Technique physiotherapy recently had the pleasure of visiting Professor Hakan Alfredson at his specialist tendon clinic at Canary Wharf. Not only was the Professor laid back in his approach, he also shared our love of sports; the conversation was easy from the start. His clinic lasted 3 hours and in that time we saw a number of professional sports people, from rugby players to elite sprinters. All of the athletes presented with chronic forms of tendinopathy.
There are some obvious assumptions that could be drawn about a guru in the field of tendinopathy; you would expect an incredible knowledge base, tick, which in some may produce a large ego and sense of arrogance. Professor Alfredson is certainly not one of these, his sense of sharing information with both clinicians and patients is conveyed in an effortless manner, and I wondered if this was one of the reasons why he is regarded so highly around the world. Some of my questions were at times obvious (and probably a little low-brow), but the Professor answered them without batting an eyelid.
It was a real pleasure to meet him and I certainly learnt some new things about tendon pathology, and also about what makes a good bedside manner.
So below is an attempt to pass on some of the knowledge that this good man taught me:
- The important difference between acute and chronic tendinopathy
There is no longer the theory that one diagnosis fits all for patient’s presenting with tendinopathy. The management of the condition is very much dependent on where the subject is on a scale of acute vs. chronic. It is essential to ascertain whether this is the patient’s first bout of symptoms in the affected region (Alfredson and Cook, 2007).
If it is the subjects first instance of pain and discomfort, fitting a pattern of tendinopathy (morning stiffness and pain, significant discomfort relating to their sport), then a more traditional method of protect, rest, ice, compress and elevate (PRICE) along with NSAIDs is the safest and most effective treatment strategy. Manual techniques such as soft tissue massage have also been shown to effectively reduce pain in the very early stages, allowing a quicker recovery from the acute painful state (Gaida and Cook, 2011).
If the patient/athlete complains of multiple instances of pain over several months or years, then it may be assumed that a chronic situation has set in leading to tendon degeneration. In these situations it is worth moving the patient straight onto Professor Alfredson’s eccentric protocols.
- Ultrasound is the gold standard in the diagnosis of chronic tendinopathy
Studies have shown both MRI and colour doppler ultrasound (CDUS) to be effective in the diagnosis of Tendinosis. CDUS has been shown to be more effective than MRI in terms of accuracy (Warden et al, 2007). It is also harder to distinguish between the specific conditions affecting the tendon when using MRI. For instance during the clinic, our first patient was referred for a queried partial tear to the tendon, however on inspection with CDUS it was found to be chronic tendinosis without any evidence of a tear to the tendon.
- Alfredson’s protocol is the first port of call in chronic situations
The eccentric heel-drop protocol (Achilles tendinopathy) or eccentric knee-dip protocol (patella tendinopathy) can be used as an evidence-based treatment for those suffering from chronic tendinopathy. This treatment protocol is based over a 3-month period and involves a gradual loading of the muscle tendon unit using pain as a guide.
Eccentric Heel drop protocol for Achilles tendinopathy:
3 sets of 15 heel drops should be performed TWICE per day with a straight and bent leg. This equates to 180 repetitions daily. As soon as pain dissipates weights should be added using a rucksack until pain returns. This program should be performed for 12 weeks in total (Alfredson, 2005).
Eccentric Knee-dip protocol for patella tendinopathy:
3 sets of 15 knee dips should be performed TWICE per day. This equates to 90 repetitions daily. As with the heel drops protocol, weights should be added in a rucksack as soon as pain dissipates, over a period of 12 weeks. Slow resistance strength training programs have also been shown to be effective at improving functional outcomes in this group of athletes (Gaida and Cook, 2011).
If no significant improvement in pain is found after a period of 4-6 months, further intervention should be considered.
- Surgery Vs Injections
In more complex or long standing cases, Alfredson’s eccentric protocol may not be effective at returning the patient to satisfactory levels of discomfort, which may allow a return to sport. Many sports medicine professionals follow the pathway of injections first and then using surgery as a last resort.
Alfredson’s preferred method of injection is polidocanol, a sclerosing agent that breaks down in-grown neovessels deemed to be one of the main causes of pain in tendinopathy. Follow-up at 6 months and 2 years resulted in 8 out of 10 patients being pain free (Ohberg and Alfredson, 2002).
Professor Alfredson has refined his surgical techniques over the years. His high quality research has improved our understanding of what is occurring in tendon pathology. As stated, it seems that pain is caused more due to changes in blood vessels and in-growing nerves around the tendon, instead of changes that occur within the tendon itself.
Whereas surgical treatments of old involved open resection of the pathological tendon, Alfredson is now using scraping techniques that do not involve meddling with the actual tendon unit. Clinical outcomes are significantly better in those treated with his newer scraping techniques, and in long-term follow-up, patients were more likely to return to normal sporting activities.
Interestingly, in clinic Professor Alfredson has moved away from the idea that injections are the first port of call before surgery. His reasoning is that sclerosing injections often need 2-3 treatments over a 3-6 month period. He argues that surgery is often a one-off and both interventions show similar results at long-term follow-up. However his patient cohort is more likely to include high-level athletes that need rapid intervention in order to return to sport. I would argue that recreational athletes can afford to take the time to get back to basics in terms of strength and movement training, and this longer treatment approach will ensure a more comprehensive recovery and return to activities, reducing the likely-hood of future recurrences.
- Plantaris involvement
Lastly, in a recent study by Alfredson (2011), the author found a substantial number of subjects presenting with chronic mid-portion Achilles tendinopathy who also reported significant medial Achilles discomfort. When these subjects underwent surgery, 58 of 73 subjects were found to have a thickened plantaris tendon which was in close relation to the chronic Achilles portion. In Alfredson’s study, these 58 had the plantaris excised. As yet there are no long-term clinical follow-ups, but we will aim to keep abreast of the situation.
Technique would also like to give special thanks to Mr Andrew Willett, CEO of Pure Sports Medicine for inviting us along to Professor Alfredson’s clinic.
Alfredson F, Cook J. A treatment algorithm for managig Achilles tendinopathy: new treatment options. Br J Sports Med. 2007; 41: 211-216.
Gaida JE, Cook J. Treatment options for Patella Tendinopathy: Critical Review. Current Sports Medicine Reports. 2011; 10: 255-270.
Warden SJ, Kiss ZS, Malara FA. Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy. Am J Sports Med. 2007; 35: 427-436.
Alfredson, H. The chronic painful Achilles and patellar tendon: research on basic biology and treatment. Scnd J Med Sc Sports. 2005; 15: 252-259.
Ohberg L ,Afredson H. Ultrasound guided sclerosing of neovessels inpainful chronic Achilles tendinosis: pilot study of a new treatment. Br J Sports Med. 2002; 36: 173-177.
Alfredson H. Midportion Achilles tendinosis and the planatris tendon. Br J Sports Med. 2011; 45: 1023-1025.