New York State Medical Treatment Guidelines for

Achilles Tendinopathy in workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Achilles Tendinopathy.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Achilles Tendinopathy

The largest and strongest tendon in the body, the Achilles tendon connects the soleus and gastrocnemius muscles in the leg to the heel at the calcaneus bone. Achilles tendon disorders, such as Achilles tendinitis, tendinosis, or tendinopathy, are painful ailments that affect the Achilles tendon. The plantar flexion of the ankle is made possible by the Achilles tendon. Disorders of the achilles tendon can make walking challenging.

The first line of treatment for all painful Achilles tendon diseases is nonoperative. Early intervention is thought to be crucial since chronic diseases make maintenance more challenging and unpredictable.

Diagnostic Studies for Achilles Tendinopathy in workers compensation patients

  1. X-ray for Diagnosis of Achilles Tendon Disorders, Retrocalcaneal Bursitis, or Blunt Trauma or Suspected Fracture

    X-ray for Diagnosis of Achilles Tendon Disorders, Retrocalcaneal Bursitis, or Blunt Trauma or Suspected Fracture are recommended for diagnosing insertional Achilles tendon disorders or retrocalcaneal bursitis or evaluating blunt trauma or suspected fracture.

    Rationale for Recommendation: Radiography is ineffective in identifying soft-tissue problems, and it is not recommended as a first-line diagnostic method for mid-portion tendon abnormalities in the absence of trauma or a suspected fracture. A significant posterior calcaneal spur may be seen on an X-ray.

    Calcaneal tuberosity or Achilles tendon ossification. in other MRI or ultrasound are more effective treatments for Achilles problems. Therefore, Only insertional plain radiographic film investigations are advised. either acute damage or achilles tendinopathy.

     

  2. Ultrasound for Diagnosis of Achilles Tendinopathy

    Ultrasound for Diagnosis of Achilles Tendinopathy is recommended for finding fluid in the retrocalcaneal bursa and for diagnosing Achilles tendinopathy. It may also be particularly helpful for differentiating between paratenonitis and tendinosis.

    Rationale for Recommendation: Mid Portion tendinopathy is usually diagnosed using ultrasound.

    Magnetic Resonance Imaging (MRI) for Diagnosis of Achilles Tendinopathy is recommended for diagnosing Achilles tendinopathies include retrocalcaneal bursitis, tendinosis, and paratenonitis

    Rationale for Recommendation: The internal structure of the tendon and its surrounding tissues can be learned a great deal from MRIs, which can also reveal an enlarged paratenon with adhesions. According to NYS WCB MTG – Ankle and Foot Disorders 21, it may be possible to discern between inflammatory and degenerative changes in soft tissue using MRI. a good way to distinguish between inflammatory and degenerative soft tissue changes.

     

  3. CT for Diagnosis of Achilles Tendinopathy

    CT for Diagnosis of Achilles Tendinopathy is not recommended to identify Achilles tendinosis. The reasoning behind the recommendation is that CT is ineffective in separating inflammatory from degenerative changes in soft tissue. CT is not advised because it has limitations when compared to MRI.

Medications for Achilles Tendinopathy

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients. For patients who are not candidates for NSAIDs, acetaminophen (or the analogue paracetamol) may be a viable alternative, even if the majority of research indicates it is just marginally less effective than NSAIDs.

There is proof that NSAIDs are less dangerous and just as effective in treating pain as opioids, such as tramadol.

  1. Non-steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, Chronic, or Post-operative Achilles Tendinopathy Pain

    Non-steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, Chronic, or Post-operative Achilles Tendinopathy Pain are recommended for the treatment of pain from Achilles tendinopathy that is acute, subacute, chronic, or postoperative.

    Indications: NSAIDs are advised as a treatment for acute, subacute, chronic, or post-operative Achilles tendinopathy. First, try over-the-counter (OTC) medications to see whether they work.

    Frequency/Duration: Many patients could find it reasonable to use as needed.

    Indications for Discontinuation: Resolution of ankle/foot discomfort, ineffectiveness, or emergence of side effects requiring termination.

     

  2. NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding

    NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding is recommended but Patients who are at a high risk of gastrointestinal bleeding should take misoprostol, sucralfate, histamine type 2 receptor blockers, and proton pump inhibitors concurrently.

