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

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<div class="editorbox">
'''Original Editor '''- [[User:Kim Jackson|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''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
'''Purpose, Scope and Disclaimer:&nbsp;'''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&nbsp;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.  
'''Purpose, Scope and Disclaimer:&nbsp;'''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&nbsp;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.  


== Achilles Tendinopathy (mid-substance):&nbsp; Summary of the Evidence for Physical Therapy Interventions  ==
== Introduction ==
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.


*''Click to go back to the ''[[Achilles Tendinopathy Toolkit|''contents page'']]
=== Explanation of clinical implications ===
*''Click to go back to the&nbsp;[[Achilles Tendinopathy Toolkit: Treatment Algorithm|Treatment Algorithm]]''  
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.
*''Click to continue to ''[[Achilles Tendinopathy Toolkit: Appendix A|''Appendix A: Exercise Programs'']]
{| width="700" border="1" cellpadding="1" cellspacing="1"
*''Click to continue to ''[[Achilles Tendinopathy Toolkit: Appendix B|''Appendix B: Low Level Laser Therapy Dosage Calculation'']]
|-
*''Click to continue to:&nbsp;''[[Achilles Tendinopathy Toolkit: Appendix C|''Appendix C: Details of Articles on Interventions'']]
|'''Strongly consider:&nbsp;'''High level/high quality evidence that this should be included in treatment.
*''Click to continue to:&nbsp;''[[Achilles Tendinopathy Toolkit: Appendix D|''Appendix D: Medical and Surgical Interventions'']]
|-
|'''Consider:'''&nbsp;Consistent lower level/lower quality or inconsistent evidence that this should be included in treatment.
|-
|'''May consider:&nbsp;'''No clinical evidence but expert opinion and/or plausible physiological rationale that this should be included in treatment.
|-
|'''Consider NOT:&nbsp;'''High level/high quality evidence that this should not be included in treatment.
|}


=== Load Management ===
=== Load Management ===
{| class="wikitable mw-collapsible"
[[Load Management|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|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.
{| class="wikitable"
|+
|+
!'''State of pathology'''
!'''State of pathology'''
Line 18: Line 35:
|-
|-
!'''Clinical Research Evidence'''
!'''Clinical Research Evidence'''
!No
|No||Yes
!Yes
2 CPG<ref name=":1">de Vos RJ, van der Vlist AC, Zwerver J, Meuffels DE, Smithuis F, van Ingen R, van der Giesen F, Visser E, Balemans A, Pols M, Veen N, den Ouden M, Weir A. [https://doi.org/10.1136/bjsports-2020-103867 Dutch multidisciplinary guideline on Achilles tendinopathy]. Br J Sports Med. 2021 Oct;55(20):1125-1134. </ref><ref name=":2">Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR. [https://doi.org/10.2519/jospt.2018.0302 Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018]. J Orthop Sports Phys Ther. 2018 May;48(5):A1-A38.</ref>
2 CPG


1 RCT
1 RCT<ref>Silbernagel KG, et al. [https://clinicaltrials.gov/ct2/show/NCT04816188 Continued Sports Activity, Using a Pain-monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy: a Randomized Controlled Study.] ''Am J Sports Med.'' 2007;35(6):897-906. PubMed PMID: 17307888.</ref>
|-
|-
|'''Published Expert Opinion'''
!'''Published Expert Opinion'''
|Yes
|Yes
2 CPG
2 CPG
|Yes
|Yes
|-
|-
|'''Take Home Message'''
!'''Take Home Message'''
|Expert opinion and clinical practice
|Expert opinion<ref name=":0">Silbernagel KG, Crossley KM. A [https://doi.org/10.2519/jospt.2015.5885 Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation]. J Orthop Sports Phys Ther. 2015 Nov;45(11):876-86.</ref> 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.
guidelines recommend that advice and
|Two clinical practice guidelines, one RCT and expert opinion<ref name=":0" /> 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
|}


education should be given to maintain
=== Exercise ===
 
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.
pain levels of 5/10 or below on a
{| class="wikitable"
 
|+
VAS/NPRS for all activities.
! Stage of pathology
|Two clinical practice guidelines, one RCT
!'''Acute'''
and expert opinion recommends that
!'''Chronic'''
 
