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A biopsychosocial approach to chronic mid-portion Achilles tendinopathy


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A Biopsychosocial (BPS) approach was taken to a chronic mid portion Achilles Tendinopathy in a 35 year old runner - treatment modalities included conservative management, acupuncture and psychosocial focus. Full recovery was seen and measured objectively and subjectively. The author argues this approach is undervalued in sports injuries.
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© 2016 Acupuncture Association of Chartered Physiotherapist 1
Acupuncture in Physiotherapy, Volume 28, Number 1, Spring 2016, 00–00
A biopsychosocial approach to chronic mid-
portion Achilles tendinopathy
A. M. Davidson
Locomotor Outpatients Department, Homerton University Hospital NHS Foundation
Trust, London, UK
A 37- year- old male runner with a 7- month history of right- sided mid- portion Achilles ten-
dinopathy was treated with physiotherapy and acupuncture treatment in a National Health
Service outpatient department. Along with other conservative management options, acu-
puncture was used as part of a holistic biopsychosocial approach. The treatment ultimately
alleviated the pain and improved function, and helped the subject to achieve his agreed
goal. New research is emerging that supports the use of acupuncture for tendon disorders;
however, the exact treatment mechanism is not yet fully understood. Suggested mechanisms
are discussed with reference to relevant literature.
Keywords: Achilles tendinopathy, acupuncture, biopsychosocial model, load management.
Tendinopathies account for a large proportion
of musculoskeletal complaints. These conditions
have a high incidence of chronicity and recur-
rence, which results in appreciable morbidity
and loss of productivity, and represents a major
socioeconomic burden (Maffulli et al. 2003).
Chronic tendinopathy encompasses a spectrum
of disorders.
Tendons are collagenous structures that
contain tenocytes, water and ground substance.
These structures are surrounded by loose connec-
tive tissue, the paratenon, which forms an elastic
sleeve that allows free movement of the tendon.
Where tendons travel through narrow areas,
this tissue becomes a specialized “tenosynovial
sheath” that helps to reduce friction between the
tendons and the surrounding structures.
The spectrum of disorders involved in tendi-
nopathy includes lesions of the tenosynovium,
paratenon and enthesis (i.e. the attachment of
the tendon to the bone), and the tendon itself.
Achilles tendinopathy is very prevalent in both
the sporting and recreational communities, and
even in the sedentary population. Recent find-
ings suggest that up to 20% of running injuries
involve the Achilles tendon. As involvement
in recreational sports has increased over the
past 50 years, so has the incidence of tendon
rupture, which is between four and five times
more likely among men, and has a peak occur-
rence in those between 30 and 40 years of age
(Alfredson & Lorentzon 2000).
The onset of pain is often associated with
a sudden change in activity rates; for example,
from high to low and back again. This is because
the time spent resting or in a more sedentary
state reduces the tensile strength of the tendon.
When individuals return to their previous level
of activity after a prolonged rest, they run the
risk of exceeding the load- bearing capacity of
Correspondence: Andrew Michael Davidson, Locomotor
Outpatients Department, Homerton University Hos-
pital NHS Foundation Trust, Homerton Row, London
E9 6SR, UK (e- mail:
Chronic mid- portion Achilles tendinopathy
© 2016 Acupuncture Association of Chartered Physiotherapist2
the tendon and producing microtrauma on a
cellular level.
The changes apparent in the tendon itself
are a sequence of pathological events that begin
with upregulation of its cells, the tenocytes. This
is followed by a change in the ground substance
from proteoglycan to aggrecan, which has a
larger molecular weight and binds more water,
thereby causing swelling. After this, changes in
the collagen cause cleaving or separation of the
collagen bundles, as well as degeneration. Finally,
there are changes in vascularity: new vessels
develop, accompanied by neural ingrowth, which
is believed to lead to tendon pain (Alfredson &
Lorentzon 2000). Pain and dysfunction are the
main clinical signs of a tendinopathy. Other
symptoms include swelling or thickening of the
tendon. Appreciable weakness and/or a positive
squeeze test suggest a torn or ruptured tendon
(Douglas et al. 2009).
The present case report suggests that acu-
puncture has a role in the treatment of ten-
dinopathies as an adjunct to Western medical
Case report
The present subject was a 37- year- old man with
a 7- month history of right- sided mid- portion
Achilles tendinopathy pain. His condition was
coupled with reduced mobility and strength,
and an inability to return to his hobby of run-
ning. He was an avid amateur athlete who had
taken part in long- distance runs on an annual
basis over the past 10 years.
