Risk Factors for Failure of Conservative Treatment for Achilles Tendinopathy

Jennifer Spector, DPM, FACFAS:
Welcome everybody. We're so excited to have you here for our monthly news and trends column, but in a little bit of a new format. As you know, Podiatry Today regularly highlights new and emerging research along with insights from leaders in the field on these important topics. Today, we're taking a closer look at a study from Foot and Ankle Specialist on potential risk factors for failure of conservative treatment for Achilles tendinopathy. To comment on this article today, we have Dr. Maryellen Brucato with us. She's a fellow of the American College of Foot and Ankle Surgeons and Practices in New Jersey. Thank you so much for joining us today.

Maryellen Brucato, DPM, FACFAS:
Thank you for having me.

Jennifer Spector, DPM, FACFAS:
So, we're so excited to hear what you think about this article. What these authors did, is when treating a patient for Achilles tendinopathy, they set out to determine who's at most risk for needing to progress to surgical intervention.

Jennifer Spector, DPM, FACFAS:
They looked at 226 patients with insertional Achilles tendonitis over a little bit less than four years through a retrospective chart review. 78 of these patients had surgical intervention and 178 of them had non-surgical intervention only. And looking at this demographically, they didn't find any differences between the two groups, but what they did find is those that underwent surgical intervention had a higher likelihood of Haglund's deformity, they had higher visual analog pain scores, lower SF-12 physical scores and higher rates of depression. So, I'm curious after reading this article, what are your general thoughts on the findings?

Maryellen Brucato, DPM, FACFAS:
I think that they're really interesting. I would have expected that more of the comorbidities would have had a higher correlation with surgical intervention, especially a higher BMI, smoking, anything that would affect like diabetes. They didn't find a difference in anything that would affect tendon healing. You would expect them to need more surgery to fix the tendon. Conservative treatment in general does tend to not work on patients with higher BMIs, diabetes, smokers, rheumatoid arthritis even, alcohol use they have in there too. So they have a lot of things in there that I was really surprised that didn't correlate.

Jennifer Spector, DPM, FACFAS:
Yeah, absolutely. I was interested that they didn't say a whole lot about biomechanics either, or a foot type, or gastrosoleus equinus or anything like that. So it was interesting that they didn't comment on those, or that when they did comment on some of those comorbidities, they didn't find a whole lot of correlation. That being said, in your practice, have you found similar findings to what they did find or do you have a different experience with this?

Maryellen Brucato, DPM, FACFAS:
So, great question. Where they found a Haglund's deformity was associated with a higher incidence of surgical intervention. I think that makes a lot of sense because number one, you can do all the treatment in the world and heal the Achilles tendon, but the bump is still mechanically there and it's still rubbing and irritating the tendon. It's not going to go away. It's not going to improve. So you have to surgically remove it to get it better. Additionally, if a patient has this Achilles tendinopathy at the insertion, it's hard to convince them to do surgery on it.

Maryellen Brucato, DPM, FACFAS:
If it's recalcitrant, even if it's failed with conservative options, if they don't have a bump there, don't have anything physical there. However, if they have a Haglund's deformity and they can see it and they can feel a bump and I can show it to them, "Hey, look, the bump here is rubbing. It's irritating the tendon, what we have to do is make an incision over it, shave the bump down, take the tendon off, shave the bump down, put the tendon back, clean up the tendon." It's easier to, "Sell the surgery," to a patient to have something visual there.

Jennifer Spector, DPM, FACFAS:
So looking at this study, are there any aspects that you feel that clinicians could incorporate into their practices today?

Maryellen Brucato, DPM, FACFAS:
I do think it's interesting that they found a higher correlation of surgical intervention with patients with depression and other mental illness. I think that just speaks to the fact that a patient's mental health does play a role in whether their conservative treatment is going to help or not. I think that we need to treat patients as a whole. So if they're really down or they have a negative attitude about their problem and they feel like it's not going to get any better because life is hopeless. So they're hopeless about their problem. Then guess what? They're probably not going to get any better without surgery.

Maryellen Brucato, DPM, FACFAS:
So a lot of times we want to keep that in mind and then patients that just in my experience, patients that have a history of depression or mental illness, they don't do as well after surgery. So we want to make sure that we're identifying any underlying mental problems that are going on. Sometimes calling the primary care doctor before getting surgical clearance, just to discuss the patient's mental health would help. In my own experience, patients with underlying mental health disorders have higher incidents of CRPS. So we do want to look at that because they did find in the study that more patients that have those problems did wind up needing surgery. So maybe instead of jumping to surgery, maybe we should be talking to our patients and providing a little support. We're not therapists, we're not there to do therapy, but maybe providing some positive reinforcement and just some support and just kind of say, "Hey, how's everything going," versus just going in and really acting like the surgeons that we are and saying, "Well, here's the problem, we can fix it."

Maryellen Brucato, DPM, FACFAS:
We want to take a step back and kind of treat the patient as a whole. I think that's important. They also found that patients with higher pain scores needed surgery more, which kind of correlates because if they're going to do really bad, they're feeling really bad that they're probably going to need surgery. And now that I'm getting more experienced as in my career, I'm kind of feeling like when a patient comes in right away, I can kind of tell these days if they're going to wind up needing surgery or not. And I'm sure many of you have come into that experience as well. So if the pain's really high and it's really not doing well, then you can kind of tell early on that they're probably going to need surgery and you shouldn't mess around too much with the conservative stuff. Because there's so many different conservative options.

Maryellen Brucato, DPM, FACFAS:
You could keep them in a boot forever, you could do physical therapy, you could do anti-inflammatories. So, maybe this study the way that we could incorporate it into our practices, if they have these comorbidities or the higher pain levels or the Haglund's deformities, maybe we shouldn't mess around the conservative treatment. I think that's absolutely true for the Haglund's because again, none of those conservative treatments are going to take that bump away. The only thing that we're going to do to take that bump away is surgery. So you really have to figure out on the patient, is the bump causing the pain? Is it the tendon or is it a combination of both? And in my experience, it's always a combination of both. It's never just the tendon and it's never just the bump. Very rarely is it ever just the bump. So just keep that in mind.

Jennifer Spector, DPM, FACFAS:
Making those connections between really the root cause and also baseline issues that the patient has going on that could affect the outcome certainly make sense. Is there anything else that you wanted to add today?

Maryellen Brucato, DPM, FACFAS:
I do think it's a weakness that they didn't include the biomechanicals of the patients. That's a little weird. It makes me think that because it was done retrospectively maybe their notes weren't great. So when they look back at it, they couldn't really tell the biomechanics or the shape of the foot or anything like that. Like you said, there's an equinus component, things like that. So, that's definitely a weakness that I would point out about the study. I also wanted to say that the study found evidence that a Haglund's deformity on physical exam was significantly associated with the tendonitis. Radiographic evidence of the deformity was not found to be associated.

Maryellen Brucato, DPM, FACFAS:
So I think that probably speaks to the fact that taking those angles on a radiograph for Haglund's deformity doesn't always line up because some patients clinically have a huge bump and then you try to measure the angles and they're not significant. So I think that part of the study was in line with my clinical practice. You can't really rely on the radiographs for Haglund's. I think you really got to look at it clinically.

Jennifer Spector, DPM, FACFAS:
You really do have to look at the whole patient and not just one aspect, not just a presence of a deformity, not just radiographs. Certainly it does involve the entire picture. Thank you so much for your comments today. We really appreciate you lending your expertise. Hopefully the audience learned a lot from this presentation today and we look forward to having you and other docs join us for future versions of our News and Trends piece.