Achilles Tendinopathy and Achilles tendon partial and full thickness rupture
Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C
Achilles Tendinopathy and Achilles tendon partial tears and full-thickness ruptures
Here is what we are covering in this article.
- If you have an injury to your Achilles tendon, whether acute or chronic, what are your options?
- The use of Prolotherapy and platelet rich plasma as a non-surgical treatment for Achilles tendon degeneration and for partial ruptures and as adjunct treatment following complete Achilles tendon rupture and surgery.
- A review of possible surgical options
A patient will come into our clinics and tell a story we have heard many times before and one that may sound very familiar to you. It goes something like this . . .
One day, out of nowhere, I developed a tightness in the back of my ankle. I did some stretches, the tightness went away. I thought it was just one of those spasms I get occasionally and thought I had taken care of it. The next day the tightness in the back of my ankle returned and it stayed. I thought I could run through it but my problem was getting worse and worse. I went to my doctor, we did an MRI, it showed Achilles tendon damage.
- I was put on REST, no running for the next few months or until my situation improved greatly.
- I got heel supports and shoe inserts.
- I was given a lot of anti-inflammatories.
- I went to Physical Therapy and did heel drops and other exercises.
After a few months, my walking improved to the point I could jog again.
Then the tightness came back.
- I was put in a walking boot,
- I had extracorporeal shockwave therapy (ESWT),
- more physical therapy,
- Active Release Technique and Graston techniques,
- and a PRP injection. (One time one injection)
Almost two years into this my doctors are recommending surgery. They will go in and scrape down my Achilles and repair what they can. They tell me the recovery time is a year and they cannot guarantee success.
A history of anti-inflammatories and physical therapy
Two of the more recommended treatments for problems of the Achilles tendon are physical therapy and anti-inflammatory medication. As noted above, many people come to us with a medical history of multiple recommendations for PT yet they had limited results.
In a March 2021 study in the American Journal of Sports Medicine (1) researchers lead by the Institute of Sports Medicine and and the University of Copenhagen in Denmark wanted to know if limited physical therapy results were being caused by anti-inflammatory medications. Here is what they wrote:
“Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the treatment of Achilles tendinopathy, but whether they have any additive clinical effect on physical rehabilitation in the early phase of tendinopathy remains unknown.”
The researchers then investigated whether an initial short-term NSAID treatment added to a physical rehabilitation program in the early phase of Achilles tendinopathy would have an additive effect. (Did combining the two treatments provide extra relief and function to the patient?) When they started this study, the researchers thought that the combination of NSAID and rehabilitation would be superior to rehabilitation alone. So is that what happened? According to these researchers, no. Here is the conclusion of this study as published:
“Clinical symptoms in early tendinopathy improved with physical rehabilitation, but this improvement was not augmented with the addition of NSAID treatment. Furthermore, this clinical recovery occurred in the absence of any measurable structural alterations (no noticeable or measurable tears). Finally, clinical improvements after a physical rehabilitation program were greater in patients with very short symptom duration compared with patients who had longer symptom duration.”
The NSAIDs did not make physical therapy better. Further, physical therapy was better in patients with new onset of symptoms, chronic problems did not respond as well.
Understanding Chronic Achilles tendon injuries
The Achilles is the largest tendon in the body. It is a commonly injured tendon typically due to overuse and running sports injuries. Tendon injuries often start after a demanding workout and initially causes a tendinitis, where the body is trying to repair the weakened tendon. When the tendon doesn’t heal on its own and as more time passes, the tendon begins to show signs of cellular damage and collagen degeneration, or tendinosis.
Injury to the Achilles tendon increases with age and overuse. That has been clearly and well documented in the medical literature. While age and overuse make athletes and active people predisposed to injury, many patients will come into our office and describe an onset of pain that can be traced to a new and sudden burst in activity (a new exercise program). In many cases this acute injury has occurred from chronic wear and tear – the tendon has finally torn sufficiently enough to be considered an acute injury.
- This can be especially true in runners who will report that they pulled their Achilles or have a strained Achilles. Achilles tendon injuries are especially susceptible in treadmill runners as reported in The Journal of Orthopaedic and Sports Physical Therapy,(2) and people who run on sand as reported in the journal Sports Medicine.(3)
In chronic Achilles tendon injuries:
- patients report their heel and Achilles tendon area feels sore and tender to the touch, with the soreness coming and going to varying degrees.