|-
advice and education should be given to
! Clinical research evidence
 
| No
maintain pain levels of 5/10 or below on
| Yes<br>9 SR<ref>Habets B, van Cingel REH. [https://doi.org/10.1111/sms.12208 Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review of different protocols.] Scand J Med Sci Sports. 2015: 25: 3–15</ref><ref>Murphy MC, Travers MJ, Chivers P, Debenham JR, Docking SI, Rio EK, Gibson W. [https://doi.org/10.1136/bjsports-2018-099934 Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis]. Br J Sports Med. 2019 Sep;53(17):1070-1077</ref><ref>Kingma JJ, de Knikker R, Wittink HM, Takken T. [https://doi.org/10.1136%2Fbjsm.2006.030916 Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review.] Br J Sports Med. 2007 Jun;41(6):e3.</ref><ref>Kraemer R, Lorenzen J, Vogt PM, et al. [https://doi.org/10.1055/s-0029-1245820 Systematic review about eccentric training in chronic achilles tendinopathy.] Sportverletz Sportschaden. 2010, 24(4): 204-11</ref><ref>Magnussen RA, Dunn WR, Thomson AB. [https://doi.org/10.1097/jsm.0b013e31818ef090 Nonoperative treatment of midportion Achilles tendinopathy: a systematic review.] Clin J Sport Med. 2009 Jan;19(1):54-64</ref><ref>Malliaras P, Barton CJ, Reeves ND, Langberg H. [https://doi.org/10.1007/s40279-013-0019-z Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness]. Sports Med. 2013 Apr;43(4):267-86.</ref><ref>Meyer A, Tumilty S, Baxter GD. [https://doi.org/10.1111/j.1600-0838.2009.00981.x Eccentric exercise protocols for chronic non-insertional Achilles tendinopathy: how much is enough?] Scand J Med Sci Sports. 2009 Oct;19(5):609-15.</ref><ref>Wasielewski NJ, Kotsko KM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978463/ Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review.] J Athl Train. 2007 Jul-Sep;42(3):409-21</ref><ref>Woodley BL, Newsham-West RJ, Baxter GD. [https://doi.org/10.1136/bjsm.2006.029769 Chronic tendinopathy: effectiveness of eccentric exercise]. Br J Sports Med. 2007 Apr;41(4):188-98.</ref>
 
1 RCT<ref>Silbernagel KG, Thomeé R, Thomeé P, Karlsson J. [https://doi.org/10.1034/j.1600-0838.2001.110402.x Eccentric overload training for patients with chronic Achilles tendon pain--a randomised controlled study with reliability testing of the evaluation methods]. Scand J Med Sci Sports. 2001 Aug;11(4):197-206.</ref>
a VAS/NPRS for all activities.
|-
! Published expert opinion
| Yes<ref name="Magnusson 2010">Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nature Reviews Rheumatology. 2010;6(5):262‐8.</ref>
| Yes<ref name="Magnusson 2010" />
|-
! 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'''
! Clinical implication
|May consider maintenance of daily
| May consider a trial of using stretching exercises in the acute stage. No prescription parameters are provided.
activity during an acute phase,
ACSM recommends 10-30 sec hold, 2-4 repetitions.
|'''Strongly consider''' using strengthening exercise in the chronic stage *
|}


alongside advice to reduce loading from
OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews.
 
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
|}


=== Manual Therapy  ===
=== Manual Therapy  ===
 
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.
{| width="700" border="1" cellpadding="1" cellspacing="1"
{| class="wikitable"
|-
|-
! colspan="3" scope="row" |  
! colspan="3" scope="row" |  
'''Joint mobs'''''<br>''  
'''Joint mobilisations'''''<br>''  
 
|-
|-
! scope="row" | '''Stage of pathology'''  
! scope="row" | '''Stage of pathology'''  
| '''Acute'''  
!scope="row"| '''Acute''' || '''Chronic'''
| '''Chronic'''
|-
|-
! scope="row" | '''Clinical research evidence'''  
! scope="row" | '''Clinical research evidence'''  
| No  
| No  
|  
|Yes  
Yes  
 
1CPG
1CPG
|-
|-
! scope="row" | '''Published expert opinion'''  
! scope="row" | '''Published expert opinion'''  
Line 94: Line 107:
| 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.
| 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.
|-
|-
! scope="row" | '''[[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]'''  
! scope="row" | '''Clinical implication'''  
| <u>May consider</u>  a trial of joint
| <u>May consider</u>  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.
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.
| <u>May consider</u>  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.
| <u>May consider</u>  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.
|-
|-
! colspan="3" scope="row" |  
! colspan="3" scope="row" |'''Soft-tissue techniques'''  
'''Soft-tissue techniques'''  
 
|-
|-
! scope="row" | '''Stage of pathology'''  
! scope="row" | '''Stage of pathology'''  
| '''Acute'''  
! scope="row" | '''Acute''' || '''Chronic'''
| '''Chronic'''
|-
|-
! scope="row" | '''Clinical research evidence'''  
! scope="row" | '''Clinical research evidence'''  
| No  
| No  
| Yes<br>1 CPG
| Yes<br>1 CPG<ref>Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR. [https://doi.org/10.2519/jospt.2018.0302 Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018.] J Orthop Sports Phys Ther. 2018 May;48(5):A1-A38.</ref>
1 RCT
1 RCT<ref>Stefansson SH, Brandsson S, Langberg H, Arnason A. [https://doi.org/10.1177/2325967119834284 Using Pressure Massage for Achilles Tendinopathy: A Single-Blind, Randomized Controlled Trial Comparing a Novel Treatment Versus an Eccentric Exercise Protocol.] Orthop J Sports Med. 2019 Mar 21;7(3):2325967119834284.</ref>


1 Other*<br>  
1 Other*<ref>Christenson RE. [https://doi.org/10.1016/j.math.2006.02.012 Effectiveness of specific soft tissue mobilizations for the management of Achilles tendinosis: single case study--experimental design]. Man Ther. 2007 Feb;12(1):63-71.</ref><br>
|-
|-
! scope="row" | '''Published expert opinion'''  
! scope="row" | '''Published expert opinion'''  
Line 134: Line 133:
|-
|-
! scope="row" |  
! scope="row" |  
'''[[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]'''  
'''[[Achilles Tendinopathy Toolkit: Section C - Summary of Evidence and Recommendations for Interventions#Explanation_of_clinical_implications|Clinical implication]]'''  


| <u>'''May consider'''</u> a trial of soft tissue techniques, such as frictions or pressure massage, to improve range of motion.
| <u>'''May consider'''</u> a trial of soft tissue techniques, such as frictions or pressure massage, to improve range of motion.
Line 144: Line 143:
<nowiki>*</nowiki>Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc).  
<nowiki>*</nowiki>Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc).  


