New Concepts in Managing Non-Insertional Achilles Injuries

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Key takeaways:

• The Achilles tendon's unique structure and function: The Achilles tendon is a powerful energy-storing structure, capable of storing and returning nearly 90% of the energy required to stretch it. This elastic recoil is crucial for efficient locomotion.
• "The free energy supplied by this elastic recoil significantly reduces the metabolic cost of locomotion and has played a huge role in our success as bipeds."
• Non-insertional Achilles tendinopathies are prevalent: These injuries, occurring at the midportion of the tendon, are common among runners due to impaired circulation in this area.
• Limitations of traditional treatment: The widely used Alfredson protocol, while helpful, shows limited long-term effectiveness. Nearly 60% of patients still experience pain five years later.
• New insights into tendon healing: Recent research suggests that stimulating intratendinous fluid flow and interfascicular sliding is critical for effective tendon remodeling.
• Heavy-load, long-duration isometric contractions: These exercises increase fluid outflow from the tendon core, promoting healing.
• "The applied load must be heavy and sustained for long-duration."
• Bent knee heel raises: These specifically target the soleus muscle, enhancing the non-uniform sliding of tendon fibers against each other, which stimulates tenocyte remodeling.
• "Individuals with damaged Achilles tendons show a more uniform pattern with limited variation in interfascicular sliding."
• Importance of synergist strengthening: Engaging muscles like the flexor hallucis longus helps offload the Achilles tendon during recovery.
• "By exercising the toe muscles in a lengthened position, strength gains are increased nearly fourfold compared to conventional exercises."
• Proposed exercise protocol: The document suggests a protocol incorporating bent knee heel drops, heavy-load isometric contractions, and exercises that engage the toe muscles. The frequency can be adjusted based on individual fitness levels.
• "I’ve been using this exercise protocol for almost 2 years now, and in my experience, it definitely produces better outcomes than the Alfredson protocol, especially in elite athletes."

Further research:

• Optimal exercise frequency for different patient demographics.
• Long-term effectiveness of the proposed protocol compared to other interventions.

Conclusion:
This document presents a compelling case for incorporating new concepts into Achilles tendinopathy rehabilitation. By understanding the importance of intratendinous fluid flow, interfascicular sliding, and synergist strengthening, clinicians can potentially achieve better and faster recovery for their patients.