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How does Achilles tendinopathy affect the quality of life?
28 Jul 2023

Traditionally, ailments have been addressed solely from a physical standpoint. Nowadays, however, a new integral and holistic approach is gaining traction. Along with it comes the evidence: understanding the patient and comprehending the impact of their injury on their daily life are fundamental parts of the treatment and, consequently, their recovery.

What is Achilles tendinopathy?

Achilles tendinopathy (AT) is an overuse injury of the Achilles tendon, the band of tissue that connects the calf muscles at the back of the leg to the heel bone.

It is a clinical condition characterized by pain and thickening of the tendon, affecting the tendons and nearby structures, leading to functional limitations and reduced load-bearing capacity [1, 2].

How does Achilles tendinopathy occur?

Its etiology is multifactorial: some studies indicate that intrinsic factors could include biomechanical abnormalities of the lower limb (e.g., leg length discrepancy), diabetes, hypertension, obesity, gout, age, etc. These risk factors might combine with extrinsic factors, including excessive mechanical overload (such as sudden increases or reductions in training levels) [3] and inadequate sports equipment [4, 5, 6].

Who can suffer from Achilles tendinopathy?

Achilles tendinopathy is one of the most common ankle and foot overuse injuries, affecting recreational athletes (with a prevalence ranging from 11.8% to 14.4%) and elite athletes (with a prevalence ranging from 32% to 45%), especially those involved in jumping sports like basketball and volleyball [7]. However, AT also occurs in individuals engaged in running activities [4] and professional dancers [8].

Nevertheless, it is not limited to the athletic population and has a high incidence in the general population.

Economic impact of Achilles tendinopathy

Achilles tendinopathy negatively impacts the social connection and psychological well-being of patients, reducing their quality of life. It is not easy to diagnose in its early stages [2, 9], has a poor prognosis, and a high incidence of chronicity and recurrence [10, 11].

In fact, the number of tendon-related interventions performed worldwide has been increasing over time, with approximately 30 million interventions each year. This translates to higher healthcare costs, estimated at around 140 billion euros [8, 12]. As can be seen, these injuries are associated with high socio-economic and healthcare costs, long-term postoperative rehabilitation, and productivity loss [12].

Psychological impact of Achilles tendinopathy

Despite the evidence, few studies support the effect of the disease on the patient’s quality of life and the effectiveness of the treatment.

This need led to the development of the review “Psychosocial and individual factors affecting Quality of Life (QoL) in patients suffering from Achilles tendinopathy: a systematic review” (Josep Verges et al., 2022).

The review aimed to summarize the current information about the quality of life in patients suffering from this condition from different angles: comparing it to a healthy population, identifying individual factors influencing it, among others.

Study results

All the studies reported that patients with AT had a worse quality of life, and some factors had a more significant adverse effect on the quality of life than others.

  • In the studies included in this review comparing the quality of life between patients with AT and without AT, patients with AT generally reported poor quality of life compared to the non-AT population [13, 14, 15].
  • When comparing women to men, women reported a worse quality of life. Knobloch et al. [16] found that the outcomes were unfavorable for women compared to men. Additionally, women did not benefit as much from eccentric training or stretching as men [17, 16].
  • Age was another factor influencing patients’ perception of quality of life. Fen et al. [18] reported lower patient satisfaction among patients over 60 years old compared to younger patients. Similarly, Knobloch et al. [16] found worse quality of life and less improvement in women over 50 years old compared to younger women of the same gender.
  • Patients with AT reported a similar or worse quality of life than individuals with other musculoskeletal diseases such as rheumatoid arthritis (RA), osteoarthritis (OA), and fibromyalgia [2].
  • Weight, height, and BMI did not show a significant impact.
  • Mc Auliffe et al. [19] found that AT had a psychological impact on patients as they experienced a loss of self-esteem. Furthermore, patients reported frustration because professionals could not explain the condition and had different opinions. Turner et al. [20] confirmed that 5 out of 15 patients felt frustration or dissatisfaction with their healthcare network. Participants in this study reported that the provided information was inconsistent, and doctors did not explain the condition in simple terms.
  • Patients participating in different exercise programs (strengthening and stretching) showed improvements in quality of life.
  • It was reported that the loss of the ability to exercise has a significant impact on patients’ quality of life [21], affecting overall health and quality of life [16].
  • The studies included in this review show that quality of life affects patients with both low and high activity levels, as both groups showed higher degrees of kinesiophobia.
  • Surgery is a common treatment option when non-surgical options fail [22]. The surgical intervention for AT improved patients’ quality of life, although the results varied depending on age.

Interventions and Achilles tendinopathy

Conservative treatment for AT includes therapeutic ultrasound, shock wave intervention, platelet-rich plasma (PRP) injection, and simulated injection, and depending on the tendon degeneration, minimally invasive and open surgery can also be performed [4]:

  • One study found that shock wave intervention had better results than therapeutic ultrasound intervention.
  • PRP injection did not show significant differences in quality of life.
  • Some studies showed that surgical intervention and its impact on quality of life depended on demographic variables and only improved physical components.

