Search the Community

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (May 2023) Improving Clinical Outcomes: Diagnostic Accuracy of Chronic Mid-body Achilles Tendinopathy Tests by William Slapar, PT, DPT, OCS, CMTPT, CAFS Clinical Scenario...What would you do? A 36 yr old recreational athlete who does Tae Kwan Do and running presents with L posterior ankle/heel and distal leg pain pointing to the achilles tendon area. She had overused the L wb leg two weeks ago while demonstrating R sided kicks through two consecutive classes and later that week had tried hill runs to break up the monotony of her distance running. She did have similar symptoms three years ago after progressing her first marathon training too fast but has been sx-free since then other than occasional stiffness. The achilles is tender to touch and slightly swollen but without frank crepitus during AROM PF-DF. Pain is reproduced with squatting and < 5x heel raises. Plain films are WNL. She does exhibit some asymmetric L overpronation in SLB standing/mini squats testing and has limited STJ neutral squat DF at approximately 15° L vs 25° R. She has an antalgic gait with poor push off of L foot and shortened R step length. She has iced and used ibuprofen OTC per bottle instructions with some relief. My clinical thinking is: She has achilles tendonitis. Advise to DC ibuprofen and continue with Tylenol for symptom control if needed. Temporary heel lifts x 2 weeks and FU to determine next course of action. Findings suspicious for achilles tendonitis but in-office US testing is indicated to confirm diagnosis before treatment can begin. She has achilles tendonitis. Delay US testing unless 3-4 week FU shows insignificant progress. Advise formal PT including biomechanical evaluation and Laser trial. Findings suspicious of achilles tendonitis but MRI indicated (due to prior hx to R/O more significant tendinopathy/degenerative tearing) including to assist in determining possible PRP recommendation. Initiate physical therapy. She has achilles tendonitis. Advise to continue ibuprofen. No other tests needed. Temporary walking boot x 2 weeks and FU to determine next course of action. CURRENT EVIDENCE Hutchison AM, Evans R, Bodger O, et al. What is the best clinical test for Achilles tendinopathy? Foot and Ankle Surgery. 2013;19(2):112-117. https://doi.org/10.1016/j.fas.2012.12.006 SUMMARY: Achilles tendinopathy can be a common complaint especially for active lifestyle and athletically active people. In the office it can present at different portions of the calf/ankle: insertional, mid body, or at the musculotendinous junction. This three joint muscle (knee, talocrural, subtalar joints) is key to normal function with roles at the knee and foot/ankle in both NWB and WB uses. There are numerous other differential diagnoses that can contribute to retro ankle pain, including retrocalcaneal bursitis, osteophytes and/or bony anomalies, complete or partial achilles tearing, tarsal tunnel syndrome, sural neuritis or neuroma, posterior tibial tendon dysfunction/rupture, arthritic conditions, plantar fasciitis, tenosynovitis of flexor hallucis longus, stress fracture, and/ or osteochondral lesions. Accurate diagnosis is a key starting point for clinical decision making. Many different tests are available to help improve our diagnostic accuracy of mid body achilles tendinopathy and numerous imaging options for more definitive tissue level assessment, however, these are variably expensive and must be weighed in each case regarding necessity. Hutchinson et al. reviewed and used 10 different common clinical diagnostic tests for chronic mid body achilles tendinopathy while using Ultrasound as a reference standard. The most valid tests are pain on palpation of the tendon, self-reported pain at 2-6 cm above insertion, and morning stiffness. The achilles transmits forces to and from the foot and leg/superincumbent body. While often considered a “heel raise” or “push off” muscle one of often neglected roles is to decelerate the advancing body/leg segment over the foot in mid- - - >late stance phase prior to push off. Following clinical testing PCP’s and orthopedists must then consider any further diagnostic testing needed. Utilizing valid existing clinical tests allows physicians to avoid or at least delay more costly tests that may not alter treatment recommendations. With a confident diagnosis of achilles tendinopathy treatment considerations typically include physical therapy. Excellent PT care will include in-depth biomechanical evaluation to assist in problem solving any modifiable contributing factors rather than simply addressing symptom reduction and gradual return to prior activity. Achilles symptoms may develop due to ipsilateral biomechanical factors but may also result from compensation due to contralateral limb deficiencies also. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Diagnosing chronic mid-body achilles tendinopathy is not straightforward due to amount of tissues in the surrounding area that can be inflamed or have pain associated with stressing them. But the diagnosis aspect is very important to providing the appropriate treatment. So having accurate clinical test that can improve such diagnosis is very helpful. Purpose: To evaluate the accuracy of clinical test in identifying chronic mid-body achilles tendinopathy. Using ultrasound as a reference standard Methods: Twenty-one subjects from three groups, with and without achilles tendinopathy, had an Ultrasound scan followed by ten clinical test performed by two orthopedic surgeons and one senior physiotherapist. Each test accuracy and reproducibility were determined as well. Findings: For chronic mid-body achilles tendinopathy pain with palpation (sensitivity 84%, specificity 73%, Kappa .74-.96) and self-reported pain location from 2-6 cm above insertion (sensitivity 78%, specificity 77%, Kappa .75-.81) are the most accurate test in determining it as a diagnosis from others. Author's Conclusion: Only pain location and pain upon palpation were noted to be accurate and reliable in the diagnosis of chronic mid portion achilles tendinopathy. Further studies need to be conducted due to limitations of the study. THE PEAK PERFORMANCE PERSPECTIVE PCP’s and orthopedists alike deal with patients presenting with posterior distal leg and foot/ankle pain that is suspicious for achilles tendonitis or tendinopathy. Posterior ankle pain can be difficult to differential diagnose because of the many tissues potentially involved, including Achilles tendinopathy, retrocalcenal bursitis, os trigonum, neuritis of sural nerve, tenosynovitis of flexor hallucis longus, osteochondral lesions, etc.) which are stressed in particular ways more than others. Available clinical tests can vary significantly in their diagnostic value. Oftentimes, various imaging(i.e. US, MRI) is utilized by MDs to assess specific tissue quality and for higher sensitivity/specificity for diagnosing, however, these are more expensive and while providing more detailed information about tissue changes/quality may not alter non-operative treatment recommendations. Especially in these times of rising healthcare costs providers are expected by patients and insurers alike to control costs where possible without compromising quality of care. A common procedure is to plain films done to clear any osseus issues or other red flags that could affect treatment recommendations. Diagnostic ultrasound has become a more popular and less costly alternative to the MRI for assessing achilles tendonitis/tendinopathy. Hutchison 2012 et al clearly showed that providers can make an accurate diagnosis of chronic mid body Achilles Tendinopathy through palpation and the patient's subjective symptoms. Palpable tenderness locally showed 84% sensitivity and 73% specificity. “Active listening”for the patient’s local pain site description (being 2-6 cm above the Achilles insertion), is 78% sensitive and 77% specific to such a diagnosis. While these sensitivity or specificity values are adequate and not high, they are the highest of the 10 tested. London Royal test, the arc sign, single leg heel raise, and the hop test all have very poor sensitivity, all individually < 50%. Using “clusters” has been effective for other body parts to improve diagnostic accuracy but Hutchinson states that it is not justified since there were only very small gains in accuracy when using two of the top three most accurate tests: pain with palpation, morning stiffness, and self-reported pain. Hutchinson reminds also about test reproducibility/reliability as well. Consistency of test outcomes is a key component especially when different providers are examining patients. The three tests that were the most reproducible are once again, pain with palpation, self-reported pain, and morning stiffness. Limitations of this study was there was a low sample size with it only being 21 participants, no details on age range ( just 18+ y/o), or of gender. One of the patients from the Achilles tendinopathy group also had retrocalcaneal bursitis. Another potential limitation is the use of ultrasound as a reference standard (however, US has shown good accuracy compared to the gold standard, operative findings). Achilles tendinopathy is a very common diagnosis seen by physicians and PT’s/ATC’s alike. The mid portion/body type is the most common (vs insertional) and correlates to poorer vascularization and thus difficulty for the tendon to repair microtrauma. A key concern then is determining the reason for achilles microtrauma…especially in cases where a bilateral or reciprocating activity produced only a unilateral symptom. Most often a biomechanical deficiency is contributing to this asymmetric overloading - making identifying and addressing it properly crucial. Physicians making referrals for treatment should expect both local tissue recovery (reducing pain and inflammation and/or myofascial/scar issues) and addressing biomechanical faults related to the mechanism of injury (MOI) are being addressed in therapy. Specifying treatment orders can be difficult because there are a vast number of possible contributing factors to achilles overload. While the achilles/calf are certainly dominant sagittal plane loaded tissues there remain triplanar loading effects that must be considered. Common factors we note clinically include overpronation due to rearfoot and/or especially forefoot varus compensations, asymmetric anteversion causing dynamic valgus