At the time of the injury, the subject was not
preparing for any event. He had recently taken
a 2- week holiday, which had involved minimal
loading, and then returned to his normal sched-
ule when he got back. The subject experienced
a gradual onset of pain after a run, and this pro-
gressed over the next few days; however, there
was no clear mechanism of injury or trauma.
He attempted to manage his own symptoms
with activity modification for 4 months, but this
did not have any effect on his symptoms.
The tendinopathy eventually progressed to the
point where the subject had to stop all loading
activity because the pain had begun to affect his
gait, especially in the morning and after pro-
longed sitting. He sought help from his general
practitioner, who prescribed non- steroidal anti-
inflammatory drugs, and advised him to perform
stretches and use ice to reduce his symptoms at
rest. The subject’s inability to return to running
had a significant impact on his perceived quality
of life. The present author’s subjective assess-
ment is outlined in “Appendix 1”.
The subject’s main goal was to reduce the
pain and return to his previous level of fitness.
However, he had developed unhelpful beliefs
about his condition. He had been told that he
probably had “arthritis” in his tendon because
of his age and the amount of running that he
had done. He was also concerned that he might
suffer a rupture should he return to his previ-
ous level of training.
Clinical impression
A thorough subjective history was taken. After
ruling out alternative diagnoses such as a stress
fracture or retrocalcaneal bursitis, and using
ultrasound sonography to confirm the presence
of tendinopathic changes (Fig. 1), a diagnosis
of mid- portion Achilles tendinopathy in a state
of degenerative disrepair was made.
The subject had bilateral pes planus, and a
slightly antalgic gait with reduced weight- bearing
and heel strike on the right. Although there
was no heat or redness in the affected area, a
squeeze test of the mid- portion of the tendon
was positive for pain. An ultrasound scan
showed no evidence of intrasubstance tears.
Figure 1. Doppler ultrasound scan of a mid- portion
Achilles tendinopathy. The arrows indicate the presence
of neovessels.
A. M. Davidson
© 2016 Acupuncture Association of Chartered Physiotherapist 3
The thickness of the average Achilles
tendon is approximately 6 mm. However, at
1.1 cm, the subject’s right Achilles tendon was
approximately twice its normal size on pres-
entation. There were also moderate signs of
mid- substance neovascularity on the ultrasound
scan. An Öhberg score of 3+ (Sengkerij et al.
2009) and a visual analogue scale (VAS) score
of 8/10 were recorded.
The examination findings were explained to the
subject in detail. The intention was to provide
him with an understanding of his symptoms,
and offer him reassurance about the apparently
poor findings of the ultrasound scan. Although
there may be a correlation between the presence
of neovascularity and pain, there is no estab-
lished cause- and- effect relationship at present,
and the evidence base remains ambiguous (Rees
et al. 2014).
The subject was informed that stress and
anxiety can indirectly influence pain by increas-
ing neural sensitivity (O’Sullivan 2005). To give
his rehabilitation focus and purpose, a long-
term SMART (specific, measurable, attainable,
relevant and time- bound) goal was mutually
agreed. This involved completing a pain- free (or
VAS < 3/10) run of 5–8 miles (approximately
8–13 km) at 50% of his normal running pace
within 3 months. The initial focus was on
improving his distance rather than his speed
since tendon pain and flare- ups are associated
with sudden increases in load and tension.
The subject was given a 2- week plan, and
was asked to avoiding walking barefoot. He was
referred to the foot health department for gait
and posture assessment, and the fitting of heel
lifts. He was also taught an eccentric loading
programme because there is evidence to sup-
port this as a method of inducing procollagen
synthesis within tendons (Öhberg et al. 2004).
However, there has also been a recent drive
to focus on the concept of load management,
which underpinned this exercise plan (Cook &
Purdam 2009).
