What Do You Think?



Posted by Jeremy Windsor on Apr 27, 2021

Tony Page recently got in touch to tell us about the problems he's been having with his achilles tendon. Here's what he wrote...


"I started running regularly as a pre-registration house officer and continued to run, more frequently in spring, summer and autumn than in winter, for the next 25 years. Then I developed an Achilles tendinopathy (AT). I stopped running for a few weeks and it got better by itself. This pattern was repeated a couple more times but on the last occasion I didn’t start running again - I started riding a bike instead. That was about ten years ago.

During the first lockdown everybody, it seemed, was cycling. My bike needed a service - the disc brakes weren’t working properly and I thought it had become unsafe to ride. Booking it in at the bike shop I was told that there was a waiting list and it would be a month before the mechanic could work on it. Not looking forward to a month without regular exercise I thought I’d have a go at running once more. I no longer had a pair of running shoes, but did have a comfy, if battered, old pair of approach shoes. They didn’t have much cushioning, but as I’d be running across fields, albeit with some road work, I thought this would be OK. As it turned out, I was wrong, but not knowing this at the time I gradually increased my distances up to 7 miles and was enjoying my running so much that I continued to run after the bike had been fixed. I’d been running most days for about 6 weeks when I noticed that the mid-portion of both Achilles tendons were becoming a bit uncomfortable and were tender to a gentle squeeze. I eased off the running, cycled a bit more frequently and the tendons seemed to settle.

 

The old approach shoes


When I’d had the problem years ago, I’d paused the running and any rock climbing and continued to go fellwalking. This didn’t make things worse, so this time I continued to walk in the hills as I had done previously. I’d recently persuaded my old walking/climbing mate to start fell walking again - I’d given him up to road biking but he seemed keen to get into the hills after the first lockdown and to be enjoying walking once more. We live in south Lakes and I let him choose where to go. Summer into autumn we did some longish days with quite a bit of ascent. Both tendons were uncomfortable towards the end of a day’s walking but I persisted as I didn’t want to disappoint him. Then, after one particularly long walk both Achilles tendons swelled up, were very tender to a gentle squeeze and I was limping quite badly. Reluctantly, I cancelled the weekly hill walks. In October, before the second lockdown, my wife and I had a week booked in a cottage in Ullapool and I’d hoped to get up some Munros. Instead, I was confined to short valley walks and couldn’t keep up with her - and she is on the waiting list for knee replacements!


An Teallach, NW Highlands


AT is common, though exactly how common is more difficult to ascertain. Two recent studies did not distinguish between mid-portion and insertional AT. The first, in Dutch general practice, reported a prevalence of 2.35 per 1000 and a second, in Danish general practice, reported a prevalence of 5.2 per 1000. As might be expected, studies of runners have found a much higher prevalence. The occurrence in mountaineers seems unclear - one study of climbers reported a prevalence of 12.5%, but many mountaineers will also be runners, an obvious confounding factor.

Current thinking suggests that Achilles tendinopathy represents a failed healing response, rather than inflammatory condition. A recent overview, including the biology of the condition, can be found here. As to treatment, local steroid injections are generally not recommended following a number of case reports describing tendon rupture. There are, however, a multiplicity of other treatments and a recent systematic review and network meta-analysis examined 29 trials investigating 42 different interventions. The study can be found here. The interventions were classed as exercise (most commonly eccentric exercises), injection (various categories), acupuncture, extra-corporeal shock wave therapy and mucopolysaccharide supplement therapy. There were concerns about the high risk of bias in three-quarters of the trials and no trial was deemed as having a low risk of bias. The certainty of the evidence was judged very low to low in all trials but one, where it was judged to be moderate. The authors concluded that there were no clinically significant differences between the various treatments at 3-month and 12-month follow-up. Perhaps surprisingly, given that only 25 patients had wait-and-see as a treatment intervention against 1615 who had one of the various active interventions, they felt able to conclude that all active treatments were better than wait-and-see and even concluded that it would be unethical to conduct future studies using wait-and-see as a treatment arm.


