The guidelines crafted by the New York State Workers Compensation Board are there to give doctors, podiatrists, and healthcare experts a hand in giving the right treatment for Achilles Tendinopathy.
Healthcare professionals can lean on these guidelines from the Workers Compensation Board of New York to figure out the best care for folks dealing with ankle and foot issues.
It’s important to note that these guidelines don’t replace the wisdom and know-how of healthcare providers. The final call on care decisions rests with the patient, made alongside their healthcare provider, drawing on their unique situation and needs.
Achilles Tendinopathy
The Achilles tendon, the body’s largest and toughest tendon, links the leg’s soleus and gastrocnemius muscles to the heel at the calcaneus bone. Conditions like Achilles tendinitis, tendinosis, or tendinopathy bring pain to this crucial tendon. It’s responsible for enabling ankle plantar flexion, and when the Achilles tendon is in trouble, walking can become quite a challenge.
When it comes to dealing with painful Achilles tendon issues, the initial approach is non-surgical. Acting early is seen as vital because chronic conditions can complicate and make the treatment process more unpredictable.
Diagnostic Studies for Achilles Tendinopathy in workers compensation patients
Using X-rays to Diagnose Achilles Tendon Disorders, Retrocalcaneal Bursitis, or Blunt Trauma or Suspected Fracture
Opting for X-rays to diagnose Achilles tendon disorders, retrocalcaneal bursitis, or assess blunt trauma or suspected fractures is recommended. This is especially useful for identifying insertional Achilles tendon disorders or retrocalcaneal bursitis, and it can reveal significant features like a posterior calcaneal spur.
Reasoning behind the Recommendation: X-rays aren’t great at spotting soft-tissue issues, making them less ideal for mid-portion tendon problems without trauma or suspected fractures. For a more comprehensive understanding, MRIs or ultrasounds are better suited, but for insertional concerns, stick to plain radiographic film investigations for either acute damage or Achilles tendinopathy.
Using Ultrasound to Diagnose Achilles Tendinopathy
Employing ultrasound to diagnose Achilles tendinopathy is advised, particularly for detecting fluid in the retrocalcaneal bursa and pinpointing Achilles tendinopathy. It can also be quite useful in distinguishing between paratenonitis and tendinosis.
Reasoning behind the Recommendation: When it comes to mid-portion tendinopathy, ultrasound is the go-to diagnostic tool.
Magnetic Resonance Imaging (MRI) for Diagnosing Achilles Tendinopathy
Turning to MRI for diagnosing Achilles tendinopathies, including retrocalcaneal bursitis, tendinosis, and paratenonitis, is recommended. MRIs offer a detailed look at the internal structure of the tendon and surrounding tissues, highlighting features like an enlarged paratenon with adhesions. As per NYS WCB MTG – Ankle and Foot Disorders 21, MRIs are effective in distinguishing between inflammatory and degenerative changes in soft tissue.
Reasoning behind the Recommendation: MRIs provide valuable insights into tendon structure and surrounding tissues, aiding in distinguishing between inflammatory and degenerative soft tissue changes.
Using CT Scans to Diagnose Achilles Tendinopathy
Relying on CT scans for the diagnosis of Achilles tendinopathy, specifically tendinosis, is not advisable. The rationale behind this recommendation is that CT scans lack the effectiveness in distinguishing between inflammatory and degenerative changes in soft tissue. CT is not the preferred choice due to its limitations when compared to the more comprehensive insights provided by MRI.
Medications for Achilles Tendinopathy
Using Ibuprofen, Naproxen, or other earlier generation NSAIDs is recommended as the first choice for the majority of patients. If NSAIDs are not suitable, Acetaminophen (or the equivalent Paracetamol) could be a viable alternative, although most research suggests it’s only slightly less effective than NSAIDs.
There’s evidence indicating that NSAIDs are not only less risky but also as effective as opioids like Tramadol in managing pain.
Non-steroidal Anti-inflammatory Drugs (NSAIDs) for Addressing Acute, Subacute, Chronic, or Post-operative Achilles Tendinopathy Pain Opting for Non-steroidal Anti-inflammatory Drugs (NSAIDs) for the treatment of acute, subacute, chronic, or postoperative pain related to Achilles tendinopathy is recommended.
When to Use: NSAIDs are suggested for managing acute, subacute, chronic, or post-operative Achilles tendinopathy pain. Start with over-the-counter (OTC) medications to see if they bring relief.
How Often/For How Long: Many patients may find it reasonable to use NSAIDs as needed.
When to Stop: Discontinue if ankle/foot discomfort resolves, if they prove ineffective, or if side effects emerge necessitating cessation.