The principle of load management is to
determine the level at which the patient can
safely load the affected joint without pain. This
is then gradually progressed during rehabilita-
tion on the basis of the available biochemical
and histological evidence associated with degen-
erative tendinopathies. Fu et al. (2010) proposed
a combination of theories that indicated that,
while trauma might initiate the inflammatory and
remodelling phase of healing, multiple intrinsic
and extrinsic factors in a poorly suited environ-
ment could result in a failed healing response
(Fig. 2). Therefore, because a tendinopathy is
essentially an overload injury, managing load
and stress through the tendon and joint is
The subject was reviewed after 2 weeks. His
pain had reduced from 8/10 to an intermittent
5/10 on the VAS. A light jog had caused his
symptoms to flare up for several days. He was
advised to avoid running and concentrate on
non- impact- based forms of exercise to maintain
fitness; for example, cycling, swimming, cross-
training and rowing. The subject continued to
use ice and a non- steroidal anti- inflammatory
gel, which seemed to help somewhat. His exer-
cise technique was reviewed to ensure that his
training was relatively pain- free. The focus was
on slow, controlled movements to eccentrically
load the tendon, and improve his hip and knee
During his third visit, 2 weeks later, the sub-
ject reported that he had again tried to go for a
run because his pain was improving. This time,
the flare- up was so severe he had to take a day
off work. At this stage, it was deemed appropri-
ate to offer him acupuncture treatment, primar-
ily in order to provide pain relief. After the risks
and benefits of acupuncture were explained, the
subject gave his consent and was provided with
an information form.
In order to support the clinical reasoning
for the points selected (Table 1), the present
author utilized the “layering method” sug-
gested by Bradnam (2001). While not entirely
based on clinical research, this approach is
based on “an existing knowledge of anatomy,
segmental and peripheral nerve innervation of
tissues, and the neuroanatomy of the sympa-
thetic nervous system” (Bradnam 2003, 2007,
p. 21).
Chronic mid- portion Achilles tendinopathy
© 2016 Acupuncture Association of Chartered Physiotherapist4
Clinical reasoning for acupuncture
It was difficult to determine what the present
subject’s primary pain mechanism was, and the
relevance or even presence of inflammation as
part of a chronic tendinopathy is the subject of
debate. Rees et al. (2014) pointed out that recent
advances in immunohistochemistry have actu-
ally shown that there are inflammatory reactions
in both early overload and in chronic tendi-
nopathy. These authors contended that, even if
inflammation is not detected at a certain point
in time, this does not imply that it was not the
cause of the tendinopathic change in the first
place. Rees et al. (2014) went on to argue that
it is very likely that inflammatory mediators are
present at some stage of the development of
In addition, failed tendon healing responses
have been shown to produce multiple chemi-
cal irritants that can increase the sensitivity
of nociceptors to noxious and innocuous
stimuli within the pathological tissue (Khan
et al. 1999). Excitatory neurotransmitters such
as substance P and glutamate have consistently
been shown to be present in chronic tendinopa-
thy, and these are believed to further aggravate
the pain response through a complex series
of events. This has led to a greater focus on
the role of the nervous system in these condi-
tions. Therefore, the primary pain mechanism
in the present case was considered to be a
nociceptive/inflammatory one, and the desired
acupuncture mechanism was predominantly
Acupuncture has been recommended for
short- term pain relief in tendon pathology;
however, while this was the desired effect,
acupuncture was also chosen for its potential
to improve tissue healing (Neal & Longbottom
2012). Bradnam (2001) explained that the desired
peripheral response mechanism stimulated by
acupuncture facilitates the release of sensory
neuropeptides, inducing local vasodilation and
Figure 2. Three- stage model of the failed healing process. Image reprinted from Fu et al. 2010, Fig. 1, p. 6) in accordance
with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license (© 2010 Fu et al.; licensee BioMed
Central Ltd).
