Achilles Tendinopathy Toolkit: Section C - Summary of Evidence and Recommendations for Interventions

Original Editor - Kim Jackson for The BC Physical Therapy Tendinopathy Task Force:

Prof. Alex Scott, Dr Joseph Anthony, Dr Allison Ezzat, Prof Angie Fearon, JR Justesen, Dr Allison Ezzat, Dr Angie Fearon, Carol Kennedy, Michael Yates, Paul Blazey and Alison Hoens.

Top Contributors - Lucy Aird, Kim Jackson, Alex Scott, Cindy John-Chu, Olajumoke Ogunleye, Admin, Wanda van Niekerk and Rishika Babburu

Purpose, Scope and Disclaimer: The purpose of this document is to provide physical therapists with a summary of the evidence for interventions commonly used to manage mid‐substance Achilles tendinopathy. This decision‐making tool is evidence‐informed and where there is insufficient evidence, expert‐informed. It is not intended to replace the clinician’s clinical reasoning skills and inter‐professional collaboration. ‘Acute’ refers primarily to the stage with the cardinal signs of heat, redness, pain, swelling and loss of function and a very recent onset of symptoms.

Introduction[edit | edit source]

Clinicians want to provide evidence-informed management of tendinopathy but many struggle with accessing, appraising and synthesizing the vast array of literature available on this topic. This section forms part of the Achilles Tendinopathy toolkit project created by the BC (British Columbia) Physical Therapy Knowledge-Broker facilitated project team. The evidence below has been modified for Physiopedia and produced in collaboration with the authorship team to support the information found in the toolkit.

Explanation of clinical implications[edit | edit source]

When researching treatment options it is important to consider the clinical implications. The following interventions have been reviewed and graded according to the supporting evidence. See the table below for an explanation.

Strongly consider: High level/high quality evidence that this should be included in treatment.
Consider: Consistent lower level/lower quality or inconsistent evidence that this should be included in treatment.
May consider: No clinical evidence but expert opinion and/or plausible physiological rationale that this should be included in treatment.
Consider NOT: High level/high quality evidence that this should not be included in treatment.

Load Management[edit | edit source]

Load management can be described as the temporary reduction of external physiological stressors with the goal of improving overall fitness and performance while maintaining musculoskeletal and metabolic health.

Monitoring load as part of Achilles tendinopathy rehabilitation is essential in order to enhance recovery and minimise the risk of re-injury. A good understanding of the principles of exercise rehabilitation can help identify a programme that suits each individual. Accurate measurement and monitoring of external and internal loads is vital to a successful outcome and return to function.

State of pathology Acute Chronic
Clinical Research Evidence No Yes

2 CPG[1][2]

1 RCT[3]

Published Expert Opinion Yes

2 CPG

Yes
Take Home Message Expert opinion[4] and clinical practice guidelines recommend that advice and education should be given to maintain pain levels of 5/10 or below on a VAS/NPRS for all activities. Two clinical practice guidelines, one RCT and expert opinion[4] recommends that advice and education should be given to maintain pain levels of 5/10 or below on a VAS/NPRS for all activities.
Clinical implication May consider maintenance of daily activity during an acute phase, alongside advice to reduce loading from symptomatic (painful) activities to 5/10 on the VAS/NPRS May consider maintenance of daily activity during an acute phase, alongside advice to reduce loading from symptomatic (painful) activities to 5/10 on the VAS/NPRS

Exercise[edit | edit source]

Exercise prescription is part of all rehabilitation programmes and it is important to choose exercises that are relevant, effective and safe. Although there are many exercise principles advocated, the evidence is not always available to support these claims. The table below gives an overview of the current available evidence.

Stage of pathology Acute Chronic
Clinical research evidence No Yes
9 SR[5][6][7][8][9][10][11][12][13]

1 RCT[14]

Published expert opinion Yes[15] Yes[15]
Take home message A small amount of expert opinion exists to support the use of stretches in the acute stage. No evidence to support or refute the use of isometric exercise in the acute phase. There is a large amount of clinical research evidence to support the use of exercise in the chronic stage but the precise parameters to ensure effectiveness are not clear.

Eccentric exercise in particular is supported although some protocols use both concentric and eccentric exercise. One RCT showed heavy slow resistance training is equally as effective as eccentric training and appears to have higher compliance than eccentric training.

Clinical implication May consider a trial of using stretching exercises in the acute stage. No prescription parameters are provided.

ACSM recommends 10-30 sec hold, 2-4 repetitions.

Strongly consider using strengthening exercise in the chronic stage *

OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews.