=== Exercise  ===
=== Low level laser therapy (LLLT) ===
 
[[Low Level Laser Therapy|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!
{| width="700" border="1" cellpadding="1" cellspacing="1"
{|class="wikitable"
|-
! scope="row" | Stage of pathology
| '''Acute'''
| '''Chronic'''
|-
! scope="row" | Clinical research evidence
| No
| Yes<br>9 SR
1 RCT
|-
|-
! scope="row" | Published expert opinion
! scope="row" | Stage of pathology
| Yes<ref name="Magnusson 2010">Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nature Reviews Rheumatology. 2010;6(5):262‐8.</ref>
! scope="row" |'''Acute'''||'''Chronic'''
| Yes<ref name="Magnusson 2010" />
|-
|-
! scope="row" | Take home message
! scope="row" | Clinical research evidence
| 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.
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|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.
 
=== Low level laser therapy (LLLT)  ===
 
{| width="700" border="1" cellpadding="1" cellspacing="1"
|-
! scope="row" | Stage of pathology
| '''Acute'''
| '''Chronic'''
|-
! scope="row" | Clinical research evidence  
| Yes<br>2 Other <br><br>
| Yes<br>2 Other <br><br>
| Yes<br>1 MA<br>8 RCT
| Yes<br>1 MA<ref name=":8">Tumilty, S., Munn, J., McDonough, S., Hurley, D. A., Basford, J. R., & Baxter, G. D. (2010). [https://doi.org/10.1089/pho.2008.2470 Low level laser treatment of tendinopathy: a systematic review with meta-analysis.] ''Photomedicine and laser surgery'', ''28''(1), 3–16. </ref><br>8 RCT<ref>Bjordal, J. M., Lopes-Martins, R. A., & Iversen, V. V. (2006). [https://doi.org/10.1136/bjsm.2005.020842 A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 concentrations.] ''British journal of sports medicine'', ''40''(1), 76–80. </ref><ref>Darre E, Klokker M, Lund P. Laserbehandling af akillessenetendinit. Ugeskr Laeger. 1994; Nov 7; 15</ref><ref>Mårdh, A., & Lund, I. (2016). [https://doi.org/10.15171/jlms.2016.16 High Power Laser for Treatment of Achilles Tendinosis - a Single Blind Randomized Placebo Controlled Clinical Study]. ''Journal of lasers in medical sciences'', ''7''(2), 92–98. </ref><ref>Stergioulas, A., Stergioula, M., Aarskog, R., Lopes-Martins, R. A., & Bjordal, J. M. (2008). [https://doi.org/10.1177/0363546507312165 Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles tendinopathy.] ''The American journal of sports medicine'', ''36''(5), 881–887. </ref><ref>Tumilty, S., McDonough, S., Hurley, D. A., & Baxter, G. D. (2012). [https://doi.org/10.1016/j.apmr.2011.08.049 Clinical effectiveness of low-level laser therapy as an adjunct to eccentric exercise for the treatment of Achilles' tendinopathy: a randomized controlled trial.] ''Archives of physical medicine and rehabilitation'', ''93''(5), 733–739. </ref><ref>Tumilty, S., Munn, J., Abbott, J. H., McDonough, S., Hurley, D. A., & Baxter, G. D. (2008). [https://doi.org/10.1089/pho.2007.2126 Laser therapy in the treatment of achilles tendinopathy: a pilot study]. ''Photomedicine and laser surgery'', ''26''(1), 25–30. </ref><ref name=":8" /><ref>Tumilty, S., Mani, R., & Baxter, G. D. (2016). [https://doi.org/10.1007/s10103-015-1840-4 Photobiomodulation and eccentric exercise for Achilles tendinopathy: a randomized controlled trial.] ''Lasers in medical science'', ''31''(1), 127–135. </ref>
3 Other<br>
3 Other<ref>Bjordal JM, Couppe C and Ljunggren. [https://www.ncbi.nlm.nih.gov/books/NBK68932/ Low Level Laser Therapy for Tendinopathy. Evidence of A Dose-Response Pattern]. Physical Therapy Reviews. 2001; 6: 91-99.</ref><ref>Bjordal JM, Lopes-Martins RAB, Joensen J, et al. [https://doi.org/10.1179/1743288X10Y.0000000001 The anti-inflammatory mechanism of low level laser therapy and its relevance for clinical use in physiotherapy]. Physical Therapy Reviews. 2010; 15(4): 286–293.</ref><ref>Peplow PV, Chung TY & Baxter GD. [https://doi.org/10.1179/1743288X10Y.0000000008 Application of low level laser technologies for pain relief and wound healing: overview of scientific bases]. Physical Therapy Reviews. 2010; 15(4): 253–285.</ref><br>
|-
|-
! scope="row" | Published expert opinion  
! scope="row" | Published expert opinion
| Yes  
| Yes
| Yes
| Yes
|-
|-
! scope="row" | Take home message  
! scope="row" | Take home message
| There is no clinical evidence, but there is a&nbsp;physiological rationale, and multiple animal studies to support the use of LLT in the acute stage.<br>
| There is no clinical evidence, but there is a&nbsp;physiological rationale, and multiple animal studies to support the use of LLT in the acute stage.<br>
| 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.<br>
| 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.<br>
|-
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]
! scope="row" |Clinical implication
| <u>May consider</u> a trial of LLLT in the acute stage at the doses&nbsp;recommended by the World Association for Laser Therapy&nbsp;(www.walt.nu) i.e., 2‐4 J/point (not per cm2)*, minimum 2‐3 points.<br><br>*''See '<nowiki/>'''[[Achilles Tendinopathy Toolkit: Appendix B|Appendix B]]&nbsp;'<nowiki/>'''for further details on calculation of dosage.''<u><br></u><u></u>
|<u>May consider</u> a trial of LLLT in the acute stage at the doses&nbsp;recommended by the World Association for Laser Therapy&nbsp;(www.walt.nu) i.e., 2‐4 J/point (not per cm2)*, minimum 2‐3 points.<br><br>*''See '<nowiki/>'''[[Achilles Tendinopathy Toolkit: Section E - Low Level Laser Therapy Dosage Calculation|Section D]]&nbsp;' <nowiki/>'''for further details on calculation of dosage.''<u><br></u><u></u>
| <u>Consider </u>a trial of LLLT in the chronic stage at the&nbsp;following parameters: 0.9 J/point (not per cm<sup>2</sup>)*; 6 points&nbsp;on tendon.
|<u>Consider </u>a trial of LLLT in the chronic stage at the&nbsp;following parameters: 0.9 J/point (not per cm<sup>2</sup>)*; 6 points&nbsp;on tendon.
If Class III, may co''<nowiki/>''nsider a tial of LLT in the chronic stage at 450J _ 520J per treatment over the whole tendon.<br>'''''<br>*'''''<i>See </i>''[[Achilles Tendinopathy Toolkit: Appendix B|Appendix B]]&nbsp;'<nowiki/>'''for further'''<nowiki/> '''details on calculation of dosage.'''''<b><br></b>
If Class III, may consider a tial of LLT in the chronic stage at 450J _ 520J per treatment over the whole tendon.<br>'''''<br>*'''''<i>See </i><nowiki/>'''''[[Achilles Tendinopathy Toolkit: Section D - Exercise Programs|Section D]]'''&nbsp;' '''for further''' '''details on calculation of dosage.'''''<b><br></b>
''<nowiki/>''
 