    Indications: Cytoprotective drugs should be taken into consideration for patients with a high-risk factor profile who also have indications for NSAIDs, especially if a prolonged course of treatment is planned. Patients who have a history of gastrointestinal bleeding in the past, the elderly, diabetics, and smokers are at risk.

    Frequency/Dose/Duration: H2 blockers, misoprostol, sucralfate, and proton pump inhibitors are advised. dosage and repetitions per manufacturer. It is generally accepted that there are no significant differences in effectiveness for preventing gastrointestinal bleeding.

    Indications for Discontinuation ; Intolerance, the emergence of negative effects, or the stopping of NSAIDs.

     

  3. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

    The advantages and disadvantages of NSAID therapy for pain should be explored with patients who have a history of cardiovascular disease or who have several cardiovascular risk factors.

     

  4. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

    NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended When it comes to cardiovascular side effects, acetaminophen or aspirin as first-line medication seem to be the safest options. As far as harmful cardiovascular effects go, acetaminophen or aspirin as first-line therapy seem to be the safest options.

    Aspirin or acetaminophen as first-line medication seem to be the safest in terms of cardiovascular side effects.

     

  5. Acetaminophen for Treatment of Acute, Subacute, or Chronic Achilles Tendinopathy Pain

    Acetaminophen for Treatment of Acute, Subacute, or Chronic Achilles Tendinopathy Pain are recommended for the treatment of acute, subacute, or chronic Achilles tendinopathy pain, especially in people who have medical conditions that make NSAIDs contraindicated.

    Indications: All individuals with foot/ankle pain, including those who have postoperative, chronic, and subacute pain.

    Dose/Frequency: As per the manufacturer’s recommendations; can be used as required. Over four gm/day, there is evidence of liver toxicity.

    Indications for Discontinuation: pain, side effects, or intolerance are gone.

     

  6. Systemic Corticosteroids (oral or intramuscular preparations) for Treatment of Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy

    Systemic Corticosteroids (oral or intramuscular preparations) for Treatment of Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy are not recommended to treat postoperative or chronic Achilles tendinopathy or acute, subacute, or chronic tendinopathy.

     

  7. Opioids for Treatment of Acute, Subacute, or Chronic Achilles Tendinopathy Pain

    Opioids for Treatment of Acute, Subacute, or Chronic Achilles Tendinopathy Pain are not recommended to alleviate discomfort from chronic, subacute, or acute Achilles tendinopathy.

     

  8. Opioids for Treatment of Pain for Postoperative Achilles Tendinopathy

    Opioids for Treatment of Pain for Postoperative Achilles Tendinopathy is recommended for use in treating pain following Achilles tendon surgery or in patients who have experienced surgical complications for a brief period (not to exceed seven days).

    Indications: Postoperative pain management.

    Frequency/Dose/Duration: Frequency and dosage should be followed according to the manufacturer’s instructions; the entire course of treatment should last no longer than seven days.

    Indications for Discontinuation: Resolution of pain, adequate pain management with other treatments such NSAIDs, intolerance, negative side effects, lack of benefits, or failure to make progress after a few weeks.

    Rationale for Recommendations: The vast majority of Achilles tendinopathy sufferers don’t experience pain severe enough to need painkillers.

    Patients who experience this level of discomfort should often undergo tests to rule out other conditions. Opioids should not be used frequently.

     

  9. Vitamin Therapy for Treatment of Achilles Tendinopathy

    Vitamin Therapy for Treatment of Achilles Tendinopathy is not recommended for the management of pain from acute, subacute, or long-term Achilles tendinopathy

     

  10. Opioids for Treatment of Pain for Postoperative Achilles Tendinopathy

    Opioids for Treatment of Pain for Postoperative Achilles Tendinopathy is recommended for use in treating pain following Achilles tendon surgery or in patients who have experienced surgical complications for a brief period (not to exceed seven days).

    Indications: Postoperative pain management.

    Frequency/Dose/Duration: Frequency and dosage should be followed according to the manufacturer’s instructions; the entire course of treatment should last no longer than seven days.

    Indications for Discontinuation: Resolution of pain, adequate pain management with other treatments such NSAIDs, intolerance, negative side effects, lack of benefits, or failure to make progress after a few weeks.