Manual Therapy[edit | edit source]

Manual therapy is often suggested to address mobility impairments found on assessment. There is not much clinical research evidence to support. The table below gives an overview of the available evidence and suggestions on the clinical implications.

Joint mobilisations

Stage of pathology Acute Chronic
Clinical research evidence No Yes

1CPG

Published expert opinion Yes Yes
Take home message There is no clinical research evidence available to guide recommendations in the acute stage. There is a bio-mechanical rationale and published expert opinion that supports the use of mobilization if mobility impairments are found on assessment. There is a small amount of clinical research evidence and m ore substantial expert level of consensus to support the use of joint mobilizations to address physical impairments to improve mobility and function and this may enhance rehabilitation.
Clinical implication May consider a trial of joint mobilizations in the acute stage to improve mobility and function if impairments are identified after undertaking a comprehensive biomechanical evaluation of the hip, knee, foot and ankle. May consider a trial of joint mobilizations in the chronic stage to improve mobility and function if impairments are identified after undertaking a comprehensive biomechanical evaluation of the hip, knee, foot and ankle. Combining with a strengthening exercise program may or may not produce superior results.
Soft-tissue techniques
Stage of pathology Acute Chronic
Clinical research evidence No Yes
1 CPG[16]

1 RCT[17]

1 Other*[18]

Published expert opinion Yes

1 CPG

Yes
Take home message There is no clinical research evidence available to guide recommendations in the acute stage. There is physiological rationale and published expert opinion that supports the use of soft tissue techniques to increase range of motion. There is a small amount of clinical research evidence and expert level consensus that supports the us of soft tissue techniques to increase range of motion.

Clinical implication

May consider a trial of soft tissue techniques, such as frictions or pressure massage, to improve range of motion. May consider a trial of softtissue techniques, such as frictions or pressure massage in the chronic stage to increase range of motion. Combining with a strengthening exercise program may or may not produce superior results.

CPG- Clinical practice guideline, MA- Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews

*Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc).

Low level laser therapy (LLLT)[edit | edit source]

Low level laser therapy is a non-invasive light source treatment that generates a single wavelength of light. it is believe to affect the function of connective tissue cells by accelerating repair and reducing inflammation. As such it is often chosen as an intervention in the treatment of Achilles tendinopathy. The table below reviews the current available evidence and recommendations for its use!

Stage of pathology Acute Chronic
Clinical research evidence Yes
2 Other

Yes
1 MA[19]
8 RCT[20][21][22][23][24][25][19][26]

3 Other[27][28][29]

Published expert opinion Yes Yes
Take home message There is no clinical evidence, but there is a physiological rationale, and multiple animal studies to support the use of LLT in the acute stage.
There is conflicting clinical evidence and conflicting expert opinion to suport the use of LLT in the chronic stage. Two recent studies involving the use of higher energy (J) per treatment demonstrate improvements in pain.
Clinical implication May consider a trial of LLLT in the acute stage at the doses recommended by the World Association for Laser Therapy (www.walt.nu) i.e., 2‐4 J/point (not per cm2)*, minimum 2‐3 points.

*See 'Section D ' for further details on calculation of dosage.
Consider a trial of LLLT in the chronic stage at the following parameters: 0.9 J/point (not per cm2)*; 6 points on tendon.

If Class III, may consider a tial of LLT in the chronic stage at 450J _ 520J per treatment over the whole tendon.

*
See Section D ' for further details on calculation of dosage.

Therapeutic Ultrasound (US)[edit | edit source]

Therapeutic ultrasound is an intervention used in rehabilitation to promote tissue healing. Although it is classified under the term electrotherapy it is in fact a form of mechanical energy. There are both thermal and non-thermal changes observed in the tissues caused by the oscillation of particles as the waves through the tissue. Whether the changes are thermal or non-thermal will depend upon the setting used. There is currently no evidence to support or refute the use of US in the acute or chronic stages of Achilles tendinopathy but the physiological rationale may support its use during the acute stage.

Stage of pathology Acute Chronic
Clinical research evidence No No
Published expert opinion|- No No
Take home message There is no clinical evidence, but there is physiological rationale, to support the use of US in the acute stage. There is no clinical evidence and no physiological rationale to support the use of US in the chronic stage.
Clinical implication May consider a trial of US in the acute stage at a low to moderate dose (0.5 ‐ 1.0 W/cm2, pulsed 1:4‐1:1, 3 MHz, 5 mins for each treatment area equivalent in size to transducer head). No evidence to support or refute the use of therapeutic ultrasound in the chronic phase.


CPG- Clinical practice guideline, MA- Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews

*Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc).