|}  
|}  


=== Ultrasound (US) ===
=== Therapeutic Ultrasound (US) ===
 
[[Therapeutic Ultrasound|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.
{| width="700" border="1" cellpadding="1" cellspacing="1"
{|class="wikitable"
|-
|-
! scope="row" | Stage of pathology  
! scope="row" | Stage of pathology
| '''Acute'''  
! scope="row" |'''Acute'''||'''Chronic'''
| '''Chronic'''
|-
|-
! scope="row" | Clinical research evidence  
! scope="row" |Clinical research evidence
| No  
| No  
| No
| No
|-
|-
! scope="row" | Published expert opinion  
! scope="row" |Published expert opinion|-
| No  
| No  
| No
| No
|-
|-
! scope="row" | Take home message  
! scope="row" |Take home message  
| There is no clinical evidence, but there is physiological rationale, to <u>support</u> the use of US in the acute stage.  
| There is no clinical evidence, but there is physiological rationale, to <u>support</u> the use of US in the acute stage.  
| There is no clinical evidence and no physiological&nbsp;rationale to support the use of US in the chronic&nbsp;stage.<br>
| There is no clinical evidence and no physiological&nbsp;rationale to support the use of US in the chronic&nbsp;stage.<br>
|-
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]
! scope="row" |Clinical implication
| <u>May consider</u>&nbsp;<u></u>a trial of US in the acute stage at a low to moderate dose (0.5 ‐ 1.0 W/cm<sup>2</sup>, pulsed 1:4‐1:1, 3 MHz, 5 mins for each treatment area equivalent in size to transducer head).  
| <u>May consider</u>&nbsp;<u></u>a trial of US in the acute stage at a low to moderate dose (0.5 ‐ 1.0 W/cm<sup>2</sup>, 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.<br>
| No evidence to support or refute the use of therapeutic ultrasound in the chronic phase.<br>
Line 236: Line 197:


<nowiki>*</nowiki>Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc).  
<nowiki>*</nowiki>Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc).  
=== Extracorporeal shock wave therapy (ESWT) ===
=== Extracorporeal Shock Wave Therapy (ESWT) ===
 