Right Achilles tendon still swollen 3 months after starting eccentric exercises


If it is clear that the network meta-analysis doesn’t identify a single most effective treatment, there is still the problem of what to suggest to the individual patient. The authors recommend that as exercise therapy is cheap, safe and widely available, it should be the first-line treatment.

So, what did I do? As eccentric exercises (where the muscle-tendon complex lengthens whilst contracting) were the most common exercise interventions in the studies included in the network meta-analysis I decided to start these. There are lots of minor variations - I chose the Oxford programme simply because it is clearly described in a well-produced booklet available as a pdf. It can be found here.     

My left AT was almost back to normal even before I started the programme. There is a validated self-rating scale that can be used to monitor progress- the Victorian Institute of Sport Assessment - Achilles (VISA-A). I scored myself 6/100 at the start of treatment (the lower the score the more severe the impairment). Three weeks into the programme the right tendon was less swollen and I’d almost stopped limping. I scored 58/100 on the VISA-A. I continued to cycle, and to follow the Oxford programme, and after 6 weeks scored 94/100 on the VISA-A. I completed a short hill walk up the Beacon from Water Yeat via Beacon Tarn without symptoms, then just before the third lockdown went up Wetherlam from Tilberthwaite, again without problems.

I have now discontinued the exercises and I continue to cycle. A drive to start a long hill walk is not permitted at the moment, but I’m scoring 97/100 on the VISA-A and I’m not anticipating problems when this is allowed. My right tendon is still swollen but not painful when squeezed. I have decided give up running, for good this time.


Towards the summit of Wetherlam, just before third lockdown


Finally, some thoughts on the systematic review and network meta-analysis. Remember that 42 different interventions were condensed into five classes (exercise, injection, acupuncture, shock wave therapy and mucopolysaccharide therapy) and that there was no clinically significant difference between these classes of treatment. It is surely implausible that the underlying mode of action in these very different interventions is the same. As the certainty of the evidence was very low or low in all of the trials but one, where it was only moderate, then perhaps the most likely explanation is that inadequate trial design meant that the systematic review and network meta-analysis was never going to be able to identify a most effective treatment. I like, though, to entertain another possibility that would explain the lack of clinically significant difference – the placebo effect. The active treatments were generally either moderately dramatic (injections, applying needles, extra-corporeal shock waves) or moderately committing (daily exercise, daily medication) and if all of them were really better than wait-and-see then the placebo effect would be the most parsimonious explanation of this finding. What do you think?"


Thanks Tony!

Read about Tony's experience of treating depression here.

NEW DATE!

The Birmingham Medical Research Expeditionary Society (BMRES) and the British Mountain Medicine Society (BMMS) have joined forces to organise the 2021 Altitude Research Conference. The face-to-face event will take place in Birmingham on the 11th September. Speakers will include Peter Bartsch, Jo Bradwell and Chris Imray. There will also be presentations from members of the UK's leading research groups as well as ample opportunity for researchers, young and old, to present posters and short talks about their work.

Further details can be found here.

If you would like to find out more about mountain medicine why not join the British Mountain Medicine Society? See this link for details.


1 thought on “What Do You Think?

John Laughlin commented 1 month, 3 weeks ago
Thanks for a good summary of a condition that has plagued me on and off for years. I've had many of these treatments over the years and some work after a while but the most effective by far and quickest to get me back to running action was the application of GTN patch to the affected area, whilst continuing the eccentric rehab. Not sure why it's not mentioned in the reviews. It's the first treatment adjunct our local sports physicians would use these days.... I have one on right now! Another good, though slightly dated, resource is this 'Toolkit' https://physicaltherapy.med.ubc.ca/physical-therapy-knowledge-broker/tendinopathy-toolkit/

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