NSAIDs for Patients Prone to Gastrointestinal Bleeding Using NSAIDs for patients at high risk of gastrointestinal bleeding is advised. However, individuals with a high risk should concurrently take cytoprotective drugs like misoprostol, sucralfate, histamine type 2 receptor blockers, and proton pump inhibitors.
When to Consider: Cytoprotective drugs should be considered for patients with a high-risk profile who need NSAIDs, especially for extended treatment. Those with a history of past gastrointestinal bleeding, the elderly, diabetics, and smokers are at risk.
How Often/Dosage/Duration: Follow the recommended dosage and repetitions per manufacturer for H2 blockers, misoprostol, sucralfate, and proton pump inhibitors. There’s a general consensus that there are no significant differences in effectiveness in preventing gastrointestinal bleeding.
When to Discontinue: Discontinue if there’s intolerance, the emergence of adverse effects, or if NSAIDs need to be stopped.
NSAIDs for Patients Prone to Cardiovascular Adverse Effects When it comes to patients with a history of cardiovascular disease or multiple cardiovascular risk factors, it’s important to discuss the pros and cons of NSAID therapy for managing pain.
NSAIDs for Patients Prone to Cardiovascular Adverse Effects For patients at risk of cardiovascular side effects, it’s advisable to consider acetaminophen or aspirin as the first-line medication. In terms of potential harm to the cardiovascular system, starting with acetaminophen or aspirin appears to be the safest choice.
Choosing aspirin or acetaminophen as the initial medication seems to be the safest option when it comes to potential cardiovascular side effects.
Acetaminophen for Managing Acute, Subacute, or Chronic Achilles Tendinopathy Pain Acetaminophen is recommended for addressing acute, subacute, or chronic Achilles tendinopathy pain, especially for individuals with medical conditions that make NSAIDs unsuitable.
When to Use: Suitable for anyone experiencing foot/ankle pain, including those with postoperative, chronic, and subacute pain.
Dosage/Frequency: Follow the manufacturer’s recommendations; use as needed. Evidence of liver toxicity exists for doses exceeding four gm/day.
When to Stop: Discontinue when the pain, side effects, or intolerance are no longer present.
Systemic Corticosteroids (oral or intramuscular preparations) for Managing Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy Using systemic corticosteroids (oral or intramuscular preparations) for managing postoperative or chronic Achilles tendinopathy, or acute, subacute, or chronic tendinopathy, is not recommended.
Systemic Corticosteroids (oral or intramuscular preparations) for Managing Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy Using systemic corticosteroids (oral or intramuscular preparations) for treating postoperative or chronic Achilles tendinopathy, or acute, subacute, or chronic tendinopathy, is not recommended.
Opioids for Addressing Acute, Subacute, or Chronic Achilles Tendinopathy Pain The use of opioids for relieving discomfort from chronic, subacute, or acute Achilles tendinopathy is not recommended.
Opioids for Managing Pain after Achilles Tendon Surgery Using opioids to manage pain after Achilles tendon surgery is recommended for a brief period, not exceeding seven days. This is suitable for patients who have undergone Achilles tendon surgery or experienced surgical complications.
When to Use: Postoperative pain management.
How Often/Dosage/Duration: Follow the frequency and dosage recommended by the manufacturer; the entire treatment course should not exceed seven days.
When to Stop: Discontinue when the pain resolves, or when there’s adequate pain management with alternative treatments like NSAIDs. Also, stop if there’s intolerance, negative side effects, lack of benefits, or if there’s no progress after a few weeks.
Reasoning behind the Recommendations: Most individuals with Achilles tendinopathy typically don’t experience severe pain requiring opioid use. Those facing significant discomfort should undergo tests to rule out other conditions. Opioids should not be used routinely.
Vitamin Therapy for Addressing Achilles Tendinopathy Using vitamin therapy for the treatment of acute, subacute, or long-term Achilles tendinopathy pain is not recommended.
Opioids for Managing Pain after Achilles Tendon Surgery Employing opioids for managing pain after Achilles tendon surgery is recommended for a short duration, not exceeding seven days. This is suitable for postoperative pain management or in cases where patients have encountered surgical complications.
When to Use: Postoperative pain management.
How Often/Dosage/Duration: Follow the frequency and dosage recommended by the manufacturer; the entire treatment course should not exceed seven days.
When to Stop: Discontinue when the pain resolves, or when there’s adequate pain management with alternative treatments like NSAIDs. Also, stop if there’s intolerance, negative side effects, lack of benefits, or if there’s no progress after a few weeks.
Reasoning behind the Recommendations: The majority of individuals with Achilles tendinopathy usually don’t experience sufficient pain to require painkillers. Those with significant discomfort should often undergo tests to rule out other conditions. Opioids should not be used on a regular basis.