    Rationale for Recommendations: The majority of Achilles tendinopathy sufferers don’t experience enough pain to need painkillers. Patients who experience this level of discomfort should often undergo tests to rule out other conditions. Opioids should not be used frequently

     

  11. Vitamin Therapy for Treatment of Achilles Tendinopathy

    Vitamin Therapy for Treatment of Achilles Tendinopathy is not recommended either as a therapeutic measure or to ward off Achilles tendinopathy.

     

  12. High-dose Vitamin Therapy for Treatment of Achilles Tendinopathy

    High-dose Vitamin Therapy for Treatment of Achilles Tendinopathy is not recommended for prevention of Achilles tendinopathy.

     

  13. Topical NSAIDs for Acute, Subacute, or Chronic Achilles Tendinopathy

    Topical NSAIDs for Acute, Subacute, or Chronic Achilles Tendinopathy are recommended in order to cure acute, subacute, or chronic Achilles tendinosis.

     

  14. Lidocaine Patches for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy

    Lidocaine Patches for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy are not recommended – to treat postoperative or chronic Achilles tendinopathy or acute, subacute, or chronic Achilles tendinopathy.

Treatments for Achilles Tendinopathy

  1. Cryotherapy for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy

    Cryotherapy for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy are recommended for Achilles tendinopathy that is acute, subacute, chronic, or postoperative.

    Indications: All patients with Achilles tendinopathy.

    Frequency/Duration:Frequency/Duration:

    Indications for Discontinuation: Resolution, adverse effects, noncompliance.

     

  2. Heat Therapy for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy

    Heat Therapy for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy are recommended for Achilles tendinopathy that is acute, subacute, chronic, or postoperative.

    Indications: All patients with Achilles tendinopathy

    Frequency/Duration: Approximately three to five self applications per day as needed.

    Indications for Discontinuation: Resolution, adverse effects, noncompliance.

Mobilization / Immobilization for Achilles Tendinopathy

  1. Night Splints for Acute, Subacute, or Chronic Achilles Tendinopathy

    Night Splints for Acute, Subacute, or Chronic Achilles Tendinopathy are not recommended for treatment of acute, subacute, or chronic Achilles tendinopathy.

     

  2. Night Splints and Walking Boots for Postoperative Achilles Tendinopathy

    Night Splints and Walking Boots for Postoperative Achilles Tendinopathy are recommended for postoperative Achilles tendinopathy patients.

Rehabilitation for Achilles Tendinopathy

If supervised formal therapy is necessary as a result of a work-related injury, it should be centred on restoring the functional ability needed for the patient to engage in daily activities and return to work, with the goal of returning the injured worker to their pre-injury status to the extent that is practical.

Active therapy calls for the patient to put in an internal effort to finish a particular activity or assignment. The procedures known as passive therapy rely on modalities that are administered by a therapist rather than the patient exerting any effort on their side.

Passive therapies are typically seen as a way to speed up an active therapy programme and achieve concurrently objective functional gains. Over passive interventions, active initiatives should be prioritised.

To sustain improvement levels, the patient should be advised to continue both active and passive therapies at home as an extension of the therapeutic process.

To facilitate functional gains, assistive devices may be used as an adjuvant measure in the rehabilitation strategy.

  1. Therapeutic Exercise – Physical / Occupational Therapy for Achilles Tendinopathy

    Therapeutic Exercise – Physical / Occupational Therapy for Achilles Tendinopathy is recommended to enhance strength and range of motion while functioning. Frequency, dosage, and duration: Patients with mild functional deficits may require as few as two to three visits overall, whereas those with more severe deficits may need 12 to 15 visits with proof of continued, objective functional improvement.

    If there is evidence of functional improvement toward particular objective functional targets, more than 12 to 15 visits may be necessary when there are persistent functional deficiencies (e.g., range of motion, advancing ability to perform work activities).

    A home exercise regimen should be created as part of the rehabilitation strategy and carried out alongside the therapy.

    Indications for Discontinuation: Pain relief from achilles tendinopathy, intolerance, ineffectiveness, or disobedience.

     

  2. Extracorporeal Shockwave Therapy for Chronic Midportion Achilles Tendinopathy

    Extracorporeal Shockwave Therapy for Chronic Midportion Achilles Tendinopathy is recommended as an adjunct to an eccentric exercise for chronic, recalcitrant Achilles tendinopathy

    Indications : Moderate to severe, recalcitrant Achilles tendinopathy. Patients should have failed NSAIDs, eccentric exercises, therapy, and local injection(s).