- some patients report a clicking and popping sound.
- some will show swelling and an enlargement of the Achilles tendon. There may be bumps or nodules in the mid Achilles region. A “stiff” Achilles tendon or a sensation of tightness is also reported in patients who have difficulties pointing their toes upward.
- patients may have inflammation which may point to paratenonitis – an inflammation of the surrounding sheath, tendinitis with is inflammation of the tendon caused by wear and tear, and tendinosis, degeneration without inflammation.
Is it a partial tear or tendinopathy? Past cortisone injection treatments may provide the clue
One of the problems with an Achilles tendon injury is the extent and nature of the injury. Doctors are often confused by whether this is a partial tear problem of degenerative wear and tear on the tendon. This was also discussed in the research above on the use of physical therapy and NSAIDs, the patients in that study had no obvious injury that could be measured to any degree of success.
In an October 2020 study in the Journal of clinical medicine (4) Sports experts in Europe collaborated on publishing recommendations for understanding partial tear vs. tendinopathy problems in people with Achilles problems. They could not offer full recommendations. Here is why:
“Partial ruptures in the Achilles tendon are rather uncommon and are often misinterpreted as aggravated Achilles tendinopathy, and not always considered as a differential diagnosis. The aim of this literature review was to characterize typical symptoms, to provide an overview of available diagnosis and treatment options, and to give reference points for future research.
There were few studies and sparse knowledge of scientific value, making it difficult to give evidence-based recommendations.
Based on the few studies and the authors’ clinical experience, a diagnosis should be based on a patient’s history with a typical sharp onset of pain and inability to fully load the tendon. Previous intra-tendinous cortisone injections might be present.”
If there is a history of cortisone injections, this is a clue to a more impactful injury or tear.
Noninsertional Achilles Tendinitis and Insertional Achilles Tendinitis
- Noninsertional Achilles Tendinitis is where the tendon has begun to fray and break down in the middle of the Achilles tendon. This is an injury more typical of active patients.
- Insertional Achilles Tendinitis occurs closer to the heel area where the Achilles attaches or inserts itself to the heel bone.
In both conditions, the tendon seeks a way to stabilize itself and the heel-ankle complex area. It does so by calcifying (hardening) and by forming bone spurs on the heel.
The surgical choices
A January 2021 editorial in The archives of bone and joint surgery (5) explains the surgical option like this: (Explanatory notes in parenthesis have been added).
“Achilles insertional tendinopathy is inflammation and painful thickening of the Achilles tendon at its insertion on the posterior calcaneus (where the Achilles attaches at the back of the heel).
After a failed six month trial of non-operative management, the patient may elect to undergo operative management. Operative management involves a series of procedures including debridement of the diseased tendon, resection of the retrocalcaneal bursa, and excision of the calcaneal exostosis (developing or established “heel spurs”).
Despite a variety of surgical techniques reported in the literature, there is no single gold standard.
Previous studies has described complete detachment of the tendon at its insertion (the tendon is detached and repositioned), partial detachment, as well as tendon sparing techniques, such as splitting of the tendon. Most studies show good to excellent results using these different techniques, however there are flaws with each. With there being no gold standard, management is most commonly based on individual surgeon preference.”
Many people do have good success with Achilles Tendon surgery. These are typically not the people we see at our centers.
Prolotherapy and PRP: An introduction to non-surgical regenerative injection options
Prolotherapy is a regenerative injection technique that stimulates the repair of injured tissue. We inject in around an Achilles tear or degenerated tendon to create new healthy, regenerated tissue and get athletes and runners back to their activities.
In 2016, Caring Medical published our review of Prolotherapy in the journal: Clinical Medicine Insights Arthritis and Musculoskeletal Disorders. (6) Here we wrote:
- “Consensus is growing regarding the efficacy of dextrose prolotherapy as an alternative to surgery for patients with chronic tendinopathy who have persistent pain despite appropriate rehabilitative exercise.”
Most people that we see in the office for Achilles tendon tear or degeneration have not had success with typical treatments such as anti-inflammatories or standard immobilizing. People who do end up in our office for evaluation of Achilles tendon degeneration and tears heal very well Prolotherapy. This is documented in the research below.