[[Extracorporeal Shockwave Therapy |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.
{| width="700" border="1" cellpadding="1" cellspacing="1"
{|class="wikitable"
|-
|-
! scope="row" | Stage of pathology  
!Stage of pathology
| '''Acut'''e
!'''Acute'''
| '''Chronic'''
!'''Chronic'''
|-
|-
! scope="row" | Clinical research evidence  
!Clinical research evidence
| No  
| No
| Yes<br>2 CPG
| Yes<br>2 CPG<ref name=":2" /><ref>National Institute for Health and Care Excellence-NICE (2016). Extracorporeal shock- wave therapy for refractory Achilles tendinopathy: guidance. Available at: <nowiki>http://www.nice.org.uk/guidance/IPG312/Guidance/pdf</nowiki></ref>
1 MA
1 MA<ref>Fan, Y., Feng, Z., Cao, J., & Fu, W. (2020). [https://doi.org/10.1177/2325967120903430 Efficacy of Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Meta-analysis.] ''Orthopaedic journal of sports medicine'', ''8''(2), 2325967120903430. </ref>


1 SR
1 SR<ref>Al-Abbad, H., & Simon, J. V. (2013). [https://doi.org/10.1177/1071100712464354 The effectiveness of extracorporeal shock wave therapy on chronic achilles tendinopathy: a systematic review]. ''Foot & ankle international'', ''34''(1), 33–41. </ref>


1 Other*
1 Other*<ref>Stania, M., Juras, G., Chmielewska, D., Polak, A., Kucio, C., & Król, P. (2019). [https://doi.org/10.1155/2019/3086910 Extracorporeal Shock Wave Therapy for Achilles Tendinopathy]. ''BioMed research international'', ''2019'', 3086910. </ref>
|-
|-
! scope="row" | Published expert opinion  
!Published expert opinion
| No
| No
| Yes
| Yes
|-
|-
! scope="row" | Take home message  
!Take home message
| There is no clinical evidence and no physiological rationale to support the use of ESWT in the acute stage.  
| There is no clinical evidence and no physiological rationale to support the use of ESWT in the acute stage.
| There is conflictiong evidence to support the use of high or low energy ESWT devices in the chronic stage.  The evidence suggests that outcomes are depent upon the dosage ( measured in mJ/mm² or Bars) rather than the type of shock wave generation (focused or
| 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
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.


ESWT). Local anesthetic required in high
Because of heterogeneity in study designs, the optimum protocol has yet to be determined
 
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
|-
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]
! Clinical implication
| <u>Consider NOT</u> using Extracorporeal Shock Wave for the&nbsp;acute stage.  
|<u>Consider NOT</u> using Extracorporeal Shock Wave for the&nbsp;acute stage.
|  
|  
<u>Consider</u> a trial of ESWT in the chronic stage for refractory cases that have failed to resolve with other conservative treatment. Recommended parameters:
<u>Consider</u> a trial of ESWT in the chronic stage for refractory cases that have failed to resolve with other conservative treatment. Recommended parameters:
Line 314: Line 251:


<nowiki>*</nowiki>Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc).  
<nowiki>*</nowiki>Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc).  
=== Iontophoresis using dexamethasone  ===
=== Iontophoresis Using Dexamethasone ===
 
[[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.
{| width="700" border="1" cellpadding="1" cellspacing="1"
{|class="wikitable"
|-
|-
! scope="row" | Stage of pathology  
! Stage of pathology  
| '''Acute'''  
!'''Acute'''  
| '''Chronic'''
!'''Chronic'''
|-
|-
! scope="row" | Clinical research evidence  
! Clinical research evidence  
| Yes<br>2 CPG
| Yes<br>2 CPG<ref name=":2" /><ref>Brown CD, Lauber CA. Evidence-based guidelines for utilization of dexamethasone iontophoresis. International Journal of Athletic Therapy and Training. 2011. 16(4): 33-36.</ref>
1 RCT
1 RCT<ref>Neeter, C., Thomeé, R., Silbernagel, K. G., Thomeé, P., & Karlsson, J. (2003). [https://doi.org/10.1046/j.1600-0838.2003.00305.x Iontophoresis with or without dexamethazone in the treatment of acute Achilles tendon pain.] ''Scandinavian journal of medicine & science in sports'', ''13''(6), 376–382. </ref>
| No
| No
|-
|-
Line 331: Line 268:
| No
| No
|-
|-
! scope="row" | Take home message  
! Take home message  
|  
|  
There is a small amount of evidence to support the&nbsp;application of iontophoresis using dexamethasone&nbsp;in the acute stage. <u><br></u>
There is a small amount of evidence to support the&nbsp;application of iontophoresis using dexamethasone&nbsp;in the acute stage. <u><br></u>


| There is no evidence or expert opinion thqt qn<u><br></u>
| There is no evidence or expert opinion that anti inflammatory intervention with iontophoresis using dexamethasone has a useful role in the chronic stage<u>.<br></u>
|-
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]
! Clinical implication
|  
| Consider, in the acute stage, a trial of iontophoresis, 0.4% dexamethasone (aqueous), 80 mA‐min; 6 sessions over 3 weeks.  
<u>May consider</u>, 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.  
A program of concentric‐eccentric exercises should be continued in combination with iontophoresis, if exercise loading is tolerated.  