A. M. Davidson
© 2016 Acupuncture Association of Chartered Physiotherapist 5
Table 1. Clinical reasoning for acupuncture: (VAS) visual analogue scale; (VISA- A) Victorian Institute of Sports Assessment – Achilles
questionnaire; (N/A) not applicable; (NSAIDs) non- steroidal anti- inflammatory drugs; (SMART) specific, measurable, attainable, relevant,
time- bound; (BL) Bladder; (KI) Kidney; (GB) Gall Bladder; and (LI) Large Intestine
Outcome measure
Treatment Acupuncture points Clinical reasoning Response VAS VISA- A
Session 1
7/10 39
Session 2
Revised exercises
Pain management
Soft tissue work
7/10 N/A
Session 3
Non- impact exercises
Pain management
Reassurance about likely mild
flare- up in 24 h
Prone position, local points to
stimulate pain relief and increase
blood flow, low initial dose since
highly irritable
GB34 is an influential point for
tendons and a relaxation point
Painful during
Relaxed after
Improved gait
3/10 N/A
Session 4
Graded impact exercise
Agreed to start a return to
running in 4 weeks
Prone position, local points for
pain relief/circulation
Increased dose since last treatment
well tolerated, musculotendinous
junction for blood flow
Hyperstimulation anaesthesia
Painful during
Relief after
Improved gait
3/10 N/A
Session 5
Progress to alternating fast
walk and light jog
Heel raises with resistance
Prone position, local points for pain
Calming effects for anxiety/stress,
try to encourage lasting pain relief
Increased points into/around tendon
to encourage breakdown of
dysfunctional collagen to aid tendon
Painful during
Relief after
Improved gait
2/10 N/A
Session 6
As above As above As above Painful during
Relief after
Improved gait
2/10 N/A
Session 7
Progress to alternating light
and regular jog for a maximum
of 15 min
As above As above Mild flare- up
during jog,
eased off after
stretches and
2/10 N/A
Session 8
Return to run self- management
Aim to meet SMART goal in
4 weeks
Minimal symptoms, focus on return
to running and improving strength
Chronic mid- portion Achilles tendinopathy
© 2016 Acupuncture Association of Chartered Physiotherapist6
modulating local immune responses. She sug-
gested that this is best achieved by needling
close to the injured tissue, and using low-
intensity stimulation to encourage a peripheral
(rather than central) release of neuropeptides
(Bradnam 2001).
A healthy tendon requires a strict balance
between cell proliferation and death. It is
believed that the hypoxic environment present
in a tendinopathy may be a primary cause
of apoptosis, i.e. programmed cell death.
Programmed cell death is the natural elimina-
tion of redundant cells; however, it can inter-
fere with cell proliferation (Neal & Longbottom
2012). Neovascularity is thought to be the
body’s response to this hypoxic state. However,
studies have shown that this process does not
actually improve tendon vascularity, and as a
result, treatments that promote blood flow
have been explored for these conditions (Neal
& Longbottom 2012). Acupuncture has been
shown to improve vasodilation within human
tissue, and it may also be able to improve ten-
don blood flow.
Since the subject’s ultrasound scan showed a
high level of neovascularity, this suggests that
hypoxia was a part of his tendon pathology,
further supporting the use of acupuncture.
Outcome measures
The condition- specific Victorian Institute
of Sports Assessment – Achilles (VISA- A)
questionnaire was used to measure the present
subject’s perceived level of function (Robinson
et al. 2001). In addition, a visual analogue scale
(VAS) was employed specifically to measure
his level of pain. Before the subject underwent
acupuncture, his VISA- A and VAS scores
were 39 and 7 /10, respectively. On reflec-
tion, it might also have been helpful to use the
Patient- Specific Functional Scale, which would
have allowed him to choose his own tasks and
Results and discussion
The results of the treatment are shown in
Table 1. The present subject’s final VISA- A and
VAS scores were 64 and 2/10, respectively.
Acupuncture appeared to produce pain relief,
improved function, and provided results com-
parable to those of other adjunctive treatments
(e.g. extracorporeal shockwave therapy, platelet-
rich plasma therapy, and autologous blood and
corticosteroid injections) without the added
risks of rupture or weakening tendon integrity.
A holistic approach was used, and as such,
the present results should be interpreted with
caution. The subject received treatment that
was consistent with a biopsychosocial health-
care model, which included the reduction of
any health- related stress or anxiety, and the
improvement of his sleep pattern. Conservative
physiotherapy management was also provided
in order to improve his range of movement and
strength, and graded load management was used
to progress the subject’s return to his previous
activity levels. Nevertheless, acupuncture does
seem to have played a key role in his recovery,
and he subjectively reported a positive response
to the treatment.
Further research into the mechanisms under-
lying acupuncture would help clinicians to target
their interventions more specifically to a condi-
tion. However, considering the relatively low risk
and potentially significant effects of acupunc-
ture, one could defend a more pragmatic view
of its use in the UK National Health Service
(NHS), especially if the primary outcome is
pain relief, which has a stronger evidence base.
Although the present subject had a chronic
tendinopathy, it is not possible to rule out natu-
ral regression as the source of his relief. The
pathophysiology of tendon pain is complex
and multidimensional, and the stages of tendon
healing are dynamic and influenced by multiple
No confounding factors were controlled for,
such as the subject’s use of or engagement
in: medication, anti- inflammatory gel and ice;
eccentric loading, exercise and stretches; stress
management; improved footwear and an altered
running technique; soft- tissue manipulation,
education and taping.