Sometimes we may have to differentiate the treatment based on the type of injury. We can inject dextrose into a degenerative tendon and regenerate tissue but if we’re trying to essentially glue back fibers from a more significant tear, we get healing factor cells from the patient. This would be platelet rich plasma or PRP cells that come from the patient’s own blood. These cells are injected into the tendon using ultrasound guidance. We may also recommend immobilization to the area. Immobilization is usually not ideal because tendons need motion to heal, however, the exception to that is when we are putting PRP or Prolotherapy in the tendon and we are trying to heal that tendon from more significant damage, then immobilization is sometimes necessary.
A brief discussion of ultrasound diagnose and Prolotherapy treatments for Achilles tendon problems
A transcript summary and explanatory notes are below the video.
Danielle R. Steilen-Matias, MMS, PA-C.
- We do see a lot of patients with Achilles tendon pain. These are typically avid athletes, runners, hikers, etc.
- When these patients come to see us for these problems, we can use an ultrasound image to help show us tears and tendon degeneration. Later during treatment we can use the ultrasound to help guide our injections into the specific problem areas of injury.
- At 0:55 of the video the ultrasound imaging begins
- Often times we find that patients with chronic Achilles pain have more of an issue with degeneration as compared to acute tearing or inflammation. This means that the tendon is becoming weaker because it is wearing out. This is when we can have a good expectation that we can help this patient with Prolotherapy injections to strengthen the tendon.
- Often Achilles tendon problems whether it’s tendinosis, tendonitis, or a tendon tear normally involves not just the distal attachment but actually the substance of the tendon (the tendon body or structure) you’ll see that I am injecting more and more proximal (closer into the tendon) and the area is done very thoroughly with a very strong solution which makes the treatment very very comprehensive in its scope and very, very effective. This particular patient did extremely well just needed a couple business and their back to all their activities.
Chronic Recalcitrant (Difficult to treat) Achilles Tendinopathies and Prevention of Achilles tendon rupture: Introducing Platelet Rich Plasma Therapy
We do see many patients who have had failed Platelet Rich Plasma treatments. One of the reasons for the failure is not adequate treatment. PRP is usually not a single miracle injection. We will explain this below.
Platelet Rich Plasma Therapy is an autologous derivative of whole blood that contains a supraphysiological (greater than the normal amount) concentration of platelets. You can learn more about this treatment here What is Platelet Rich Plasma Therapy?
Doctors writing in the Journal of tissue engineering and regenerative medicine have made the case that platelet rich plasma injections awaken and stimulate native stem cells to repair Achilles tendon damage. Here are the bullet points:
- The study’s purpose was to investigate whether platelet-rich plasma would activate tendon-derived stem cells to promote regeneration of Achilles tendon post-rupture in rats.
- In the in vitro study, platelet rich growth factors significantly enhanced cell DNA synthesis (cell replication) improved viability and promoted proliferation, while facilitating cell migration and the recruitment of tendon-derived stem cells.
- In other words, PRP promoted the creation and multiplication of stem cells.(7)
What does this mean to the patient?
- More evidence that PRP can non-surgically repair an Achilles tendon in various degrees of rupture and tear.
In addition to the research cited above, another Italian research team evaluated the long-term clinical outcome in patients affected by mid-portion Chronic Recalcitrant Achilles Tendinopathies (CRAT) treated with administration of single platelet-rich plasma (PRP).
A total of 73 patients age 43 years old predominantly males had 83 tendons treated with a single PRP injection. They were then evaluated using standard scoring systems.
Here are their results
- 91.6% were rated as satisfactory and patients would repeat the treatment.
- 8.4% were classified as unsatisfactory at the 6 months follow-up and underwent a second PRP injection.
- In addition to this, patients reported no Achilles tendon rupture.
Therefore the conclusion: The use of a single PRP injection can, therefore, be a safe and attractive alternative in the treatment of non-insertional CRATs.(8)
What are we seeing in this image?
Achilles tendon degeneration is helped with PRP Prolotherapy. After trying a variety of other treatment methods, this patient was able to have their Achilles tendon restored to full function.
Prolotherapy for Achilles tear and tendinopathy
Researchers have shown the effectiveness and safety of Prolotherapy injections for the management of lower limb tendinopathy and fasciopathy. In the Journal of Foot and Ankle Research
The doctors were looking to identify and evaluate existing research to determine the clinical effectiveness and safety of Prolotherapy injections for the treatment of lower limb tendinopathy and fasciopathy.