Extracorporeal Shock Wave Therapy (ESWT)[edit | edit source]

ESWT also known as shock wave therapy and has often been used in the treatment of urinary stones and fracture healing. The shock waves are actually sound waves, and as they pass through tissues the positive and negative phases cause direct mechanical forces and generate cavitation and gas bubbles. There is no evidence or physiological rationale to support its use in the acute stages of Achilles tendinopathy. Although there is often conflicting evidence in the research relating to its use in the chronic stages it has been suggested that it may have some benefits, especially where more commonly used conservative treatment interventions have not resulted in a positive outcome.

Stage of pathology Acute Chronic
Clinical research evidence No Yes
2 CPG[2][30]

1 MA[31]

1 SR[32]

1 Other*[33]

Published expert opinion No Yes
Take home message There is no clinical evidence and no physiological rationale to support the use of ESWT in the acute stage. There is conflicting evidence to support the use of high or low energy ESWT devices in the chronic stage. The evidence suggests that outcomes are dependent upon the dosage ( measured in mJ/mm² or Bars) rather than the type of shock wave generation (focused or

radial ESWT vs. radial pulsed-pressure ESWT). Local anesthetic required in high energy protocols may decrease the effectiveness of ESWT. Therefore, using low energy ESWT protocols without the need for anesthetic are recommended as more practical, more tolerable, and less expensive with equivalent results to high energy protocols. Low energy protocols could apply to focused or radial ESWT; or radial pulsed-pressure ESWT devices.

Because of heterogeneity in study designs, the optimum protocol has yet to be determined

Clinical implication Consider NOT using Extracorporeal Shock Wave for the acute stage.

Consider a trial of ESWT in the chronic stage for refractory cases that have failed to resolve with other conservative treatment. Recommended parameters:

Focused or Radial ESWT, including pulsed-pressure ESWT devices.

Low energy: EFD (energy flux density) 0.10 – 0.28 mJ/mm² (equivalent to approximately 2-4 Bars using a pulsed- pressure device)

1500-3000 shocks

4-15 Hz

3-5 sessions, weekly intervals.

ESWT may enhance outcomes compared to exercise alone, therefore patients should be instructed to continue with a well-designed exercise program.

Appropriate time intervals for follow-up should be delayed in the short term (within 3 months of starting ESWT treatment) to allow for cellular repair models to be influenced through the mechanotransduction action of ESWT.

The benefit of ESWT may further improve in the medium (6 months) and long term (12 months).

CPG- Clinical practice guideline, MA- Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews

*Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc).

Iontophoresis Using Dexamethasone[edit | edit source]

Iontophoresis is a process where an electrical current is passed through the skin. The affected body part is submerged in water which allows ionised (charged) particles to cross the normal skin barrier. Iontophoresis is considered as a non invasive method to deliver drugs transdermally.

Stage of pathology Acute Chronic
Clinical research evidence Yes
2 CPG[2][34]

1 RCT[35]

No
Published expert opinion Yes No
Take home message

There is a small amount of evidence to support the application of iontophoresis using dexamethasone in the acute stage.

There is no evidence or expert opinion that anti inflammatory intervention with iontophoresis using dexamethasone has a useful role in the chronic stage.
Clinical implication Consider, in the acute stage, a trial of iontophoresis, 0.4% dexamethasone (aqueous), 80 mA‐min; 6 sessions over 3 weeks.

A program of concentric‐eccentric exercises should be continued in combination with iontophoresis, if exercise loading is tolerated.

No evidence to support or refute the use of iontophoresis in the chronic phase.

CPG- Clinical practice guideline, MA- Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews

*Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc).

Rigid Taping[edit | edit source]

Rigid taping is commonly used as an adjunct or temporary technique, to restrict movement, reduce swelling, and support anatomical structures in the acute and chronic stages of Achilles tendinopathy. It is also used post injury to protect against re-injury.

Stage of pathology Acute Chronic
Clinical research evidence Yes

1 CPG[2]

Yes

1 CPG

1 SR[36]

2 Other*[37][38]

Published expert opinion Yes Yes
Take home message There is expert opinion to support the use of rigid taping in the acute stage.


There is expert opinion and a small amount of clinical evidence to supportthe use of rigid taping in the chronic

stage.

Clinical implication May consider a trial of rigid taping in the acute stage. May consider a trial of rigid taping in

the chronic stage.

CPG - Clinical practice guideline; MA - Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews

*Other study designs (e.g. Cohort, case control, case series, quasi-experimental studies, etc).

