Information on Achilles Tendon tears and tendinopathy

Marc Darrow, MD, JD.

People share their stories with us every day. Some have had dozens of physical therapy sessions, some have had more than a dozen of iontophoresis – electric stimulation treatments. Some have had all these treatments and a few steroid shots and various applications of different kinesiology tapes too. Even after all this they are exploring our treatments because: “none of these worked long-term for me.”

The patient experience. Is it a complete rupture or a partial rupture? Do I need the surgery or not?  Different doctors give different recommendations

In a September 2019 study, (1) doctors give a report on what patients may hear in their consultation: Treatment recommendation; What stage is their Achilles tendon injury: This report comes from questions given to and answered by 91 surgeons.

  • The surgeons agreed on the importance of the physical examination in terms of diagnosis.
  • The surgeons could not come up with a consensus on the value of diagnostic imaging (ultrasound/MRI) for Achilles tendon tears.
  • There was consensus that non-surgical treatment is preferred for sedentary and and patients with degenerative damage.
  • There was agreement that surgery for patients who are younger and athletic and present with larger tendon gap sizes was preferred.
  • There was consensus on most of the non-surgical methods used:
    • Initial Immobilization or casting in a plaster cast with the foot in equinus position (toes point upward) and its gradual regression to lesser angles.
    • Only how long should the patient be immobilized for lacked consensus.
  • While surgery was generally preferred, there was a lack of consensus on the entire followed protocol.
    • Orthopedic and trauma surgeons differed significantly on their surgical and suturing techniques and methods of postoperative Immobilization.
    • Orthopedic surgeons advised a significantly longer time until return to sport after both non-surgical treatment and surgery than trauma surgeons.

It is easy to see how a patient can be confused by all the different recommendations to have surgery, what type of surgery, or not have a surgery. It is also easy to see why many patients want to avoid surgery.

But how severe is the problem?

An April 2024 paper (2) suggests that doctors assess severity of Achilles tendon problems look at: “Pain with loading the Achilles tendon, time for pain to settle following aggravating activity, as well as time taken for the tendon symptoms to subside after prolonged sitting or sleeping are the best questions indicative of the severity of disability in patients with Achilles tendinopathy.”

An April 2024 paper (3) examined comparative results between surgical and conservative treatment of acute Achilles tendon ruptures at a minimum follow-up of 1 year in terms of the complications, functional outcomes and clinical results.

Four hundred five patients were reviewed at a mean follow-up of 24 months. Surgical treatment was done in 372 patients (92%) and conservative treatment in 33 patients (8%), with these two sets of patients having comparable preoperative characteristics.

There was a similar number of reruptures in the conservative group (3 cases, 9%) as in the surgical group (15 cases, 4%) . There were more general complications in the conservative group (24%) than in the surgical group (11%). There was a 9% rate of surgery-related complications (infection, nerve damage, anesthesia after-effects).

Strict then relative immobilization provided the best balance between functional recovery and tendon lengthening without increasing the occurrence of rerupture. Early weightbearing accompanied by immobilization and rehabilitation within 30 days did not lead to more reruptures than if it was started beyond 30 days.

A December 2023 study (4) sought to determine the therapeutic efficacy of extracorporeal shock wave therapy (ESWT) for Achilles tendinopathy and found very-low-quality evidence suggesting that ESWT was just as  effective in decreasing pain than any other conservative treatment, thus concluding, the therapeutic efficacy of ESWT for Achilles tendinopathy is inconclusive.

How do you know if you have a partial Achilles Tendon tear?

The challenge to you and your doctors is in fact knowing if you have a partial Achilles Tendon tear or Achilles tendinopathy. A October 2020 paper (5) suggests that “a partial Achilles tendon tear is rather uncommon, is not always considered as a differential diagnosis, and might be misinterpreted as aggravated Achilles tendinopathy. While Achilles tendinopathy and Achilles tendon rupture can be easily differentiated from each other, partial Achilles tendon rupture meets the symptom criteria of both. This might lead to difficulties in diagnosing and choosing the most appropriate treatment option (e.g., load vs. immobilization). The physician might end up being caught between two (diagnostic recommendations). To the best of our (study author) knowledge, there is no consensus regarding diagnosis and treatment for partial Achilles ruptures.