- Results of the analysis provide support for Prolotherapy as an effective treatment in both reducing pain and improving function in tendinopathy and fasciopathy.
- The analysis also suggests Prolotherapy injections provided equal or superior short-, intermediate- and long-term results to alternative treatment modalities, including eccentric loading exercises for Achilles tendinopathy, platelet-rich plasma for plantar fasciopathy and usual care or lignocaine injections for Osgood-Schlatter disease. No adverse events following prolotherapy injections were reported in any study in this review.(9)
In an April 2017 study, doctors writing in the Scandinavian journal of medicine and science in sports reported positive results in 12 of 13 research studies for achieving pain relief and patient satisfaction for patient’s receiving Prolotherapy on chronic painful Achilles tendinopathy.(10)
Prolotherapy injections show significant clinical results in study
Researchers from London Independent Hospital and Queen Mary University of London examined intra-tendinous Achilles tear (A tear within the tendon). They also examined Prolotherapy as a treatment for this tear, which they write “involves injecting an irritant, such as hyperosmolar dextrose, to stimulate a tissue healing response and ultimately reduce pain.”
In their study, 43 patients with an intra-tendinous tear were given Prolotherapy injections A 4-6 week period of walking boot immobilization was followed by progressive rehabilitation (6-8 weeks).
- 30 patients (70%) responded with VISA-A scores (A scoring system to measure Achilles tendon pain) showing significant healing after 3 months and even more so at 12 months. Showing long-lasting results.
- After 5 months, 27% of tears were no longer detectable in imagining.
- Treatment resulted in clinically significant improvements.(11)
Prolotherapy researcher John Lyftogt MD reported positive results in two studies published in the Australian Musculoskeletal Medicine Journal, for chronic Achilles tendinopathy (average length of symptoms two years) with subcutaneous dextrose Prolotherapy.(12,13)
In 2007, Canadian researchers published a study on the use of hyperosmolar dextrose prolotherapy (25%) to treat 32 patients representing 33 tendons with chronic tendinosis of the Achilles. At an average of 12 months after treatment, 20 patients remained symptom-free, nine experienced only mild symptoms, and one patient reported moderate symptoms. (14)
This was supported by research published in 2010 which showed the results of Prolotherapy in 99 patients with long-term pain related to the Achilles tendon. Patients received an average of five injection sessions spaced on average 5.6 weeks apart. A statistically significant improvement in pain scores was observed for both midportion and insertional in mean percent reduction in pain at 28 month follow-up. (15)
This research supported that of a paper published in 2009 that Prolotherapy and eccentric loading exercises for painful Achilles Tendon provided great improvements in the patient’s condition. (16)
For patients who have already received steroid injections or surgery for Achilles tendinopathy, but still have pain, Prolotherapy and Platelet Rich Plasma Injections may be a good regenerative treatment to consider to improve the entire heel, Achilles, ankle complex, especially with tight Achilles tendon pain that may be causing Equinus a condition that limits the motion of the ankle.
Can stem cells repair Achilles tendon damage?
When there is advanced tearing or more damage to the Achilles tendon, in addition to PRP discussed above, stem cell therapy may be introduced. We do want to point out that the use of stem cell injections is usually considered after PRP and Prolotherapy injections. Why? Because the PRP and Prolotherapy injections can deliver as good, even superior results at considerably less expense. This is based on our observations in treating thousands of patients.
Researchers in South Korea also examined adipose stem cell therapy in a new study from March 2017. Writing in the American Journal of Sports Medicine, the Korean doctors found:
- In tendon injury, Human Adipose-Derived Mesenchymal Stem Cells can enhance tendon healing by secreting their own protein and have potential as a therapeutic option in human tendinopathy.(17)
- Also from March 2017, Italian researchers found PRP and adipose-derived mesenchymal stem cells to be effective treatments for difficult to treat Achilles tendinopathy. These treatments should be taken into consideration for those patients who require an earlier return to daily activities or sport.(18)
A September 2019 study in the journal Stem Cells International (19) examined the effect of stem cell therapy, PRP therapy and a combined approach in 41 Rats with chemically induced achilles tendon damage. The researcher reported that PRP and stem cells plus PRP yielded better biomechanical results than eccentric training, showing that these treatments offer better tend function outcomes.” These results were achieved in rats and clearly, as the researchers themselves point out, this research simply “opens the door for opportunities to continue this research.” It should not be taken as definitive that it would help in humans.
