In the third instalment of our tendonitis special, we take a look a deeper look at how patients can manage the condition.
Sarah is relieved that it isn’t likely to be anything serious and says she will go home to rest and ice her ankle. She buys some paracetamol tablets, saying she is out of them at home, and asks how long she should stay off the running for.
Going back to the movement that caused the original injury is not advised for several weeks. Gentle exercise, however, is recommended, focusing on movements that cause the muscle to which the affected tendon is attached to both contract and stretch. Massage is also a good idea, either formally from a physiotherapist or simply by rubbing the affected area to encourage blood flow and keep the fibres soft. It goes without saying that comfortable footwear is a must, though this should be supportive rather than soft, and a low heel or a heel raise in each shoe can help take pressure off the Achilles tendon.
If symptoms don’t improve, or indeed suddenly worsen, a trip to the GP is a good idea. A more in-depth examination plus tests such as x-rays or a magnetic resonance imaging (MRI) scan may be conducted to exclude other, more serious, problems, such as a fracture or a ruptured tendon. The latter usually presents as abrupt pain in the heel or calf, accompanied by swelling and bruising.
In some cases of tendonitis, corticosteroid injections – sometimes combined with local anaesthetics – may be needed to further reduce pain and inflammation. However, they are not the miracle cure many regard them as, with an effect that sometimes only lasts a few weeks and in other cases proves completely ineffective. For those who do respond, the treatment can be repeated, but no more than three times in total and with an interval of at least six weeks in between injections to minimise the chance of the tendon becoming weak (and hence liable to tearing or rupturing), and to protect the skin, which may become thinner or lighter as a result of the therapy.
Extracorporeal shock wave therapy may be used if other treatment options have failed. ESWT involves passing shock waves through anaesthetised skin to the affected tendon. It isn’t a risk free procedure, however, side effects can include redness, swelling, pain, nausea and rupture of the tendon. The National Institute for Health and Care Excellence (NICE) has issued guidance on the use of ESWT for refractory Achilles tendinopathy, available at http://www.nice.org.uk/guidance/IPG312, which states that the intervention is not associated with any major safety concerns but that evidence of efficacy is inconsistent.
Autologous blood injection is another management option that doctors may discuss with patients. In this procedure, a small amount of the patient’s own blood – which may be separated into red blood cells and platelets – is injected in and around the damaged tendon, sometimes after the fibres have been disrupted by a process called dry needling. The aim is to supply the tendon with growth factors to help the healing process. The procedure may be repeated if needed, and patients who have had it done need to avoid overusing or straining the tendon for a few weeks before embarking on a course of physiotherapy. In its guidance on the intervention, available at http://www.nice.org.uk/guidance/ipg438, NICE states the autologous blood injection is safe but there are uncertainties about how well it works, and therefore patients should fully understand the risks and benefits before making a decision on whether they want to have the procedure.
Keyhole surgery – removing the damaged section of tendon or deposits that have formed or repairing a rupture – is a last resort because the risks, including scarring and infection are generally considered to outweigh the chances of success.
Come back tomorrow for the final instalment of our special tendonitis feature, where we look at the advice you can give patients to help them manage the risks in the long term.