Vitamin Therapy for Dealing with Achilles Tendinopathy Using vitamin therapy for the treatment of Achilles tendinopathy, either as a therapeutic measure or for prevention, is not recommended.
High-dose Vitamin Therapy for Preventing Achilles Tendinopathy Using high-dose vitamin therapy for preventing Achilles tendinopathy is not recommended.
Topical NSAIDs for Managing Acute, Subacute, or Chronic Achilles Tendinopathy Using topical NSAIDs for acute, subacute, or chronic Achilles tendinopathy is recommended as a means to address acute, subacute, or chronic Achilles tendinosis.
Lidocaine Patches for Addressing Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy Using lidocaine patches for acute, subacute, chronic, or postoperative Achilles tendinopathy is not recommended. This includes the treatment of postoperative or chronic Achilles tendinopathy, as well as acute, subacute, or chronic Achilles tendinopathy.
Treatments for Achilles Tendinopathy
Cryotherapy for Addressing Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy Using cryotherapy for acute, subacute, chronic, or postoperative Achilles tendinopathy is recommended. This applies to all patients with Achilles tendinopathy.
When to Use: Suitable for all patients with Achilles tendinopathy.
How Often/For How Long: Follow the recommended frequency and duration.
When to Stop: Discontinue when the issue resolves, in the presence of adverse effects, or if noncompliance becomes a concern.
Heat Therapy for Managing Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy Using heat therapy for acute, subacute, chronic, or postoperative Achilles tendinopathy is recommended. This applies to all patients with Achilles tendinopathy.
When to Use: Suitable for all patients with Achilles tendinopathy.
Frequency/Duration: Apply approximately three to five times per day as needed.
When to Stop: Discontinue when the issue resolves, in the presence of adverse effects, or if noncompliance becomes a concern.
Mobilization / Immobilization for Achilles Tendinopathy
Night Splints for Managing Acute, Subacute, or Chronic Achilles Tendinopathy Using night splints for the treatment of acute, subacute, or chronic Achilles tendinopathy is not recommended.
Night Splints and Walking Boots for Addressing Postoperative Achilles Tendinopathy Using night splints and walking boots for postoperative Achilles tendinopathy patients is recommended.
Rehabilitation for Achilles Tendinopathy
If supervised formal therapy becomes necessary due to a work-related injury, the focus should be on restoring the functional abilities required for the individual to carry out daily activities and return to work. The ultimate goal is to bring the injured worker back to their pre-injury status to the extent that is practical.
Active therapy involves the patient actively engaging in a specific activity or task, putting in internal effort. On the other hand, passive therapy relies on modalities administered by a therapist, with the patient not exerting effort on their part.
While passive therapies can accelerate an active therapy program and lead to concurrent functional gains, priority should be given to active initiatives over passive interventions.
To maintain the achieved improvement levels, it’s advisable for the patient to continue both active and passive therapies at home as an extension of the therapeutic process. This ensures ongoing progress and supports the individual in sustaining their functional gains.
To enhance functional gains, the use of assistive devices can be integrated as an additional measure in the rehabilitation strategy.
Therapeutic Exercise – Physical / Occupational Therapy for Achilles Tendinopathy Engaging in therapeutic exercises through physical or occupational therapy is recommended to improve strength and range of motion during functional activities. The frequency, dosage, and duration depend on the severity of deficits. Patients with mild functional deficits may require as few as two to three visits overall, while those with more severe deficits may need 12 to 15 visits, provided there is ongoing, objective functional improvement.
If persistent functional deficiencies are observed, exceeding 12 to 15 visits may be necessary, especially if there is evidence of progress toward specific functional targets (e.g., range of motion, advancing ability to perform work activities). A home exercise regimen should be incorporated into the rehabilitation strategy and carried out alongside therapy.
When to Stop: Discontinue therapy when there is pain relief from Achilles tendinopathy, intolerance, ineffectiveness, or noncompliance.
Extracorporeal Shockwave Therapy for Chronic Midportion Achilles Tendinopathy Using extracorporeal shockwave therapy is recommended as an adjunct to eccentric exercise for chronic, stubborn Achilles tendinopathy.
Indications: Suitable for moderate to severe, recalcitrant Achilles tendinopathy. Patients should have previously attempted NSAIDs, eccentric exercises, therapy, and local injection(s).
Frequency/Duration: Administer three to four sessions per week spread over three to four weeks.
When to Stop: Discontinue after completing the recommended course, achieving symptom relief, encountering side effects, experiencing intolerance, or in cases of noncompliance.
Extracorporeal Shockwave Therapy for Managing Acute, Subacute, or Postoperative Achilles Tendinopathy The use of extracorporeal shockwave therapy is not recommended for the treatment of acute, subacute, or postoperative Achilles tendinopathy.