proximally and triplanar achilles strain distally, reduced dorsiflexion, and weak quads or hip extensors causing overload demands on the plantar flexors for deceleration. Traditional therapies usually implemented are eccentrics to help with the deceleration aspect but usually performed using a vertical force only instead of an angular force that respects horizontal forces of locomotion. Changing up different angles to provide stimulus towards the nature of function can help train more specific to the goals. Although eccentrics are helpful there is some data suggesting heavier loads strength training is key and less focus on isolated/emphasized eccentrics may be required. Of course a well-rounded approach involving manual therapy for joint and soft tissue mobilization is often necessary. Class IV laser therapy has also been a helpful modality to speed healing and reduce inflammation/pain. THE PEAK PERFORMANCE EXPERIENCE Sally said: ”The foot is feeling a lot better and and I’m able to walk farther, stand longer, and go to my grandson’s lacrosse games. I can go up and down stairs better also!” HX: 69 y/o female having progressive pain in the L posterior ankle with any weight bearing activities. Plain films are unremarkable. She was put in a walking boot for 6 weeks. Subjective: 8/10 pain with weight bearing activities, especially walking and going down stairs. Stairs is a one step at a time and walking stride is asymm. Objective: (*=pain) Initial Eval 1 mo ReEval Amb. Sx onset, asymm stride w/ antalgic type gait >15min, incr. *, near symm stride SLB , rotations Sx onset w/ rearfoot varus , no supination control 21 sec, vertical calcaneus, with min pro control and mod supination SL calf raise unable * 15x* (* at the 15th rep) Royal London Test (+) (-) NWB calc. Ev (AROM/ PROM) (0 deg /1deg) (2 deg / 3 deg) WB DF ( knee flexed) 5 degrees * 18 deg NWB DF ( knee ext) 8deg PF’d * 1 degree (100%+) Step down test unable , * 2”, 30x Palpation (TTP) Achilles ( 3cm above insertion), medial Gastroc( mod. to serve) minor TTP of med gastroc, Achilles Key Findings: At evaluation in standing, the patient shows a L foot rear foot varus, with deficits in side to side comparison of dec. calc everison. In ambulation, initial pain during all WB phases of gait of the L LE., due to lack of calc eversion. Unable to test strength due to increase in pain with all WB strength/functional testing. Lack of dorsiflexion in WB and NWB for the gastroc and soleus. Treatment: Pt treatment started with Class IV laser, with manual to address hypomobilities in the rear foot and ankle, soft tissue mobilization to address TrPs in the gastroc/ soleus structures. Using a wedge to improve tolerance of load on the achilles in a more Plantar Flexed position to reduce strain during load of the achilles. Then to reduce incline and plantar flexed ankle to a neutral or foot on floor during exercises. She worked on balance and gait training in the frontal plane first then transitioned into the Sagittal plane to reduce the amount strain in the beginning of the treatment. Balance exercises to improve pronation and calcaneal eversion control during weight acceptance of ambulation. Outcome: The patient is now able to walk without an onset of sx until 15 min of continuous walking, able to enjoy going to grandson lacrosse games, and starting back into a walking routine. Pt is able to go down the stairs in the morning with </=2/10 pain in the morning with reciprocal steps. Pt is still in Pt to continue strengthening for deceleration from elevated surfaces, increasing the endurance and strength of the plantar flexors for ambulation. Key Findings: At evaluation in standing the patient shows a L foot rear foot varus, with deficits in side to side comparison of dec. calc everison. In ambulation, initial pain during all WB phases of gait of the L LE., due to lack of calc eversion. Unable to test strength due to increase in pain with all WB strength/functional testing. Lack of dorsiflexion in WB and NWB for the gastroc and soleus. Treatment: Pt treatment started with Class IV laser, with manual to address hypomobilities in the rear foot and ankle, soft tissue mobilization to address TrPs in the gastroc/ soleus structures. Using a wedge to improve tolerance of load on the achilles in a more Plantar Flexed position to reduce strain during load of the achilles. Then to reduce incline and plantar flexed ankle to a neutral or foot on floor during exercises. She worked on balance and gait training in the frontal plane first then transitioned into the Sagittal plane to reduce the amount strain in the beginning of the treatment. Balance exercises to improve pronation and calcaneal eversion control during weight acceptance of ambulation. Outcome: The patient is now able to walk without an onset of sx until 15 min of continuous walking, able to enjoy going to grandson lacrosse games, and starting back into a walking routine. Pt is able to go down the stairs in the morning with </=2/10 pain in the morning with reciprocal steps. Pt is still in Pt to continue strengthening for deceleration from elevated surfaces, increasing the endurance and strength of the plantar flexors for ambulation. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com