What’s in a name?
Persistent tendon pain is a common musculoskeletal condition that affects active individuals, repetitive-manual workers and sedentary people alike (Clark et al., 2020; Scott et al., 2013). Historically, inconsistent, and inaccurate medical terms have been utilised to describe tendon pain. The term ‘tendinitis’ was first used to describe pain, tendon thickening and impaired function but implies triphasic inflammatory process that is not consistent with what we know about the pathoaetiology, and importantly may lead patients to a passive treatment path and away from exercise interventions. The term ‘tendinosis’ has been used in research publications and patient imaging reports, whilst ‘tendinopathy’ has emerged as the preferred term for persistent tendon pain and clinical diagnosis. It is important to have consensus, as differing terminology may lead to patient confusion or reduced confidence in health professional advice.
In 2018, world-leading tendon experts gathered in Groningen, Netherlands to reach consensus in the terminology, core domains and minimum standards of participant reporting for clinical tendinopathy research (Scott et al., 2020; Rio et al., 2019; Vicenzino, 2020). It was agreed that tendons that are painful in response to mechanical loading, should be referred to as tendinopathy and that common sites of tendon pain warrant a specific diagnostic name; for example, “Achilles tendinopathy” (Scott et al., 2020).
Achilles tendinopathy – what are clinicians currently doing?
Achilles tendinopathy (AT) may present as insertional or midportion (Martin et al., 2018) and mid-portion AT is suggested to be more prevalent (Silbernagel et al., 2020; Kvist., 1991). Numerous interventions have been proposed for midportion AT, such as exercise, stretching, heel lifts, night splints and taping, with varying evidence for their effectiveness (Martin et al., 2018). Despite a number of treatment modalities suggested to be efficacious in the management of midportion AT, it is unclear what interventions are being used in clinical practice. Recent work through La Trobe University highlights that Australian allied health professionals predominantly use exercise and education, but also use adjuncts such as heel lifts and massage, in the management of midportion Achilles’ tendinopathy (Bonello, Menz, Munteanu, Rio & Docking, 2022). With respect to exercise, a combination of differing exercise modalities (ie isometric, isotonic) are shown to be utilised by allied health professionals; rather than any single exercise (Bonello et al., 2022). Passive therapies such as massage, taping, heel lifts and shockwave appear to be used as an adjunct with selection driven by clinical experience rather than research evidence (Bonello et al., 2022). Understanding the treatment modalities that are utilised, and the factors that influence these choices (such as cost, access, or evidence), are helpful to inform research and positively impact clinical practice.
Are we all talking about the same thing?
Currently, La Trobe researchers are undertaking a project investigating how physiotherapists diagnose Achilles tendinopathy. This project aims to survey 1,000 national and international sports and musculoskeletal physiotherapists, to establish the key clinical questions and tests physiotherapists used during a clinical examination of Achilles tendinopathy (ethics approval HEC20320).
Physiotherapists from specialised experience in the area of tendinopathy, sports and musculoskeletal physiotherapists, as well new graduate physiotherapists are invited to complete.
How to participate:
If you are a qualified and registered physiotherapist working in musculoskeletal or sports physiotherapy field and willing to share 10-minutes of your time, we would be most grateful!
To participate simply visit https://redcap.latrobe.edu.au/redcap/surveys/?s=FRLXFDW379
The survey is distributed online via REDCap, and all responses are completely anonymous. As part of a big picture we hope to able to significantly advance the research and management of Achilles tendinopathy in physiotherapy and for this we thank you for your contribution.
Post by: Christian Bonello under the supervision of Dr Ebonie Rio.
- Clark, Zhu, M., Gamble, G. D., Naot, D., Paine, S.-J., Dalbeth, N., Cornish, J., & Musson, D. S. (2020). Epidemiology of tendon and ligament injuries in Aotearoa/New Zealand between 2010 and 2016. Injury Epidemiology, 7(1), 5–5. https://doi.org/10.1186/s40621-020-0231-x
- Scott, A., Docking, S., Vicenzino, B., Alfredson, H., Zwerver, J., Lundgreen, K., Finlay, O., Pollock, N., Cook, J. L., Fearon, A., Purdam, C. R., Hoens, A., Rees, J. D., Goetz, T. J., & Danielson, P. (2013). Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. British Journal of Sports Medicine, 47(9), 536–+. https://doi.org/10.1136/bjsports-2013-092329
- Scott, Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., de Vos, R.-J., Fu, S. N., Grimaldi, A., Lewis, J. S., Maffulli, N., Magnusson, S., Malliaras, P., Mc Auliffe, S., Oei, E. H. G., Purdam, C. R., Rees, J. D., Rio, E. K., Gravare Silbernagel, K., … Zwerver, J. (2020). ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. British Journal of Sports Medicine, 54(5), 260–262. https://doi.org/10.1136/bjsports-2019-100885
- Rio, E., Mc Auliffe, S., Kuipers, I., Girdwood, M., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., Fu, S. N., Grimaldi, A., de Vos, R.-J., Lewis, J. S., Maffulli, N., Malliaras, P., Magnusson, S. P., Oei, E. H. G., Purdam, C. R., Rees, J. D., Scott, A., … Zwerver, J. (2019). ICON PART-T 2019–International Scientific Tendinopathy Symposium Consensus: recommended standards for reporting participant characteristics in tendinopathy research (PART-T). British Journal of Sports Medicine, 54(11), 627–630. https://doi.org/10.1136/bjsports-2019-100957
- Vicenzino, B., de Vos, R.-J., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B. K., Fu, S. N., Gravare Silbernagel, K., Grimaldi, A., Lewis, J. S., Maffulli, N., Magnusson, S., Malliaras, P., Mc Auliffe, S., Oei, E. H. G., Purdam, C., Rees, J. D., Rio, E. K., Scott, A., … Zwerver, J. (2020). ICON 2019—International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients. British Journal of Sports Medicine, 54(8), 444–451. https://doi.org/10.1136/bjsports-2019-100894
- Martin, R. L., Chimenti, R., Cuddeford, T., Houck, J., Matheson, J. W., McDonough, C. M., Paulseth, S., Wukich, D. K., & Carcia, C. R. (2018). Achilles pain, stiffness, and muscle power deficits: Midportion Achilles tendinopathy revision 2018. The Journal of Orthopaedic and Sports Physical Therapy, 48(5), A1eA38. https://doi.org/10.2519/jospt.2018.0302
- Silbernagel, K. G., Hanlon, S., & Sprague, A. (2020). Current clinical concepts: Conservative management of Achilles tendinopathy. Journal of Athletic Training, 55(5), 438e447. https://doi.org/10.4085/1062-6050-356-19
- Kvist M. Achilles tendon injuries in athletes. Ann Chir Gynaecol. 1991;80(2):188–201.
- Bonello, Menz, H. B., Munteanu, S. E., Rio, E., & Docking, S. I. (2022). Treatment preferences and use of diagnostic imaging in midportion Achilles tendinopathy by Australian allied health professionals. Physical Therapy in Sport, 53, 21–27. https://doi.org/10.1016/j.ptsp.2021.11.001