An independent review of PRP and autologous cell use in post-surgical recovery

We receive many emails about accelerating the healing of a surgically repaired tendon. These emails come from athletes or people who need to get back to work much faster than their surgical rehabilitation is allowing them to. Generally speaking autologous cell therapy may be effective in augmentation repair of a surgery. Of course each patient is unique and a consultation would be required to come up with a realistic healing program for that patient’s specific goals.

Preferably we would like to see the patient before the surgery to see if it is possible to repair the Achilles tendon without the need for surgery. If the patient can avoid a surgery, then the patient can avoid the recovery that surgery requires.

A brief description of autologous cell therapy

  • PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. Learn more about PRP treatments.
  • Bone marrow derived stem cells is the injection of a damaged area of the body with stem cells that have been drawn from the patient’s own bone marrow. Stem cells are “de-differentiated pluripotent” cells, which means that they continue to divide to create more stem cells; these eventually “morph” into the tissue needing repair — for our purposes, collagen, bone, and cartilage.

These treatments may or may not be effective in partial Achilles tendon tears or strengthening the other structures of the ankle / foot complex.

Doctors at the Feinstein Institute for Medical Research have published a detailed paper in which they look at the realistic healing options a patient can expect after an Achilles Tendon rupture. Here is a brief summary of this research that was published in the medical journal Current reviews in musculoskeletal medicine.(6)

  • Problem: Healing Achilles tendons form a fibrovascular scar resulting in a tendon which may be mechanically weaker than the native tendon.
  • The resulting strength deficit causes a high risk for reinjury and other complications.

Platelet-rich plasma

  • In the early phase of ruptured Achilles tendon healing, PRP has been shown in animal studies to increase early collagen production. Collagen being a building block of soft tissue as found in tendons.
  • Ruptured rat Achilles tendons injected with PRP after surgery show an accelerate healing and promote a better functioning scar tissue.
  • The potential benefits in humans were demonstrated in a case study of an athlete with a partial tear who received three PRP injections and no surgical intervention. He was able to return to playing in a full basketball game just 75 days after the injury and remained without complications 18 months later (7)
  • An additional six athletes with ruptured Achilles tendons treated with PRP after surgery recovered their range of motion earlier and took less time to resume training as compared to athletes who underwent surgery without PRP treatment. These findings were supported by a review of 10 relevant studies (8) showing a strong positive effect of PRP after Achilles tendon rupture treatment.

Bone marrow aspirate

  • Bone marrow aspirate concentrate (BMAC) is produced by density gradient centrifugation of bone marrow usually aspirated from the iliac crest. Its major function is to deliver mesenchymal stem cells (MSCs) to the injury site, and like PRP, BMAC is also rich in platelets and therefore growth factors
  • A recent preclinical study found transected rat Achilles tendons injected with bone marrow cells display greater strength than tendons treated with other stem cells or control. By 28 days after surgery, the failure load (ability to withstand failure load) for rat Achilles tendons treated with bone marrow cells is equal to that of uninjured tendon (9).

Surgery for Achilles Tendon Re-Tear may not be advisable

In a December review study, (10) doctors looked at the medical outcomes of 385 patients (total 390 surgeries) who had an Achilles tendon repair. What they were looking for was those patients who had a re-tear following the surgery and if conservative care options may be a better option than another surgery for that injury.

In their review the doctors found subacute Achilles tendon re-rupture occurred in 5.1% of patients. They also found in comparing injury healing in the patients who had a re-tear and those patients who did not have a re-tear, non-surgical conservative care following diagnosis of Achilles tendon re-rupture may be the preferred way to treat as opposed to another surgery, they based this on observed functional and disability studies in the patients. The doctors here concluded: “Conservative treatment for subacute Achilles tendon re-rupture following primary Achilles tendon repair yields clinical outcomes comparable to those without Achilles tendon re-rupture. Therefore, we recommend that surgeons consider relying on the patient’s natural healing capabilities rather than opting for aggressive surgical interventions, as expediting such operations may be unnecessary for subacute injuries.”