Orthotics[edit | edit source]

Orthotics are often used during the acute stage of Achilles tendinopathy to reduce the load through the tendon. There is inconsistent evidence on the benefits of using orthotics during the chronic stage

Stage of pathology Acute Chronic
Clinical research evidence Yes

1 CPG

1 Other*

Yes

1 CPG

2 SR[36][39]

2 RCT[40][41]

6 Other*[42][43][44][37][38][45]


Published expert opinion Yes Yes
Take home message There is a small amount of clinical evidence to support the use of orthotics in the acute stage in specific cases, to reduce load through the Achilles tendon. There is inconsistent evidence and expert opinion regarding the

effectiveness of orthotics in the chronic stage

Clinical implication

May consider a trial of orthotics in the acute stage – may consider taping first to assess potential response to orthotics.

May Consider a trial of orthotics in the chronic stage to reduce strain in the Achilles tendon, if indicated by the clinical assessment.

CPG - Clinical practice guideline; MA - Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews

*Other study designs (e.g. Cohort, case control, case series, quasi-experimental studies, etc).

Night splints and braces[edit | edit source]

Night splints are rigid supports that are used to protect, support or immobilse the injured joint. The use of night splints in Achilles tendinopathy to maintain the length and of muscle and tendon but clinical guidelines recommend that these are not used during the acute stage.

Stage of pathology Acute Chronic
Clinical research evidence No

1 CPG

Yes

1 CPG[2]

2 SR[46][39]

3 RCT[47][48][49]

1 Other*

Published expert opinion Yes Yes
Take home message Clinical practice guidelines recommend

against the use of night splints for Achilles tendinopathy.

There is a small amount of evidence and expert opinion that adding a night splint to eccentric exercise provides no benefit.
Clinical implication Consider NOT using night splints in the acute stage Consider NOT using night splints in the

acute stage

CPG - Clinical practice guideline; MA - Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews

*Other study designs (e.g. Cohort, case control, case series, quasi-experimental studies, etc).

Bracing[edit | edit source]

Using a brace (airheel) is often used during the acute stages and also as an adjunct to eccentric exercise. However, despite there being expert opinion there is no high level clinical research to support its use during the acute stage and only a small amount of evidence available of the benefits in the chronic stage of Achilles tendinopathy.

State of Pathology Acute Chronic
Clinical research evidence No

1 CPG

Yes

1 CPG[2] 1 SR[36] 3 RCT[1][50][51]

Published Expert Opinion Yes Yes
Take Home Message There is expert opinion to consider

using a brace (Airheel) in the acute stage.

There is a small amount of evidence

suggesting that adding a brace (Airheel) to eccentric exercise provides no benefit. There is expert opinion that a brace (Airheel) may be considered in the chronic stage.

Clinical implication May consider trialing a brace in the

acute stage.

May consider trialing a brace in the

chronic stage.

Heel raise inserts[edit | edit source]

Heel raise inserts are sometimes used to reduce the load on the Achilles tendon but there is very little evidence to support their use. Refer to the table below for more guidance.

Stage of pathology Acute Chronic
Clinical research evidence No Yes
1 CPG[52]

2 RCT[53][42]

2 Other*[54][55]

Published expert opinion No Yes
Take home message There is physiological rationale that the

application of heel inserts can reduce load on the Achilles tendon

There is conflicting evidence and expert opinion for and against the use of heel inserts in the chronic stage
Clinical implication May consider a trial of inserts in the acute stage to reduce loads through the Achilles tendon. Consider a trial of heel inserts in the chronic stage.

Dry Needling Techniques[edit | edit source]

Dry needling is an invasive procedure where a fine needle or acupuncture needle is inserted into the skin and muscle. There is no published evidence to support its use in the acute stages and no high quality evidence to support or refute its use in the chronic stages.

Stage of pathology Acute Chronic
Clinical research evidence No
Yes
1 RCT[56]
Published expert opinion No No
Take home message There is no evidence or published expert consensus to support the use of acupuncture or other needling techniques in the acute stage There is a small amount of evidence that dry needling (Gunn intramuscular

stimulation) provides no additional benefit to exercise.

Clinical implication Consider NOT using dry needling in the acute stage. No high-quality evidence to support or refute the use dry needling in the chronic stage.

CPG - Clinical practice guideline; MA - Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews

*Other study designs (e.g. Cohort, case control, case series, quasi-experimental studies, etc).

**“Dry needling is a broad term that refers to a treatment technique that uses solid filament needles to puncture the skin for therapeutic purposes. It includes a range of approaches, such as acupuncture, trigger point dry needling, intramuscular stimulation, or similar treatment...” – The Safe Practice of Dry Needling in Alberta. Health Quality Council of Alberta, 2014

Resources[edit | edit source]

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