| <u>Consider NOT</u> using iontophoresis using dexamethasone&nbsp;in the chronic stage.<br>
| No evidence to support or refute the use of iontophoresis in the chronic phase.<br>
|}
|}


Line 350: Line 286:
<nowiki>*</nowiki>Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc).<br>  
<nowiki>*</nowiki>Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc).<br>  
=== Rigid Taping ===
=== Rigid Taping ===
 
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.
{| width="700" border="1" cellpadding="1" cellspacing="1"
{|class="wikitable"
|-
|-
! scope="row" | Stage of pathology  
! Stage of pathology  
| '''Acute'''  
! '''Acute'''  
| '''Chronic'''
! '''Chronic'''
|-
|-
! scope="row" | Clinical research evidence  
! Clinical research evidence  
| Yes
| Yes
1 CPG<ref name=":2" />
| Yes
| Yes
<br>
1 CPG
 
1 SR<ref name=":3">Scott, L. A., Munteanu, S. E., & Menz, H. B. (2015). [https://doi.org/10.1007/s40279-014-0237-z Effectiveness of orthotic devices in the treatment of Achilles tendinopathy: a systematic review]. ''Sports medicine (Auckland, N.Z.)'', ''45''(1), 95–110. </ref>
 
2 Other*<ref name=":4">Riddle, D. L., & Freeman, D. B. (1988). [https://doi.org/10.1093/ptj/68.12.1913 Management of a patient with a diagnosis of bilateral plantar fasciitis and Achilles tendinitis. A case report.] ''Physical therapy'', ''68''(12), 1913–1916. </ref><ref name=":5">Smith, M., Brooker, S., Vicenzino, B., & McPoil, T. (2004). [https://doi.org/10.1016/s0004-9514(14)60103-3 Use of anti-pronation taping to assess suitability of orthotic prescription: case report.] ''The Australian journal of physiotherapy'', ''50''(2), 111–113. </ref><br>
|-
|-
! scope="row" | Published expert opinion  
! Published expert opinion  
| Yes  
| Yes  
| Yes
| Yes
|-
|-
! scope="row" | Take home message  
! Take home message  
| There is expert opinion to <u>support</u> the use of&nbsp;antipronation taping in the acute stage.<br>  
| There is expert opinion to support the use of rigid taping in the acute stage.<br>  
<br>  
<br>


| There is expert opinion and a small amount of clinical evidence to support the use of controlled pronation taping in the chronic stage.<br>
| There is expert opinion and a small amount of clinical evidence to supportthe use of rigid taping in the chronic
stage.
|-
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]
! Clinical implication
| <u>May consider </u>using antipronation taping in the acute&nbsp;stage.  
| May consider a trial of rigid taping in the acute stage.
| <u>May consider</u> using antipronation taping in the chronic&nbsp;stage.<br>
| May consider a trial of rigid taping in
the chronic stage.<br>
|}
|}


CS ‐ Case studies; SR - Systematic Review
CPG - Clinical practice guideline; MA - Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews
 
<nowiki>*</nowiki>Other study designs (e.g. Cohort, case control, case series, quasi-experimental studies, etc).


=== Orthotics  ===
=== Orthotics  ===
 
[[Introduction to Orthotics|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
{| width="700" border="1" cellpadding="1" cellspacing="1"
{| class="wikitable"
|-
|-
! scope="row" | Stage of pathology  
!Stage of pathology  
| '''Acute'''  
!'''Acute'''  
| '''Chronic'''
!'''Chronic'''
|-
|-
! scope="row" | Clinical research evidence  
! Clinical research evidence  
| Yes<br>2 CS&nbsp;<ref>Gross ML, Davlin L, Evanski PM. (1991). Effectiveness of orthotic shoe inserts in the long-distance runner. Am J Sports Med. 19: 409–412.</ref><ref>Greene BL. (2002). Physical therapist management of fluoroquinolone-induced Achilles tendinopathy. Phys Ther. 82(12): 1224-31.</ref><br>  
| Yes
| Yes<br>3 CS&nbsp;<ref>Riddle DL, Freeman DB. (1988). Management of a patient with a diagnosis of bilateral plantar fasciitis and Achilles tendinitis. A case report. Phys Ther. 68(12): 1913-6</ref><ref>Smith M, Brooker S, Vicenzino B, McPoil T. (2004). Use of anti-pronation taping to assess suitability of orthotic prescription: case report. Aust J Physiother. 50(2): 111-3.</ref><ref>Donoghue OA, Harrison AJ, Laxton P, Jones RK. (2008). Orthotic control of rear foot and lower limb motion during running in participants with chronic Achilles tendon injury. Sports Biomech. 7(2): 194-205.</ref><br>2 RCT<ref>Mayer F, Hirschmuller A, Muller S, Schuberth M, Baur H. (2007). Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy. Br J Sports Med. 41(7): e6</ref><ref>Munteanu, S. E., Scott, L. A., Bonanno, D. R., Landorf, K. B., Pizzari, T., Cook, J. L., &amp; Menz, H. B. (2014). Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial. Br J Sports Med. doi: 10.1136/bjsports-2014-093845</ref><br>1 SR&nbsp;<ref>Scott, L., Munteanu, S., &amp; Menz, H. (2015). Effectiveness of Orthotic Devices in the Treatment of Achilles Tendinopathy: A Systematic Review. Sports Medicine, 45(1), 95-110. doi: 10.1007/s40279-014-0237-z</ref>
1 CPG
 