In addition, the fact that the present author
was a novice must be taken into account.
A. M. Davidson
© 2016 Acupuncture Association of Chartered Physiotherapist 7
Acupuncture points and techniques were altered
between and during treatment sessions, affecting
reproducibility. It is reasonable to assume that
it was the combined effect of the interventions
that ultimately led to the subject’s successful
Future research might benefit from investi-
gating a more pragmatic use for acupuncture
in the NHS. The Keele STarT Back Screening
Tool for back pain is a good analogy: by iden-
tifying certain characteristics in a patient, the
practitioner can predict what type of treatment
the individual will respond to, depending on the
psychosocial factors influencing their situation.
Similarly, one might be able to identify which
tendon stages/patient presentations are more
likely to improve with acupuncture, and which
ones may not. An ad hoc cost- effectiveness
analysis could then determine its viability.
I would like to thank the subject of this case
study, and my AACP cohort and tutor for help-
ing me to develop my acupuncture skills. I am
also grateful to Homerton University Hospital
NHS Foundation Trust for providing me with
supervised training following my completion of
the AACP foundation course.
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Andrew Davidson works as a senior physiotherapist
and part- time researcher in the locomotor outpatient
department of Homerton University Hospital NHS
Foundation Trust. His speciality is musculoskeletal
therapy for persistent pain, and he has a particular
interest in the management of tendinopathies.
Chronic mid- portion Achilles tendinopathy
© 2016 Acupuncture Association of Chartered Physiotherapist8
Appendix 1
Clinic assessment form
Name: [redacted] DOB: [redacted]
Therapist: LM Andrew Davidson Designation: B6 PT
Date: [redacted] NHS: [redacted] RiO: [redacted]
Occupation/hobbies: Desk- based/running
Main presenting problem: Right- sided posterior heel pain
PC: Posterior heel pain
HPC: Gradual onset; no trauma or direct mechanism of injury over the past 7 months; no swelling,
redness or heat
PMH: Nil
DH: Ibuprofen PRN
SH: Lives with partner, full- time employment, office job (seated)
Aggravates: Pain on impact loading and prolonged
sitting; some pain in the morning
Eases: Ice, non- steroidal anti- inflammatory
drugs, rest
Night pain: Nil
Twenty- four- hour pattern: Increased a.m.,
decreased p.m.
Numerical Rating Scale score: 7
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
Background: The 'layering method', a clinical reasoning model for Western acupuncture, is a theoretical framework based on pain and tissue mechanisms. This focus on the mechanics of disability is a limitation of the original model. From a holistic viewpoint, the psychological status of an individual should be considered in clinical reasoning models. Objectives: The first objective was to summarize the original layering model. The second was to determine mechanisms underlying integration of sensations and emotions in the human brain and their effect on the body via output transfer systems of the autonomic, immune, and endocrine systems. The third objective was to determine whether acupuncture can modulate similar regions in the brain and to formulate appropriate clinical reasoning questions. Major findings: Interoceptive sensory stimuli and emotions are integrated in limbic and frontal brain regions to allow emotional responses to feedback from the body and provide the individual with a 'sense of self'. A strong connection with brainstem nuclei modulating output transfer systems allows emotions to regulate homeostatic balance. Acupuncture may be interpreted as an interoceptive stimulus by the brain. Neuroscience research has shown that acupuncture can modulate neural activity in similar brain regions to those processing emotional responses to sensory inputs. Conclusions: Acupuncture may influence emotional responses and their impact on the neurobiology of the human body. A biopsychosocial clinical reasoning model based on the modulation of emotional processing in the brain is proposed. This suggests that acupuncture may be used as an adjuvant to other therapies in disorders with a biopsychosocial component.
Full-text available
Tendinopathy is a debilitating condition in athletic and sedentary populations for which a gold standard treatment strategy does not yet exist. While the pathophysiology of tendinopathy is well understood, a debate remains as to the nature of the pain mechanism in tendinopathy which makes treatment selection challenging. This clinical discussion presents evidence to suggest that acupuncture may have a role in the treatment of tendinopathy, through the facilitation of tendon blood flow and fibroblastic activity, making recommendations for further research.