Ruptured Achilles Tendon
Achilles tendon ruptures can take on many types. There can be a partial rupture or a complete rupture. The Achilles with a rupture can still be intact – it could also be “totally gone.”
Doctors writing in the medical journal Lancet examined the use of Platelet Rich Plasma Therapy for patients with a ruptured Achilles tendon.
- Twenty patients with a ruptured Achilles tendon had tendon tissue samples taken. Ten of the patients had PRP, ten patients had placebo treatments.
The findings reveal that locally applied PRP accelerated healing based on cellularity (the number of cells) and glycosaminoglycans (an amino sugar in hyaluronic acid or chondroitin sulfate useful in healing) content were significantly higher in PRP-treated tendons than in controls.(20)
Realistic expectations of stem cells and platelet-rich plasma treatments and a ruptured Achilles tendon
Stem cell therapy is the injection of stem cells into the damaged Achilles tendon. You can learn more about the treatment here What is Stem Cell Therapy?
In recent research, and as mentioned in the above citations, doctors in Turkey, bone marrow-derived stem cells (MSCs these are stem cells taken in a simple aspiration procedure from the iliac crest of the pelvis or from abdominal fat) promoted the recovery of the ruptured Achilles tendon and increase its structural strength.
The doctors concluded:
- “The use of PRP and MSCs provides hope for the treatment of Achilles tendon ruptures that limit human beings’ functionalities and quality of life, particularly for athletes. It is thought that the use of MSC can be more effective for tendon healing.”(21)
Treatment following Achilles Tendon Surgery
Spanish researchers writing in the medical journal Knee Surgery, Sports Traumatology, Arthroscopy used animal models to examine the biomechanical effects of intra-tendinous injections of Platelet Rich Growth Factors on the healing Achilles tendon after surgical repair. The researchers found that Platelet Rich Growth Factors increased Achilles tendon repair strength at eight weeks compared with the use of placebo.(22)
There have been numerous studies testing the validity of the use of Platelet Rich Plasma during open surgery. These studies have led some to question whether or not PRP can help with post-surgical rehabilitation if applied at the time of surgery.
- Doctors in Italy wrote in a July 2016 paper: “The addition of PRP to the surgical treatment of Achilles tendon rupture does not appear to offer superior clinical and functional results.”(23)
One of the big problems with studies on PRP or stem cell enhancements at the time of surgery is the problem of dilution.(24) In our article on arthroscopic knee surgery for osteoarthritis, I came upon a study that found that during surgery, surgical dyes, irrigation fluids, and other liquids forced into the repair area significantly diluted healing agents during surgery and more importantly post-surgery.
PRP in Achilles Tendon Surgery
However, doctors writing in the medical journal Foot and Ankle Specialists said:
Treatment protocols with PRP have been performed in 2 ways- administered adjunctively during tendon surgery and as a stand-alone injection (please see our article What is Platelet Rich Plasma Therapy?)
The senior researcher had utilized PRP by both methods to treat Achilles tendinopathy over a 7 year period. Twenty-six patients were followed, half having undergone Achilles tendon surgery in combination with PRP administration and the other half PRP injections alone.
Both the stand-alone injection group and surgical/injection groups had statistically significant degrees of improvement in pre-MRI and post-MRI imaging studies. There was no statistically significant difference between the 2 treatment groups.(25)
PRP did help in surgery and helped equally without surgery. This is why seeking a consultation with a doctor experienced in the varied PRP, stem cells, and a comprehensive Prolotherapy approach can offer the patient more options pre and post-surgery for enhanced and accelerated Achilles repair.
One note on immobilization
In stark contradiction to the Rice, Ice, Compress, Elevate theory in managing post-surgical treatment, doctors in August of 2016 published their research that functional weight-bearing mobilization enhanced the early healing response of Achilles tendon recovery. In addition, early ankle range of motion was improved without the risk of Achilles tendon elongation (laxity and instability) and without altering long-term functional outcome.(26)
In this article, we have shown that Prolotherapy, PRP Prolotherapy, and Stem Cell Prolotherapy can be viable options for your Achilles tendon problems. If you have any questions about your specific case, our team would be happy to talk with you and see if you are a candidate for our clinics.
Do you have a question about tendon damage and repair? Get help and information from Caring Medical
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This article was updated May 6, 2021