Dutch multidisciplinary guideline on Achilles tendinopathy

Abstract

Objective: To provide a comprehensive, evidence-based overview of the risk factors, prevention, diagnosis, imaging, treatment and prognosis for Achilles tendinopathy. To make clinical recommendations for healthcare practitioners and patients.

Design: Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary and authorisation phase. Patients participated in every phase.

Data sources: Multiple databases and existing guidelines were searched up to May 2019. Information from patients, healthcare providers and other stakeholders were obtained using a digital questionnaire, focus group interview and invitational conference.

Study eligibility criteria: Studies on both insertional and/or midportion Achilles tendinopathy were eligible. Specific eligibility criteria were described per module.

Data extraction and synthesis: To appraise the certainty of evidence, reviewers extracted data, assessed risk of bias and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were: patient values and preferences, costs, acceptability of other stakeholders and feasibility of implementation. Recommendations were made based on the results of the evidence from the literature and the considerations.

Primary outcome measure: The primary and secondary outcome measures were defined per module and defined based on the input of patients obtained in collaboration with the Netherlands Patient Federation and healthcare providers from different professions.

Results: Six specific modules were completed: risk factors and primary prevention, diagnosis, imaging, treatment prognosis and secondary prevention for Achilles tendinopathy.

Summary/conclusion: Our Dutch multidisciplinary guideline on Achilles tendinopathy provides six modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are given for risk factors, prevention, diagnosis, imaging, treatment and prognosis. This guideline can assist healthcare providers and patients in clinical practice.

Keywords: achilles tendon; injury prevention; risk factor; treatment; ultrasonography.

Figure 1

Distinguishing Achilles tendinopathy based on location of the symptoms. Insertional Achilles tendinopathy is localised within the first 2 cm of the attachment of the Achilles tendon on the calcaneus (left side figure) and midportion Achilles tendinopathy is localised >2 cm above this attachment (right side figure).

Figure 2

Overview of the Dutch multidisciplinary guideline process and the six modules.

Figure 3

Proposed flow chart for designing the progressive calf muscle strengthening exercises (gastrocnemius and soleus muscles) and plyometric exercises. The degree of pain (measured by a Visual Analogue Scale or Numeric Rating Scale) during and after the exercises and the muscle fatigue are leading for the speed of the progression. Note that for insertional Achilles tendinopathy, exercises are initially advised on a flat surface.