    Frequency/Duration:three to four sessions per week spread over three to four weeks.

    Indications for Discontinuation: course completion, symptom relief, side effects, intolerance, and disobedience.

     

  3. Extracorporeal Shockwave Therapy for Acute, Subacute, or Postoperative Achilles Tendinopathy

    Extracorporeal Shockwave Therapy for Acute, Subacute, or Postoperative Achilles Tendinopathy are not recommended for treatment of acute, subacute, or postoperative Achilles tendinopathy.

     

  4. Acupuncture for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy

    Acupuncture for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy are not recommended for the treatment of acute, subacute, chronic, or postoperative Achilles tendinopathy.

     

  5. Dry Needling for Acute, Subacute, or Chronic Achilles Tendinopathy

    Dry Needling for Acute, Subacute, or Chronic Achilles Tendinopathy are not recommended Evidence-Based Practice: Extracorporeal Shockwave Therapy for Achilles Tendinopathy

    Rationale for Recommendation: Dry needling is not advised for the treatment of Achilles tendinopathy because there are other efficient methods available.

     

  6. Massage and Tendon Mobilization for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy

    Massage and Tendon Mobilization for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy are not recommended for the treatment of postoperative, chronic, subacute, or acute Achilles tendinopathy.

     

  7. Therapeutic Ultrasound for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy

    Therapeutic Ultrasound for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy are not recommended for the treatment of postoperative, chronic, subacute, or acute Achilles tendinopathy

     

  8. Iontophoresis with Glucocorticosteroid for Acute, Subacute, or Chronic Achilles Tendinopathy

    Iontophoresis with Glucocorticosteroid for Acute, Subacute, or Chronic Achilles Tendinopathy are recommended for the treatment of either chronic or subacute achilles tendinopathy.

    Indications: Achilles tendinopathy may be acute, subacute, or chronic.

    Frequency/Duration: Four dexamethasone or other glucocorticoid treatments spread over two weeks. Concurrent eccentric exercise should be a part of therapy.

    Indications for Discontinuation: Efficacy, side effects, intolerance, and disobedience.

     

  9. Iontophoresis with Glucocorticosteroid for Postoperative Achilles Tendinopathy

    Iontophoresis with Glucocorticosteroid for Postoperative Achilles Tendinopathy is not recommended for the treatment of Achilles tendinopathy following surgery.

    Iontophoresis with NSAIDs for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy are not recommended for the management of postoperative, chronic, subacute, or acute Achilles tendinopathy.

    Rationale for Recommendations: Iontophoresis with glucocorticosteroids is advised for acute, subacute, or chronic Achilles tendinopathy even though there is little evidence for its efficacy in those conditions, even if the procedure has not been formally studied in those patients.

     

  10. Phonophoresis for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy

    Phonophoresis for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy are not recommended for the management of postoperative, chronic, subacute, or acute Achilles tendinopathy.

     

  11. Low-level Laser Therapy for Select Chronic Achilles Tendinopathy

    Low-level Laser Therapy for Select Chronic Achilles Tendinopathy is recommended to treat a small number of individuals with persistent Achilles tendinopathy

    Indications: Patients should typically have tried and failed NSAIDs, eccentric exercises, iontophoresis, and injection for chronic Achilles tendinopathy (s).

    Frequency/Duration: 12 sessions spread over 8 weeks. A concurrent active therapeutic exercise regimen should be part of the therapy.

    Indications for Discontinuation: Efficacy, side effects, intolerance, and disobedience.

     

  12. Low-level Laser Therapy for Acute, Subacute, or Postoperative Achilles Tendinopathy

    Low-level Laser Therapy for Acute, Subacute, or Postoperative Achilles Tendinopathy are not recommended There is Support for Low-Level Laser Therapy in the Treatment of Achilles Tendinopathy

Injection Therapy for Achilles Tendinopathy

  1. Glucocorticosteroid Injections (Low-Dose) for Paratendon Bursitis

    Glucocorticosteroid Injections (Low-Dose) for Paratendon Bursitis is recommended as a form of therapy for paratendon bursitis.

    Indications: Prior attempts for treatment with other therapies, such as NSAIDs and workouts, should have failed or produced unsatisfactory outcomes.

