so much for having me. It was a great, great thing to talk with you both. One more big thank you to Ruth for sharing her time, her knowledge, and her expertise with us as well as all of you. And as always, we want to thank you for listening to JOSPT Insights.

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