Treating a ruptured Achilles Tendon: Comparing Platelet Rich Plasma therapy and Stem Cells.

In the medical journal Connective tissue research, (11) Turkish doctors examined laboratory rats who were injured to create and simulate an Achilles Tendon rupture.

The animals were then divided into three groups:

  • A Platelet Rich Plasma treated group,
  • a stem cell treated group,
  • and a control group.

After thirty days the scientists found that: the levels of growth factors playing key roles in tendon recovery were significantly higher in the stem cell group than those of the PRP and control groups. The PRP group did show a promotion of healing, but not at the level of the stem cell group.

  • The scientists summarized in their conclusion that: “The use of PRP and stem cells provides hope for the treatment of the Achilles tendon ruptures that limit human beings’ functionalities and quality of life, particularly for athletes. It is thought that the use of stem cells can be more effective for tendon healing.”

While studies are now coming out on stem cells and Achilles repair, the efficiency of PRP on Achilles tendon injuries has already been the subject of frequent research.

In the medical journal Foot and Ankle Surgery, doctors examined 83 Achilles tendons (73 patients, 59 males and 14 females; average age 43) affected by non-insertional CRAT or Chronic Recalcitrant Achilles Tendinopathies. These are difficult to treat cases.

  • The patients were treated with a single PRP injection and evaluated with various scoring systems.
    • Seventy-six tendons (91.6%) were rated as satisfactory and patients would repeat the treatment.
    • Seven tendons (8.4%) were classified as unsatisfactory at the 6 months follow-up and underwent a second PRP injection.
    • In addition to this, patients reported no Achilles tendon rupture.(12)

A study by Mexican doctors published in the medical journal Acta ortopédica mexicana (13) found that Non-surgical treatment of Achilles tendinopathies and plantar fasciitis showed good results in up to 90% of cases. However for the remaining 10% of patients with these conditions, this represents a true challenge for the orthopedic surgeon. New technologies for the development of orthobiologic materials make it possible to use platelet-rich plasma (PRP) as an alternative to treat cases that have been refractory to prior treatment and that have a chronicity exceeding 12 months. . . .The use of PRP in patients with Achilles tendinopathy and plantar fasciitis is an effective and safe alternative for the management of patients with a poor response to conventional non-surgical treatment.”

A third study confirmed a positive long-term clinical outcome in patients affected by mid-portion Chronic Recalcitrant Achilles Tendinopathies treated with a single platelet-rich plasma (PRP) treatment.(14)

PRP is not a one-time – one injection treatment

Often people will reach out to us and they will tell us that they heard PRP will not help partial Achilles tears. They heard that from their doctor. Their doctor may subscribe to bulletins or other ortho-updates that describe research like this. It is a July 2021 study (15). The study authors describe the effects of Platelet-Rich Plasma Injection vs sham (placebo) injection on chronic midportion Achilles tendinopathy. This is a one-shot PRP injection vs. a one shot placebo injection. “Among patients with chronic midportion Achilles tendinopathy, treatment with a single injection of intratendinous platelet-rich plasma, compared with insertion of a subcutaneous dry needle, did not reduce Achilles tendon dysfunction at 6 months. These findings do not support the use of this treatment for chronic midportion Achilles tendinopathy.”

In our experience, one shot of PRP will typically not achieve treatment goals. It takes a healing program.

Can we help you?

People share their stories with us every day. Some have had dozens of physical therapy sessions, some have had more than a dozen of Iontophoresis, electric stimulation treatments. Some have had all these treatments and a few steroid shots and various applications of different kinesiology tapes too. Even after all this they are exploring our treatments because: “none of these worked long-term for me.” Use the form below to ask me your questions about your Achilles tendon problems.