Full-text available
The western approach to acupuncture as practised by many physiotherapists has been criticised because of the lack of clinical reasoning underpinning treatment choices. In accordance with recent advances in the understanding of neurophysiology and pain mechanisms western acupuncture can now be implemented with more reference to the basic sciences. A clinical reasoning model based on physiological mechanisms is proposed to aid physiotherapists in making treatment decisions and to provide a framework in which to guide alteration to interventions during the course of recovery. The model has yet to be validated by scientific research. Brandham L. (2003) A Proposed Clinical Reasoning Model for
Full-text available
Our understanding of the pathogenesis of "tendinopathy" is based on fragmented evidences like pieces of a jigsaw puzzle. We propose a "failed healing theory" to knit these fragments together, which can explain previous observations. We also propose that albeit "overuse injury" and other insidious "micro trauma" may well be primary triggers of the process, "tendinopathy" is not an "overuse injury" per se. The typical clinical, histological and biochemical presentation relates to a localized chronic pain condition which may lead to tendon rupture, the latter attributed to mechanical weakness. Characterization of pathological "tendinotic" tissues revealed coexistence of collagenolytic injuries and an active healing process, focal hypervascularity and tissue metaplasia. These observations suggest a failed healing process as response to a triggering injury. The pathogenesis of tendinopathy can be described as a three stage process: injury, failed healing and clinical presentation. It is likely that some of these "initial injuries" heal well and we speculate that predisposing intrinsic or extrinsic factors may be involved. The injury stage involves a progressive collagenolytic tendon injury. The failed healing stage mainly refers to prolonged activation and failed resolution of the normal healing process. Finally, the matrix disturbances, increased focal vascularity and abnormal cytokine profiles contribute to the clinical presentations of chronic tendon pain or rupture. With this integrative pathogenesis theory, we can relate the known manifestations of tendinopathy and point to the "missing links". This model may guide future research on tendinopathy, until we could ultimately decipher the complete pathogenesis process and provide better treatments.
Background—There is no disease specific, reliable, and valid clinical measure of Achilles tendinopathy. Objective—To develop and test a questionnaire based instrument that would serve as an index of severity of Achilles tendinopathy. Methods—Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire to assess the severity of Achilles tendinopathy. The final version consisted of eight questions that measured the domains of pain, function in daily living, and sporting activity. Results range from 0 to 100, where 100 represents the perfect score. Its validity and reliability were then tested in a population of non-surgical patients with Achilles tendinopathy (n = 45), presurgical patients with Achilles tendinopathy (n = 14), and two normal control populations (total n = 87). Results—The VISA-A questionnaire had good test-retest (r = 0.93), intrarater (three tests, r = 0.90), and interrater (r = 0.90) reliability as well as good stability when compared one week apart (r = 0.81). The mean (95% confidence interval) VISA-A score in the non-surgical patients was 64 (59–69), in presurgical patients 44 (28–60), and in control subjects it exceeded 96 (94–99). Thus the VISA-A score was higher in non-surgical than presurgical patients (p = 0.02) and higher in control subjects than in both patient populations (p<0.001). Conclusions—The VISA-A questionnaire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects. The continuous numerical result of the VISA-A questionnaire has the potential to provide utility in both the clinical setting and research. The test is not designed to be diagnostic. Further studies are needed to determine whether the VISA-A score predicts prognosis.
It is currently widely accepted that chronic tendinopathy is caused by a degenerative process devoid of inflammation. Current treatment strategies have focused on physical treatments including eccentric exercises, peritendinous injections of blood or blood products and interruption of painful stimuli. Results have been at best moderately good and at worst a failure. The evidence for degeneration alone as the cause of tendinopathy is surprisingly weak. There is compelling evidence that inflammation is a key component of chronic tendinopathy. Newer anti-inflammatory modalities provide alternative potential opportunities in treating chronic tendinopathies and should be explored further.
The Simmonds Thompson test, described in 1957 and 1962,(1-3) respectively, remains the principal clinical test for rupture of an Achilles tendon. However, there is some discrepancy in the literature regarding its mechanical significance. A positive test has been reported to indicate a complete rupture of the tendon,(4) and the cited mechanical reason for the positive test (complete rupture) is the loss of integrity of the soleal part of the tendon. This is consistent with Thompson's initial description, in which he reported that " ... by anatomical dissections ... plantar flexion of the foot depends on an intact soleus muscle attachment to an intact tendon of Achilles." O'Brien,(5) however, reported that a negative test depended on an intact connection of the gastrocnemius aponeurosis to that of die soleus muscle and further described a needle test to assess this. We report the cases of 2 patients with surgically treated Achilles tendon rupture with positive Simmonds-Thompson tests in which only the gastroenemius portion of the triceps surae complex was disrupted. In both patients, the Simmonds-Thompson test finding was negative after we repaired the tear.
