Shock wave therapy and topical glyceryl trinitrate
The role of repetitive shock wave therapy and topical glyceryl trinitrate in the treatment of chronic noninsertional Achilles tendonopathy is less clear. In a double-blinded RCT of 49 patients, shock wave therapy did not produce better outcomes than placebo.5
However, a prospective cohort study of 68 patients found that patients who received shock wave therapy had significantly lower mean visual analog scale scores for pain compared with controls after 1 month (P<0.001), 3 months (P<0.001), and 12 months (P<0.001) of treatment.6 In a double-blinded RCT of 65 patients, more patients treated with topical glyceryl trinitrate therapy were asymptomatic during activities of daily living at 6 months compared with placebo (P<0.001).7
Both shock wave therapy and topical glyceryl trinitrate may have a significant role to play in treating chronic noninsertional Achilles tendonopathy, but more studies are needed to support their use.
Surgery appears to work better for athletes
Surgery is an option for patients with chronic noninsertional Achilles tendonopathy who have failed conservative measures and a 3- to 6-month rehabilitation program. In a systematic review of 26 studies of patients managed surgically, the mean success rate (full return to preinjury activity level) was 77%. However, a negative correlation was observed between the reported success rate and the overall methods score, a rating of the quality of studies (r=0.53; P<0.01). Only 5 of the studies reviewed were prospective cohort studies; the remaining 21 were retrospective cohort studies and case studies.8
Athletes responded significantly better to surgery than nonathletic patients, returning to full activity in 4.5 months compared with 7.1 months for nonathletes (P<0.03). Fewer athletes had surgical complications (9% compared with 19% of nonathletes).9 More studies are needed to clarify the role of surgery in managing Achilles tendonopathy.
Recommendations
The American College of Foot and Ankle Surgeons recommends initial management by reducing pressure around the affected area combined with heel lifts, orthotics, NSAID therapy, and physical therapy. Immobilization may be used on a case-by-case basis. Local steroid injections aren’t recommended. Patients with resistant tendonopathy should be referred to a foot and ankle surgeon.10