    Frequency/Duration: Up to three glucocorticosteroid injections may be given over a period of three weeks, with the second and third injections only being given if the first one results in reduced discomfort and improved function.

    Indications for Discontinuation: Resolution, intolerance, unfavourable outcomes, or a lack of advantages.

     

  2. Glucocorticosteroid Injections (Low-Dose) for Acute, Subacute, Chronic or Postoperative Achilles Tendinopathy

    Glucocorticosteroid Injections (Low-Dose) for Acute, Subacute, Chronic or Postoperative Achilles Tendinopathy are not recommended for the treatment of postoperative, chronic, subacute, or acute Achilles tendinopathy.

     

  3. Platelet Rich Plasma Injections for Achilles Tendinopathy

    Platelet Rich Plasma Injections for Achilles Tendinopathy is not recommended as a means of treating Achilles tendinopathy.

     

  4. Glycosaminoglycan Polysulfate Local Injection (GAGPS) for Acute, Subacute, or Postoperative Achilles Tendinopathy

    Glycosaminoglycan Polysulfate Local Injection (GAGPS) for Acute, Subacute, or Postoperative Achilles Tendinopathy are not recommended for the treatment of postoperative or acute, subacute, or acute Achilles tendinopathy.

    Reason for Recommendations: GAGPS may be helpful for patients with chronic complaints of Achilles tendon problems, according to the little evidence that supports this claim.

     

  5. Subcutaneous Heparin Injection for Acute, Subacute, or Chronic Achilles Tendinopathy

    Subcutaneous Heparin Injection for Acute, Subacute, or Chronic Achilles Tendinopathy are not recommended for either the treatment of subacute or chronic achilles tendinopathy.

Actovegin Injections for Achilles Tendinopathy

For acute and chronic mid-portion Achilles tendinopathy, actovegin injection (deproteinized hemodialysate from calf blood) is administered into the paratendon.

  1. Actovegin Injection for Acute, Subacute, or Chronic Achilles Tendinopathy

    Actovegin Injection for Acute, Subacute, or Chronic Achilles Tendinopathy are not recommended if you have chronic, subacute, or acute Achilles tendinopathy.

    Prolotherapy with Hypertonic and Polidocanol Acute, subacute, chronic, or postoperative Achilles tendinopathy: Glucose Injections

    Not advised for the treatment of the most severe, Achilles tendinopathy that is postoperative, chronic, or both.

     

  2. Aprotinin Injection for Acute, Subacute, or Chronic Achilles Tendinopathy

    Aprotinin Injection for Acute, Subacute, or Chronic Achilles Tendinopathy are not recommended for the treatment of either chronic or subacute achilles tendinopathy.

     

  3. High-volume Image-guided Injection for Chronic Achilles Tendinopathy

    High-volume Image-guided Injection for Chronic Achilles Tendinopathy is not recommended -as a remedy for persistent Achilles tendinopathy.

Surgery for Achilles Tendinopathy

  1. Surgery for the Treatment of Chronic Achilles Tendinopathy without Rupture

    Surgery for the Treatment of Chronic Achilles Tendinopathy without Rupture is recommended for a few rare cases of rupture-free chronic Achilles tendinopathy.

    Indications: Candidates include patients with moderate to severe chronic Achilles tendinopathies who have tried multiple nonsurgical treatments without result and whose problem has persisted for at least two years. sixty days. NSAID(s), eccentric exercises, iontophoresis, injection(s), and low level laser therapy should all have failed for the patient.

     

  2. Surgery for the Treatment of Acute or Subacute Achilles Tendinopathy Without Rupture

    Surgery for the Treatment of Acute or Subacute Achilles Tendinopathy Without Rupture are not recommended -for non-ruptured acute or subacute Achilles tendinopathy.

    The patient’s symptoms must be severe enough to justify the risks of surgical intervention before surgery is advised, even if at least six months of alternative non-operative therapy without shown efficacy have been tried.

Other

Orthotic Devices (Such as Heel Lifts, Heel Pads or Heel Braces) for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy

Orthotic Devices (Such as Heel Lifts, Heel Pads or Heel Braces) for Acute, Subacute, Chronic, or Postoperative Achilles Tendinopathy are not recommended to treat Achilles tendinopathy that is acute, subacute, or chronic.

What our office can do if you have Achilles Tendinopathy

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