1 Other*<br><br>
| Yes
1 CPG
 
2 SR<ref name=":3" /><ref name=":6">Wilson, F., Walshe, M., O'Dwyer, T., Bennett, K., Mockler, D., & Bleakley, C. (2018). [https://doi.org/10.1136/bjsports-2017-098913 Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta-analysis]. ''British journal of sports medicine'', ''52''(24), 1564–1574. </ref>
 
2 RCT<ref>Mayer, F., Hirschmüller, A., Müller, S., Schuberth, M., & Baur, H. (2007). [https://doi.org/10.1136/bjsm.2006.031732 Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy.] ''British journal of sports medicine'', ''41''(7), e6. </ref><ref>Munteanu, S. E., Scott, L. A., Bonanno, D. R., Landorf, K. B., Pizzari, T., Cook, J. L., & Menz, H. B. (2015). [https://doi.org/10.1136/bjsports-2014-093845 Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial.] ''British journal of sports medicine'', ''49''(15), 989–994. </ref>
 
6 Other*<ref name=":7">Lee, K., Ling, S., & Yung, P. (2019). [https://doi.org/10.1186/s12891-019-2898-0 Controlled trial to compare the Achilles tendon load during running in flatfeet participants using a customized arch support orthoses vs an orthotic heel lift.] ''BMC musculoskeletal disorders'', ''20''(1), 535.</ref><ref>Hannigan, J. J., & Pollard, C. D. (2020). [https://doi.org/10.1016/j.jsams.2019.08.008 Differences in running biomechanics between a maximal, traditional, and minimal running shoe]. ''Journal of science and medicine in sport'', ''23''(1), 15–19. </ref><ref>Greene B. L. (2002). Physical therapist management of fluoroquinolone-induced Achilles tendinopathy. ''Physical therapy'', ''82''(12), 1224–1231.</ref><ref name=":4" /><ref name=":5" /><ref>Donoghue, O. A., Harrison, A. J., Laxton, P., & Jones, R. K. (2008). [https://doi.org/10.1080/14763140701841407 Orthotic control of rear foot and lower limb motion during running in participants with chronic Achilles tendon injury.] ''Sports biomechanics'', ''7''(2), 194–205. </ref>
 
<br>
|-
|-
! scope="row" | Published expert opinion  
! Published expert opinion  
| Yes  
| Yes  
| Yes
| Yes
|-
|-
! scope="row" | Take home message  
! Take home message  
| There is a small amount of clinical evidence to&nbsp;<u>support</u> the use of orthotics in the acute stage.  
| 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 a moderate amount of clinical evidence to<u>support</u> the use of orthotics in the chronic stage.<u><br></u>
| There is inconsistent evidence and expert opinion regarding the
effectiveness of orthotics in the chronic stage
|-
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]
! Clinical implication
|  
|  
<u>Consider</u> using orthotics – perhaps using taping first, in the acute stage.<br>  
May consider a trial of orthotics in the acute stage – may consider taping first to assess potential response to orthotics.<br>


| <u>Consider</u> using orthotics in the chronic stage.<br>
| May Consider a trial of orthotics in the chronic stage to reduce strain in the Achilles tendon, if indicated by the clinical assessment.<br>
|}
|}


CS ‐ Case studies; RCT ‐ Randomized controlled trials; SR - Systematic Review
CPG - Clinical practice guideline; MA - Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews
 
<nowiki>*</nowiki>Other study designs (e.g. Cohort, case control, case series, quasi-experimental studies, etc).


=== Night splints and braces  ===
=== Night splints and braces  ===
 
Night [[Splinting|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.
{| width="700" border="1" cellpadding="1" cellspacing="1"
{| class="wikitable"
|-
|-
! scope="row" | Stage of pathology  
! Stage of pathology  
| '''Acute'''  
!'''Acute'''  
| '''Chronic'''
! '''Chronic'''
|-
|-
! scope="row" | Clinical research evidence  
! Clinical research evidence  
| No  
| No
| Yes<br>3 RCT<ref>Knobloch K, Schreibmueller L, Longo UG et al. Eccentric exercises for the management of tendinopathy of the main body of thefckLRAchilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation. Disabil Rehabil. 2008;30:1685‐91.</ref><ref>Petersen W, Welp R &amp; Rosenbaum D. Chronic Achilles tendinopathy: a prospective randomized study comparing the therapeuticfckLReffect of eccentric training, the AirHeel brace, and a combination of both. Am J Sports Med. 2007;35:1659‐67.</ref><ref>de Vos RJ, Weir A, Visser RJ et al. The additional value of a night splint to eccentric exercises in chronic midportion AchillesfckLRtendinopathy: a randomised controlled trial. Br J Sports Med. 2007;41: e5.</ref><br>1 SR&nbsp;<ref>Scott, L., Munteanu, S., &amp; Menz, H. (2015). Effectiveness of Orthotic Devices in the Treatment of Achilles Tendinopathy: A Systematic Review. Sports Medicine, 45(1), 95-110. doi: 10.1007/s40279-014-0237-z</ref>
1 CPG
|-
! scope="row" | Published expert opinion
| Yes
| Yes
| Yes
|-
1 CPG<ref name=":2" />
! scope="row" | Take home message
 
