Achilles tendon disorders
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1262 (Published 12 March 2013) Cite this as: BMJ 2013;346:f1262
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Asplund and Best note that medical factors including hyperlipidaemia may be associated with Achilles injury [1]. Special mention should be given to familial hypercholesterolaemia (FH), which may present as Achilles tendinopathy before the development of tendon xanthomata (figure 1). The importance of early diagnosis of FH, to reduce the risk of premature coronary heart disease, cannot be overstated.
In a study of patients with definite heterozygous FH (Simon Broome criteria) in our lipid clinic, 26.3% had consulted a doctor about symptoms of Achilles tendinopathy, but none of these consultations led to their diagnosis with FH [2].
We suggest that the evaluation of Achilles tendon disorders should include cholesterol measurement.
1. Asplund CA, Best TM. BMJ 2013;346:f1262
2. Beeharry D, Coupe B, Benbow EW, Morgan J, Kwok S, Charlton-Menys V et al. Ann Rheum Dis 2006;65:312-315
Competing interests: No competing interests
I would like to congratulate the authors for this well written and comprehensive article on Achilles tendon disorders but at the same time I am disappointed that they have failed to mention High Volume Image Guided injection (HVIGI) 1, 2, 3. This is an innovative and novel treatment option which is currently gaining popularity in UK and, in future will become the treatment of choice for mid-portion Achilles tendinopathy. This is a very simple procedure carried out under Ultrasound Scanner which has colour Doppler to visualise the site of neovascularisation. The success rate measured on VISA-A is comparable to many of the other modalities but is less invasive. We have carried out this mode of treatment in almost 2500 patients with classical mid-portion AT and can boast the same results as evident in our Level 4 published studies. We are currently collaborating with colleagues in Copenhagen and Barcelona to conduct Level 1 studies.
REFERENCES
1. Chan O, O'Dowd D, Padhiar N, Morrissey D, King J, Jalan R, Maffulli N, Crisp T.
High volume image guided injections in chronic Achilles tendinopathy. Disabil Rehabil. 2008;30(20-22):1697-708.
2. Humphrey J, Chan O, Crisp T, Padhiar N, Morrissey D, Twycross-Lewis R, King J, Maffulli N.
The short-term effects of high volume image guided injections in resistant non-insertional Achilles tendinopathy. J Sci Med Sport. 2010 May;13(3):295-8.
3. Maffulli N, Spiezia F, Longo UG, Denaro V, Maffulli GD. High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon. Phys Ther Sport. 2012 Nov 3. pii: S1466-853X(12)00078-8.
Competing interests: No competing interests
Very good article. Readers are invited to watch a video of eccentric calf exercises on bmj.com/multimedia. I could not find any such video on that site, as have others.
By googeling "eccentric calf exercise" there is a 3 part video of such exercises from an Australian source, I think.
Competing interests: No competing interests
Achilles tendinopathy was described by the authors as an overuse injury, but they have not really covered the idea of finding the cause of the overuse in a patient. This would be one of the easiest and most important areas to look at in primary care. A change in training volume, training pattern, footwear or training surface (e.g. changing from treadmill running to road running) would be one of the commonest precipitatory factors for symptom onset and if addressed early, can return the 'decompensated' athlete back to exercise without further complicated treatment.
The eccentric exercises should nevertheless be incorporated into their exercise programme once they have shown a vulnerability to Achilles overuse. In my experience however, incorrect adherence to the eccentric programme in terms of technique and compliance is the most common reason for these exercises to fail. I would therefore suggest that given the difficulty readers have already expressed in finding videos of the exercises on a search engine it might be more effective to refer, even for one session, to a good sports physiotherapist who can demonstrate the exercises, give the patient a programme to follow and hopefully address the details of the precipitating factors if this has not been done in the initial consultation.
Competing interests: No competing interests
It is important to remember that insertional AT may be inflammatory (enthesitis) and is a key clinical and pathological feature of the spondyloarthropathies which include ankylosing spondylitis, psoriatic arthritis and reactive arthritis - all conditions which can affect fit active individuals. Confusion can arise between non- inflammatory and inflammatory AT as injury, through running or otherwise, can trigger onset of peripheral features of the spondyloarthropathies such as enthesitis.
Clues to an underlying inflammatory spondyloarthropathy include associated features such as morning spinal stiffness, psoriasis, joint synovitis or uveitis. Preceding urethral discharge or diarrhoea may suggest a reactive arthritis. However occasionally chronic insertional AT may be the only clinical manifestation when radiology revealing broad-based fluffy calcaneal spurs and the presence of HLA B27 gene are helpful pointers to the presence of an underlying spondyloarthropathy. It is important to make the distinction between non-inflammatory insertional and inflammatory insertional AT as the management of the latter is very different with a clear role for systemic medications including biologics such as anti-tumour necrosis factor antagonists.
Competing interests: No competing interests
Yes I thought the article was interesting and have spent half an hour on line looking for the video of eccentric calf exercises and can't find it either.
Is it posted somewhere else?
Thanks
Dr Emma O'Neill
Competing interests: No competing interests
Why is there no mention of the value of orthotics? I had a patient with insertional achilles tendinopathy who had several weeks of ankle immobilisation in an aircast boot followed by eccentric exercises with little response, but who improved dramatically with customised orthotics.
Competing interests: No competing interests
Great comprehensive article.
In the paper journal it suggests to watch a video demo of eccentric exercises. i cannot find any links to this from the online article nor anything on the multimedia tab. Help and thanks.
Competing interests: No competing interests
In their article on Achilles tendon disorders, the authors discuss the use of glyceryl trinitrate patches in the management of Achilles tendinopathy. It is important to highlight that in the UK glyceryl trinitrate patches are not licensed for this indication. Further information is available in DTB 2012;50:93-96 (Management of chronic Achilles tendinopathy).
Competing interests: DTB is published by the BMJ Group
Re: Achilles tendon disorders
In response to Dr Macaulay's comment. The use of NSAIDs is something that should not be written off. Good analgesic regimes that may include NSAIDs are part of a sensible first line of management of tendinopathy. The natural history of symptoms in relation to tendinopathy means that many people will get better with just time, so managing their pain when this is bad is a perfectly reasonable thing to do.
The term 'tendinitis' is not helpful, it is best to understand the disease as 'tendinopathy' and that there is a spectrum of conditions within this umbrella. There is strong evidence that inflammatory mediators are involved in degenerative tendinopathy but this does not mean that tendinopathy is a classically inflammatory condition, if this makes any sense!
Competing interests: No competing interests