What the research tells us: Achilles tendinopathy

What study are we looking into this month?

Are we asking the right questions to people with Achilles tendinopathy? The best questions to distinguish mild versus severe disability to improve your clinical management.

 

Who are the authors/researchers?

• Myles C. Murphy
• Brady Green
• Igor Sancho Amundarain
• Robert-Jan de Vos
• Ebonie K. Rio

 

What is the goal behind the research?

To determine which questions from the Achilles TENDINS-A, Foot and Ankle Outcome Score (FAOS), and Victorian Institute of Sports Assessment (VISA-A) are best able to distinguish mild and severe disability in patients with Achilles tendinopathy ^{(1, 2, 3)}.

 

What are your thoughts on this research?

These outcome measures are consistently used in research, but not as much in clinical practice. There are great questions within these measures, but they can be time-consuming, often forgotten, and may not seem relevant to the patient. They each have their advantages and disadvantages.

 

However, they provide an objective outcome in the subjective world of pain and function. If you are not familiar with them, I have provided a brief explanation and some example questions below.

• The FAOS is a patient-reported foot-and ankle-specific questionnaire including 42 items in evaluating pain, symptoms, function of daily living (ADL), function in sport and recreation and quality of life ⁽³⁾.

• The VISA-A is a valid and reliable index of the clinical severity of Achilles tendinopathy ⁽⁴⁾. For instance, in the VISA-A, two sample questions are:

 

Rating on a scale from 0 to 10

Do you have pain walking downstairs with a normal gait cycle?

Strong severe pain 0 to No pain 10

Or 

Do you have pain during or immediately after doing 10 (single leg) heel raises from a flat surface?

Strong severe pain 0 to No pain 10

 

Do you use this approach yourself?

Personally, I don’t use these outcome measures often, but I use my own framing of questions from each to incorporate into my assessment.

 

I believe it’s important to enquire about pain during meaningful activities and also to enquire about pain over a 24-hour period. These are the aspects people most frequently mention when describing their symptoms.

 

In the context of this study, we know that tendon pain is limiting for people who want to do more of what they enjoy. Qualitative studies echo this frustration, reporting patient comments such as, “I think it restricts me in a lot of things that I would be able to do”. Or, “You want it to happen now. You’re doing all this stuff and it’s just very slow progress.” ⁽⁵⁾

 

It’s clear that people want to get back to their meaningful activity with manageable pain levels; whether it be karate, running, or walking with friends. Tendinopathy requires an individualised approach to management. These questionnaires, in combination with our advice can help that.

 

What do you feel is of particular interest to podiatrists regarding this research?

Several points come to mind.

• We can use these measures to assess improvement and tailor our advice. It is worth checking these measures out; they may work well in some cases and have been validated.

• We know Achilles tendinopathy (AT) can persist for a long time ^{(2, 5, 6)}. One-fifth of patients with conservatively treated midportion AT still have symptoms after 10 years ⁽²⁾. Symptoms can vary, and quality of life can be reduced because of it ^{(2, 5)}. It is like plantar heel pain, meaning a lot of our advice revolves around prognosis and helping people understand that although slow progress can be frustrating, it is still progress.

• For podiatrists, understanding the severity of a condition and its potential prognosis helps us better inform our patients with education and advice. Although we know that low and stable symptoms are a good sign in tendinopathy, it can be difficult for someone who has had pain for eight months to accept.

 

Why is this of particular interest to you, to share with fellow podiatrists?

In healthcare, we all want to understand what the ‘special’ test is: the assessment, image, or questions that will give us all the answers. As we know, there isn’t one.

 

Orthopaedic tests vary in their sensitivity and specificity but they can help form a diagnostic and treatment framework ⁽⁷⁾. When it comes to Achilles tendinopathy, some questions can really help us as podiatrists:

 

1. Ask if someone experiences night pain, as it might help in the diagnosis of a bone stress injury.
2. Ask if someone has pain with high rates of loading, as it might help to rule out a peritendon (and rule in a tendinopathy).

 

Imagine if we had some questions to help differentiate between severe and mild Achilles tendinopathy? Questions that could give us more confidence in providing quality advice to patients?

 

For example, if over a two-month period someone reports their morning pain hasn’t changed at all, but they’re back to running 20 km from 0 km per day, and their pain subsides within 24 hours, then that’s a significant improvement. We may use that evidence to inform our education, which is a large part of what we do.

 

In our role, we function somewhat like guides, to assist individuals on their journey back to their desired outcomes. It involves various forms of support, with a significant part being the reassurance of staying on track despite encountering troublesome but manageable problems. This becomes all the more pronounced when various modalities have been implemented and there is more time between appointments.

 

The typical approach for managing an Achilles tendon issue involves staying consistent with rehab, engaging in meaningful activities, managing flare-ups, and allowing time for recovery. We need the confidence to inform our education when explaining that these current symptoms are typical and manageable, and that they do not indicate a need for significant changes.

 

Now you might be thinking, ‘If I had a dollar for every time you said education, I could probably retire’, and you’d be right. Patients with pain want clarity and understanding. I believe most people with persistent pain don’t expect their pain to go away quickly, but being more confident in our understanding of what constitutes improvement is helpful.

 

Were there any other areas within this research that you found interesting?

Definitely. Several questions were found in the research to be poor indicators of severity. These included whether patients have Achilles tendon stiffness, pain at rest, or pain during activities of daily living.

 

Patients often ask about these symptoms, since they are a common frustration.

 

If we know these areas are a poor indicator of severity, it doesn’t mean we say, ‘That doesn’t matter’, but it does mean we can be confident in using other metrics to gauge recovery, and thus education.

 

How can podiatrists use this new knowledge immediately?

Action points from this study share some very useful questions to aid podiatrists in forming a clinical picture. We can use the below questions in our initial assessment and during follow-up, to aid in our understanding of the severity. This can, in turn, help with our education.

 

Here are the questions that the authors concluded as being important to ask:

• The top ten best-performing items are:
• Numerical rating scale of pain with single-leg hopping.
• Numerical rating scale of pain with double-leg jumping.
• How many single-leg hops can be completed without pain?
• Time taken for pain to subside following aggravating activities (minutes).
• Numerical rating scale of pain with a single-leg calf raise.
• Numerical rating scale of pain with a double-leg calf raise.
• Time taken for stiffness/symptoms to subside following waking (minutes).
• Time taken for stiffness/symptoms to subside following prolonged sitting (minutes).
• Degree of reduction in physical activity from pre-injury levels.
• Difficulty in completing running in the past week.

 

If a podiatrist wants to discuss this with you, how can they contact you?

Instagram – @BlakeWithers.Sportspodiatrist

Podcast: Sports Medicine Project