Power Doppler ultrasonography is widely used to examine neovascularization in midportion Achilles tendinopathy. The reliability of the grading of the degree of neovascularization has not been examined previously. Power Doppler ultrasonography can be performed with a high interobserver reliability to determine the neovascularization score in patients with midportion Achilles tendinopathy. Case control study (diagnosis); Level of evidence, 4. Thirty-three symptomatic and 17 asymptomatic Achilles tendons from 25 consecutive patients were included for ultrasound examination. Victorian Institute of Sport Assessment-Achilles score was used to assess the severity of the Achilles tendinopathy. Each tendon was scored twice by different radiologists using the modified Ohberg score for neovascularization. The intraclass correlation coefficient for interobserver reliability was 0.85. Neovascularization was observed in 70% (23/33) of the symptomatic tendons and in 29% (5/17) of the asymptomatic tendons. The Spearman correlation coefficient between the Victorian Institute of Sport Assessment-Achilles score and the degree of neovascularization was - 0.16 (P = .10). An excellent interobserver reliability was found for determining the degree of neovascularization on power Doppler ultrasonography examination. Neovessels were present in a majority of symptomatic tendons. The severity of symptoms was not correlated with the neovascularization score. Power Doppler ultrasonography is widely used to evaluate tendinopathy without knowledge of the difference in observations between several testers. Interobserver reliability of the evaluation of the degree of neovascularization in chronic midportion Achilles tendinopathy is excellent.
Overuse tendinopathy is problematic to manage clinically. People of different ages with tendons under diverse loads present with varying degrees of pain, irritability, and capacity to function. Recovery is similarly variable; some tendons recover with simple interventions, some remain resistant to all treatments. The pathology of tendinopathy has been described as degenerative or failed healing. Neither of these descriptions fully explains the heterogeneity of presentation. This review proposes, and provides evidence for, a continuum of pathology. This model of pathology allows rational placement of treatments along the continuum. A new model of tendinopathy and thoughtful treatment implementation may improve outcomes for those with tendinopathy. This model is presented for evaluation by clinicians and researchers.
Tendon disorders are a major problem for participants in competitive and recreational sports. To try to determine whether the histopathology underlying these conditions explains why they often prove recalcitrant to treatment, we reviewed studies of the histopathology of sports-related, symptomatic Achilles, patellar, extensor carpi radialis brevis and rotator cuff tendons. The literature indicates that healthy tendons appear glistening white to the naked eye and microscopy reveals a hierarchical arrangement of tightly packed, parallel bundles of collagen fibres that have a characteristic reflectivity under polarised light. Stainable ground substance (extracellular matrix) is absent and vasculature is inconspicuous. Tenocytes are generally inconspicuous and fibroblasts and myofibroblasts absent. In stark contrast, symptomatic tendons in athletes appear grey and amorphous to the naked eye and microscopy reveals discontinuous and disorganised collagen fibres that lack reflectivity under polarised light. This is associated with an increase in the amount of mucoid ground substance, which is confirmed with Alcian blue stain. At sites of maximal mucoid change, tenocytes, when present, are plump and chondroid in appearance (exaggerated fibrocartilaginous metaplasia). These changes are accompanied by the increasingly conspicuous presence of cells within the tendon tissue, most of which have a fibroblastic or myofibroblastic appearance (smooth muscle actin is demonstrated using an avidin biotin technique). Maximal cellular proliferation is accompanied by prominent capillary proliferation and a tendency for discontinuity of collagen fibres in this area. Often, there is an abrupt discontinuity of both vascular and myofibroblastic proliferation immediately adjacent to the area of greatest abnormality. The most significant feature is the absence of inflammatory cells. These observations confirm that the histopathological findings in athletes with overuse tendinopathies are consistent with those in tendinosis--a degenerative condition of unknown aetiology. This may have implications for the prognosis and timing of a return to sport after experiencing tendon symptoms. As the common overuse tendon conditions are rarely, if ever, caused by 'tendinitis', we suggest the term 'tendinopathy' be used to describe the common overuse tendon conditions. We conclude that effective treatment of athletes with tendinopathies must target the most common underlying histopathology, tendinosis, a noninflammatory condition.