Main conclusions

AT is a problematic condition, both for the individual and for healthcare personnel. The summarized review showed that patients with AT have a poorer quality of life than the general population and highlighted the importance of recognizing, evaluating, and integrating different aspects of quality of life within treatment protocols to improve patient outcomes. It also shows the need to provide healthcare professionals with tools that help them better understand the patient.

In any case, further research on patients with AT is suggested to better understand the aspects leading to poor quality of life.

Sources:

  1. Aicale R, Oliviero A, Maffulli N. Management of Achilles and patellar tendinopathy: what we know, what we can do. J Foot Ankle Res. 2020;13:1–10.
  2. Sleeswijk Visser TSO, Van Der Vlist AC, Van Oosterom RF, et al. Impact of chronic Achilles tendinopathy on health-related quality of life, work performance, healthcare utilisation and costs. BMJ Open Sport Exerc Med. 2021;7:e001023.
  3. O’Neill S, Watson PJ, Barry S. A delphi study of risk factors for achilles tendinopathy- opinions of world tendon experts. Int J Sports Phys Ther. 2016;11:684.
  4. Li HY, Hua YH. Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. BioMed Res Int. 2016. https://doi.org/10. 1155/2016/6492597. Epub ahead of print 2016.
  5. 12. Magnan B, Bondi M, Pierantoni S, et al. The pathogenesis of Achilles tendinopathy: a systematic review. Foot Ankle Surg. 2014;20:154–9.
  6. 13. Silbernagel KG, Hanlon S, Sprague A. Current clinical concepts: conservative management of achilles tendinopathy. J Athl Train. 2020;55:438–47.
  7. Cardoso TB, Pizzari T, Kinsella R, et al. Current trends in tendinopathy management. Best Pract Res Clin Rheumatol. 2019;33:122–40.
  8. Loiacono C, Palermi S, Massa B, et al. Tendinopathy: Pathophysiology, Therapeutic Options, and Role of Nutraceutics. A Narrative Literature Review. Medicina (B Aires). 55. https://doi.org/10.3390/MEDICINA55 080447. Epub ahead of print 1 August 2019.
  9. 14. Wang Y, Zhou H, Nie Z, et al. Prevalence of Achilles tendinopathy in physi- cal exercise: a systematic review and meta-analysis. Sport Med Heal Sci. 2022;4:152–9.
  10. Fredberg U, Stengaard-Pedersen K. Chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflamma- tion: Review. Scand J Med Sci Sport. 2008;18:3–15.
  11. Ackermann PW, Renström P. Tendinopathy in sport. Sports. Health. 2012;4:193–201.
  12. Lomas AJ, Ryan CNM, Sorushanova A, et al. The past, present and future in scaffold-based tendon treatments. Adv Drug Deliv Rev. 2015;84:257–77.
  13. 19. Plinsinga ML, Van Wilgen CP, Brink MS, et al. Patellar and Achilles tendinopathies are predominantly peripheral pain states: a blinded case control study of somatosensory and psychological profiles. Br J Sports Med. 2018;52:284–91.
  14. Lewis TL, Yip GCK, Robertson K, et al. Health-related quality of life in patients with Achilles tendinopathy: comparison to the general popula- tion of the United Kingdom. Foot Ankle Surg. 2022;28:1064–8.
  15. Martin RRL, Manning CM, Carcia CR, et al. An outcome study of chronic Achilles tendinosis after excision of the Achilles tendon and flexor hallucis longus tendon transfer. Foot ankle Int. 2005;26:691–7.
  16. 24. Knobloch K, Schreibmueller L, Kraemer R, et al. Gender and eccentric training in Achilles mid-portion tendinopathy. Knee Surg Sport Traumatol Arthrosc 2009 185 2009;18: 648–655.
  17. 22. Nørregaard J, Larsen CC, Bieler T, et al. Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sport. 2007;17:133–8.
  18. Phen HM, Manz WJ, Mignemi D, et al. Outcomes of Operative Man- agement of Insertional Achilles Tendinopathy in the Young vs Elderly. 2020;5:247301142092610. https://doi.org/10.1177/2473011420926101.
  19. 26. Mc Auliffe S, Synott A, Casey H, et al. Beyond the tendon: Experiences and perceptions of people with persistent Achilles tendinopathy. Musculo- skelet Sci Pract. 2017;29:108–14.
  20. 21. Turner J, Malliaras P, Goulis J, et al. “It’s disappointing and it’s pretty frustrating, because it feels like it’s something that will never go away.” A qualitative study exploring individuals’ beliefs and experiences of Achilles tendinopathy. PLoS One. 2020;15:e0233459.
  21. 34. Mallows A, Head J, Goom T, et al. Patient perspectives on participation in exercise-based rehabilitation for Achilles tendinopathy: a qualitative study. Musculoskelet Sci Pract. 2021;56:102450.
  22. Tallon C, Coleman BD, Khan KM, et al. Outcome of Surgery for Chronic Achilles Tendinopathy. 2017;29:315–320. https://doi.org/10.1177/03635 465010290031101.

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