Research Review By Dr. Jeff Muir©


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Date Posted:

June 2022

Study Title:

Dutch multidisciplinary guideline on Achilles tendinopathy


de Vos R-J, van der Vlist AC, Zwerver J et al.

Author's Affiliations:

Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands; Center for Human Movement Sciences, University Medical Center Groningen, Groningen, The Netherlands; Sports Valley, Sports Medicine, Gelderse Vallei Hospital, Ede, The Netherlands

Publication Information:

British Journal of Sports Medicine 2021; 55(20): 1125-1134. doi: 10.1136/bjsports-2020-103867

Background Information:

Achilles tendon injury is common in both active athletes and the inactive, often caused by overload mechanisms. In the Dutch population, the prevalence of Achilles tendon injuries is 2-3/1000 (1), with runners having an especially high lifetime likelihood of Achilles injury (2). While the exact pathophysiology of Achilles tendon injuries is not fully understood, it is accepted that the cause(s) of injury are multifactorial.

Diagnosis is generally based on clinical findings, although no exact diagnostic criteria are described. Imaging (x-ray, ultrasound, MRI) is used frequently during diagnosis, although the exact role of imaging in diagnosis is also not yet agreed upon (3).

Treatment is generally non-surgical in the early phase (4), with surgery considered only when conservative options are exhausted without improvement. The long-term prognosis for Achilles tendinopathy is generally unfavourable. Data helping clinicians to predict those who may or may not respond favourably to treatment would be of significant benefit in addressing appropriate treatment and in minimizing recurrence of symptoms. As such, the authors sought to develop clinical guidelines regarding the diagnosis and treatment of Achilles tendon injuries.


Module 1: Risk Factors and Prevention
Achilles tendinopathy (AT) onset generally relates to aging and overuse (5). Overall, information on modifiable and non-modifiable risk factors is scarce. Current evidence on primary prevention strategies is also insufficient, however, some recommendations can be made:
  • Gradual build-up in training is recommended (taking into account the type, frequency and intensity of training).
  • Targeted calf muscle strengthening exercises (tailored to the individual) prior to athletic seasons.
  • Wear sufficiently warm clothing during winter activities.
Module 2: Diagnosis
Diagnosis of AT is often made based on clinical findings and a history of overload activities, although systemic conditions may contribute to Achilles tendinopathy (6). The exact cause of injury is important as it may lead to differing treatment approaches. General recommendations for diagnosis of AT include:
  • Diagnose midportion AT based on the presence of all the following: symptoms localized 2-7 cm proximal to the tendon insertion; painful Achilles midportion with loading; local thickening (may be absent with short-duration of symptoms); pain on palpation.
  • Diagnose insertional AT based on the presence of all of the following: symptoms localized to the Achilles insertion; painful Achilles insertion with sports activities/loading; local thickening (may be absent with short-duration of symptoms); local pain on palpation.
  • Consider additional imaging if: symptoms do not fit all criteria above; symptoms fit the criteria but there is an unexpected course change during treatment; and/or if surgery is being considered.
  • Consider surgical referral if: there is continued uncertainty about diagnosis or an unexpected course change during treatment.
  • Consider rheumatologist referral if: there is insertional AT with suspicion of, or confirmed spondyloarthritis and/or other indicator(s) (e.g. psoriasis).
  • Consider general medicine referral if: demonstrated or suspicion of familial hypercholesterolemia, cardiovascular disease (under age 60) and/or arcus lipoides (light ring around iris) are present (under age 45).
Module 3: Imaging
There is currently no consensus on which imaging modalities are most appropriate for AT. Recommendations for augmenting clinical diagnosis with imaging for midportion AT include:
  • Ultrasound is the preferred modality.
  • Seek MRI if: ultrasound is not available; there is a discrepancy between clinical and ultrasound findings; additional diagnostic information is required or surgery is being considered.
  • For insertional AT, these same criteria apply, with the additional criteria that x-ray should be considered to exclude bony abnormalities at the calcaneus.
Note that it is not recommended to obtain imaging to determine the prognosis of AT treatment. No clinical value is seen in this use of imaging.

Module 4: Treatment
Outcome measures must address both the patient and practitioner’s goals. For midportion AT, the VISA-A questionnaire (7) is recommended to evaluate the course of AT.

’Wait and see’ Policy:
Initial treatment often involves modification of activity, although there is insufficient evidence regarding the natural course of AT in the absence of treatment. It is recommended that for midportion and insertional AT, no or minimal improvements should be expected in the short term as a result of a ‘wait and see’ policy.

Non-Surgical Treatment Options:
Non-surgical treatments are the first line treatments for AT and include activity modification, exercise, shockwave therapy, medication, acupuncture, injection therapy or multimodal therapies. Patients often receive multiple treatments concurrently. Treatment recommendations include:
  • Patient education should be provided early in the treatment, including: explanation about the diagnosis and prognosis, and pain education (including addressing psychological factors).
  • Loading advice should be provided, including: temporary activity modification; gradual increase in loading activities and the use of a pain scale to monitor progress.
  • Progressive calf strengthening exercises (tailored to the individual) are recommended for a 12-week period.
If no improvement is seen after a 12-week exercise program, consider the following: shockwave therapy, other passive modalities (ex. night splint, collagen supplements, ultrasound, friction massage, laser or light therapy) and/or injection therapies. Care should be taken when considering non-steroidal anti-inflammatory drugs or corticosteroid injections.

