Bruce Buley, PT, explains how to properly identify and evaluate
Q. In your opinion, why is it important to differentiate between tendinitis and tendinosis?
It is important to differentiate between the two because the treatments are different. For tendinitis, rest and anti-inflammatories are necessary to heal the tissue; in tendinosis, there is an atrophic quality to the tissue in which no mast or inflammatory cells are seen histologically (Alfredson et al). As a result, the tissue needs to be reconditioned, but the rate and intensity of the reconditioning depends on the patient.
In patients suffering from Achilles tendinosis, neovascularization appeared to contribute to continued pain, and another study conducted by Ohbey and Alfredson (2002) found that sclerosing new blood vessels seemed to decrease pain.
In an acute tendinitis that does not respond to treatment of modalities, the use of a walking boot for six weeks to optimize rest through immobilization followed by active rehab is recommended.
Q. What evidence-based protocols do you use for Achilles tendinosis? What is your personal experience with the success of these protocols?
Alfredson et al. is the primary protocol for Achilles tendinosis though there have been some modifications regarding the extent of excursion of eccentrics depending on whether the pain is located either the insertion or the midpoint of the tendon.
Q. Do you see any negative effects from these protocols? Can you site any contraindications?
The “dicey” issue is accurately distinguishing between a tendinosis and a tendinitis. Generally speaking, longer-standing Achilles pain is usually associated with a tendinosis whereas a shorter-term problem is more likely tendinitis.
Q. Do you use lifts in shoes for this problem? For what length of time?
I often use lifts based on the mechanical logic that the tendon works less when it does not have to push through a great range of motion in acute Achilles tendinitis. I have also used a medial rear-foot wedge to help valgus at the heel strike. The idea is to decrease medial strain at the Achilles tendon as the heel goes into valgus (Donnatelli et al.).
In general, I will use the heel lift for as long as the pain is present. When pain is eliminated, reconditioning is necessary to reestablish full excursion functionally of the tendon.
Q. Do you ever use orthoses for this problem? What is the most common prescription that you use (control for pronation, supination, equinus)?
Orthoses can be helpful when the gait pattern has a significant pronatory quality. I have also used orthoses for supinators, though much less often as they are much less frequent in their presentation. I have not done orthoses for equinus patients with Achilles tendinosis.
Bruce Buley is the Clinic Director at Comprehensive Physical Therapy Center (CPTC) in Chapel Hill, NC. Bruce received his physical therapy training at downstate Medical Center in New York City and earned an advanced Master’s in physical therapy at UNC-CH. His 30 years of physical therapy experience have included treating patients with orthopedic, neurological, cardiac, pediatric and sports related problems, including foot and orthotic fabrication.
Read more about Bruce and his practice: http://cptc-nc.com/.