Acupuncture for Addressing Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy Acupuncture is not recommended for treating acute, subacute, chronic, or postoperative Achilles tendinopathy.
Dry Needling for Managing Acute, Subacute, or Chronic Achilles Tendinopathy Dry needling is not recommended for the treatment of acute, subacute, or chronic Achilles tendinopathy. The rationale behind this recommendation is that there are other efficient methods available.
Massage and Tendon Mobilization for Dealing with Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy The use of massage and tendon mobilization is not recommended for the treatment of postoperative, chronic, subacute, or acute Achilles tendinopathy.
Therapeutic Ultrasound for Managing Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy The use of therapeutic ultrasound is not recommended for the treatment of postoperative, chronic, subacute, or acute Achilles tendinopathy.
Iontophoresis with Glucocorticosteroid for Addressing Acute, Subacute, or Chronic Achilles Tendinopathy Iontophoresis with glucocorticosteroid is recommended for the treatment of either chronic or subacute Achilles tendinopathy.
Indications: Achilles tendinopathy may manifest as acute, subacute, or chronic.
Frequency/Duration: Administer four dexamethasone or other glucocorticoid treatments spread over two weeks. Concurrent eccentric exercise should be incorporated into the therapy.
When to Stop: Discontinue based on efficacy, side effects, intolerance, or noncompliance.
Iontophoresis with Glucocorticosteroid for Postoperative Achilles Tendinopathy The use of iontophoresis with glucocorticosteroid is not recommended for treating Achilles tendinopathy following surgery.
Iontophoresis with NSAIDs for Managing Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy Iontophoresis with NSAIDs is not recommended for the management of postoperative, chronic, subacute, or acute Achilles tendinopathy.
Reasoning behind the Recommendations: Iontophoresis with glucocorticosteroids is recommended for acute, subacute, or chronic Achilles tendinopathy, even though there is limited evidence for its efficacy in these conditions, and the procedure has not been formally studied in those patients.
Phonophoresis for Managing Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy Phonophoresis is not recommended for the management of postoperative, chronic, subacute, or acute Achilles tendinopathy.
Low-level Laser Therapy for Treating Select Chronic Achilles Tendinopathy Low-level laser therapy is recommended for a limited number of individuals with persistent Achilles tendinopathy.
Indications: Patients should typically have attempted and not found relief with NSAIDs, eccentric exercises, iontophoresis, and injections for chronic Achilles tendinopathy(s).
Frequency/Duration: Administer 12 sessions over 8 weeks. A concurrent active therapeutic exercise regimen should be integrated into the therapy.
When to Stop: Discontinue based on efficacy, side effects, intolerance, or noncompliance.
Low-level Laser Therapy for Addressing Acute, Subacute, or Postoperative Achilles Tendinopathy Low-level laser therapy is not recommended for the treatment of acute, subacute, or postoperative Achilles tendinopathy. Despite some support for low-level laser therapy in the treatment of Achilles tendinopathy, it is not recommended in these specific cases.
Injection Therapy for Achilles Tendinopathy
Glucocorticosteroid Injections (Low-Dose) for Paratendon Bursitis Using low-dose glucocorticosteroid injections is recommended as a therapeutic approach for paratendon bursitis.
Indications: Previous attempts with other therapies, such as NSAIDs and exercises, should have proven ineffective or yielded unsatisfactory results.
Frequency/Duration: Up to three glucocorticosteroid injections can be administered over a three-week period. The second and third injections should only be given if the first injection results in reduced discomfort and improved function.
When to Stop: Discontinue based on resolution, intolerance, unfavorable outcomes, or a lack of benefits.
Glucocorticosteroid Injections (Low-Dose) for Managing Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy Low-dose glucocorticosteroid injections are not recommended for the treatment of postoperative, chronic, subacute, or acute Achilles tendinopathy.
Platelet Rich Plasma Injections for Achilles Tendinopathy The use of platelet-rich plasma injections is not recommended as a treatment for Achilles tendinopathy.
Glycosaminoglycan Polysulfate Local Injection (GAGPS) for Addressing Acute, Subacute, or Postoperative Achilles Tendinopathy Glycosaminoglycan Polysulfate Local Injections (GAGPS) are not recommended for the treatment of postoperative or acute, subacute, or chronic Achilles tendinopathy. Limited evidence suggests potential benefits for patients with chronic complaints of Achilles tendon problems.
Subcutaneous Heparin Injection for Managing Acute, Subacute, or Chronic Achilles Tendinopathy Subcutaneous heparin injections are not recommended for the treatment of subacute or chronic Achilles tendinopathy.