Surgical Treatment Options:
Insufficient evidence exists comparing the benefits of surgical treatment versus non-surgical treatment. In general, surgery should only be considered in a patient who has not recovered after at least 6 months of appropriate active treatment.

Factors Affecting Treatment Effectiveness: There is currently insufficient data from large databases to provide recommendations or set expectations for treatment success. In general, practitioners are encouraged to personalize treatment based on the patient, but not to set specific prognosis goals based on this information.

Lifestyle Modification, Work and Sports Loading: Recommendations provided to patients must be based on evidence. Practitioners should discuss the initial active treatment options with the patient. For patients with work-related injuries, treatment mirrors that of patients with sports injuries, with patient education, load management advice and exercise therapy as first steps, which may also include temporary work modification.

Module 5: Long-term Prognosis
Response to treatment and recovery are patient-specific and may take months or years in some cases. Discussions about realistic goals are required. General recommendations or counselling should include:
  • The majority of patients recover, although symptoms may persist in the long-term (i.e. up to 10 years in 23-37% of AT patients).
  • The majority (85%) of athletes return to sport, although whether this is asymptomatic in all cases is unknown.
  • Practitioners should remind patients that there are many unknowns regarding prognosis.
Module 6: Preventing Recurrence
A prior diagnosis of AT is (logically) the biggest indicator of potential recurrence. While insufficient evidence exists regarding recurrence prevention strategies, current recommendations include:
  • Attempt full return-to-sport after a few months of active treatment, as return within days of injury is highly predictive of reinjury.
  • Ensure a gradual build-up of loading activities.
  • Consider continuation of calf muscle strengthening exercises after symptomatic recovery.

Clinical Application & Conclusions:

The authors underscore several new findings when considering the diagnosis and treatment of AT, including that: 1) diagnosis should fulfill all 4 relevant criteria for either midportion or insertional AT; 2) that initial treatment should include patient education, load management and calf exercises for at least 12 weeks; and 3) that additional therapies should be considered in non-responsive cases, although caution is recommended when considering non-steroidal anti-inflammatories or corticosteroids.

Study Methods:

The objective this project was to gather evidence and create a consensus document providing guidance for the diagnosis and treatment for broadly defined Achilles tendinopathy (AT), including midportion and insertional variants. The process included the following broad methodological steps:
  • A working group first defined insertional and midportion AT based on location and symptomatology (8, 9).
  • A patient panel of 9 patients was formed to gather information on their experiences and challenges being treated for AT.
  • A national (Dutch) survey was launched, asking patients to describe their experience with injury and treatment, including treatment goals and outcome.
  • A survey of healthcare providers was performed at an international consensus meeting, including experience treating patients with AT and other tendinopathies.

Study Strengths / Weaknesses:

  • The search strategy included feedback from practitioners and patients.
  • A broad range of practitioners and disciplines were included.
  • The guideline encompasses a broad patient population via the inclusion of categories ranging from diagnosis to prevention and including both non-surgical and surgical treatment options.
  • A detailed systematic search of the literature for relevant evidence was not done for this project.
  • Despite the multidisciplinary nature of the group, the sample of patients and practitioners included in surveys was relatively small.

Additional References:

  1. de Jonge S, van den Berg C, de Vos RJ, et al. Incidence of midportion Achilles tendinopathy in the general population. Br J Sports Med 2011; 45: 1026–8.
  2. Kujala UM, Sarna S, Kaprio J. Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med 2005; 15: 133–5.
  3. Scott A, Squier K, Alfredson H, et al. Icon 2019: international scientific tendinopathy symposium consensus: clinical terminology. Br J Sports Med 2020; 54: 260–2.
  4. van Linschoten R, den Hoed PT, de Jongh AC. [Guideline ’Chronic Achilles tendinopathy, in particular tendinosis, in sportsmen/sportswomen’]. Ned Tijdschr Geneeskd 2007; 151: 2319–24.
  5. Yasui Y, Tonogai I, Rosenbaum AJ, et al. The risk of Achilles tendon rupture in the patients with Achilles tendinopathy: healthcare database analysis in the United States. Biomed Res Int 2017; 2017: 1–4.
  6. Kirwan P, March J, Duffy T. Screend’em before you treat’em. A clinical tool to help identify spondylarthropathy in patients with tendinopathy. Abstract at the International Scientific Tendinopathy Symposium, Groningen, the Netherlands, 2018.
  7. Robinson JM, Cook JL, Purdam C, et al. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001; 35: 335–41.
  8. Cook JL, Rio E, Purdam CR, et al. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? Br J Sports Med 2016; 50: 1187–91.
  9. Challoumas D, Kirwan PD, Borysov D, et al. Topical glyceryl trinitrate for the treatment of tendinopathies: a systematic review. Br J Sports Med 2019; 53: 251–62.

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