Call for a free phone consultation with our staff 800-300-9300

Articles

Bone-marrow derived stem cells and tendon repair

References

1 Dams OC, van den Akker-Scheek I, Diercks RL, Wendt KW, Zwerver J, Reininga IH. Surveying the management of Achilles tendon ruptures in the Netherlands: lack of consensus and need for treatment guidelines. Knee Surgery, Sports Traumatology, Arthroscopy. 2018:1-1.
2 Murphy MC, Green B, Amundarain IS, de Vos RJ, Rio EK. Are we asking the right questions to people with Achilles tendinopathy? The best questions to distinguish mild versus severe disability to improve your clinical management. Physical Therapy in Sport. 2024 Apr 5.
3 Saab M, Beldame J, Charpail C, Kaba A, Mainard D, Caubère A, Maynou C, Bredicianu R, Ghorbani A, Giunta JC, Coursier R. Clinical and functional outcomes of 405 Achilles tendon ruptures after a minimum follow-up of 1 year. Orthopaedics & Traumatology: Surgery & Research. 2024 Apr 12:103886.
4 Stania M, Malá J, Chmielewska D. The Efficacy of Extracorporeal Shock Wave Therapy as a Monotherapy for Achilles Tendinopathy: A Systematic Review and Meta-Analysis. Journal of Chiropractic Medicine. 2023 Jun 14.
5 Gatz M, Spang C, Alfredson H. Partial Achilles Tendon Rupture—A Neglected Entity: A Narrative Literature Review on Diagnostics and Treatment Options. Journal of Clinical Medicine. 2020 Oct;9(10):3380.
6 Shapiro E, Grande D, Drakos M. Biologics in Achilles tendon healing and repair: a reviewCurrent Reviews in Musculoskeletal Medicine. 2015;8(1):9-17. doi:10.1007/s12178-015-9257-z.
7 Filardo G, Presti ML, Kon E, Marcacci M. Nonoperative biological treatment approach for partial Achilles tendon lesion. Orthopedics. 2010 Feb 1;33(2).
8 Sadoghi P, Rosso C, Valderrabano V, Leithner A, Vavken P. The role of platelets in the treatment of Achilles tendon injuries. Journal of Orthopaedic Research. 2013 Jan;31(1):111-8.
9 Okamoto N, Kushida T, Oe K, Umeda M, Ikehara S, Iida H. Treating Achilles tendon rupture in rats with bone-marrow-cell transplantation therapy. JBJS. 2010 Dec 1;92(17):2776-84.
10 Choi JY, Choo SK, Kim BH, Suh JS. Conservative treatment outcome for Achilles tendon re-rupture occurring in the subacute phase after primary repair. Archives of Orthopaedic and Trauma Surgery. 2023 Dec 20:1-9.
11 Yuksel S et al. Comparison of the early period effects of bone marrow-derived mesenchymal stem cells and platelet-rich plasma on the Achilles tendon ruptures in rats. Connect Tissue Res. 2016 Sep;57(5):360-73. doi: 10.1080/03008207.2016.1189909. Epub 2016 May 18.
12 Guelfi M, Pantalone A, Vanni D, Abate M, et al. Long-term beneficial effects of platelet-rich plasma for non-insertional Achilles tendinopathy. Foot Ankle Surg. 2015 Sep;21(3):178-81. doi: 10.1016/j.fas.2014.11.005. Epub 2014 Dec 11.
134 López-Gavito E, Gómez-Carlín LA, Parra-Téllez P, Vázquez-Escamilla J. Platelet-rich plasma for managing calcaneus tendon tendinopathy and plantar fasciitis. Acta Ortop Mex. 2011 Nov-Dec;25(6):380-5.
14 Gaweda K, Tarczynska M, Krzyzanowski W. Treatment of Achilles tendinopathy with platelet-rich plasma. Int J Sports Med. 2010 Aug;31(8):577-83. Epub 2010 Jun 9.
15 Kearney RS, Ji C, Warwick J, et al. Effect of Platelet-Rich Plasma Injection vs Sham Injection on Tendon Dysfunction in Patients With Chronic Midportion Achilles Tendinopathy: A Randomized Clinical Trial. JAMA. 2021;326(2):137-144. doi:10.1001/jama.2021.6986 -2242

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