| There is expert opinion to <u>support</u> the use of night splints and braces in the acute stage.  
2 SR<ref>Sussmilch-Leitch, S. P., Collins, N. J., Bialocerkowski, A. E., Warden, S. J., & Crossley, K. M. (2012). [https://doi.org/10.1186/1757-1146-5-15 Physical therapies for Achilles tendinopathy: systematic review and meta-analysis]. ''Journal of foot and ankle research'', ''5''(1), 15.</ref><ref name=":6" />
| There is a moderate amount of evidence <u>against</u> the use of night splints and braces in the chronic stage in conjunction with eccentric exercise. <br>
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]
| <u>Consider</u> a trial of night splints and braces in the acute stage.  
| <u>Consider NOT</u> using night splints and braces in the chronic stage&nbsp;in conjunction with exercise.&nbsp;
|}


RCT ‐ Randomized controlled trials; SR - Systematic Review
3 RCT<ref>de Jonge, S., de Vos, R. J., Van Schie, H. T., Verhaar, J. A., Weir, A., & Tol, J. L. (2010). [https://doi.org/10.1136/bjsm.2008.052142 One-year follow-up of a randomised controlled trial on added splinting to eccentric exercises in chronic midportion Achilles tendinopathy]. ''British journal of sports medicine'', ''44''(9), 673–677. </ref><ref>de Vos, R. J., Weir, A., Visser, R. J., de Winter, T., & Tol, J. L. (2007). [https://doi.org/10.1136/bjsm.2006.032532 The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial]. ''British journal of sports medicine'', ''41''(7), e5. </ref><ref>McAleenan M, McVeigh JG, Cullen M, et al. [https://www.academia.edu/17403316/The_effectiveness_of_night_splints_in_achilles_tendinopathy_a_pilot_study The effectiveness of night splints in Achilles tendinopathy: a pilot study]. Physiotherapy Ireland. 2010;31:29–33</ref>


=== Heel raise inserts  ===
1 Other*


{| width="700" border="1" cellpadding="1" cellspacing="1"
|-
! scope="row" | Stage of pathology
| '''Acute'''
| '''Chronic'''
|-
! scope="row" | Clinical research evidence
| No
| Yes<br>2 RCT<ref>MacLellan GE, Vyvyan B. Management of pain beneath the heel and Achilles tendonitis with visco‐elastic heel inserts. Br J Sports Med. 1982;15(2):117‐21.</ref><ref>Lowdon A, Bader DL, Mowat AG. The effect of heel pads on the treatment of Achilles tendinitis: a double blind trial. Am J Sports Med. 1984;12(6):431‐5.</ref><br>
|-
|-
! scope="row" | Published expert opinion  
! Published expert opinion  
| Yes  
| Yes  
| Yes
| Yes
|-
|-
! scope="row" | Take home message  
! Take home message  
| There is some expert opinion to <u>support</u> the use of&nbsp;heel raise inserts in the acute stage.  
| Clinical practice guidelines recommend
| There is <u>conflicting</u> evidence for and against the use of heel inserts in the chronic stage.<br>
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.
|-
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]
! Clinical implication
| <u>May consider</u> a trial of inserts in the acute stage.
| Consider NOT using night splints in the acute stage
| <u>Consider</u> a trial of inserts in the chronic stage.<br>
| Consider NOT using night splints in the
acute stage
|}
|}


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


=== Needling techniques<ref>Jens Foell S. Is electro‐acupuncture a safe and cost‐effective treatment for Achilles tendonopathy in a primary care setting?International Musculoskeletal Medicine. 2010;32( 2):51‐54.</ref><ref>Fagan N, Staten P. An audit of self‐acupuncture in primary care. Acupunct Med. 2003;21:28‐31.</ref>  ===
<nowiki>*</nowiki>Other study designs (e.g. Cohort, case control, case series, quasi-experimental studies, etc).


Acupuncture (trasitional Chinese medicine, anatomical, electrical) and intramuscular stimulation.  
=== Bracing ===
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.
{| class="wikitable"
|+
!State of Pathology
!Acute
!Chronic
|-
!Clinical research evidence
|No


{| width="700" border="1" cellpadding="1" cellspacing="1"
1 CPG
|Yes
1 CPG<ref name=":2" /> 1 SR<ref name=":3" /> 3 RCT<ref name=":1" /><ref>Knobloch, K., Schreibmueller, L., Longo, U. G., & Vogt, P. M. (2008). [https://doi.org/10.1080/09638280701786658 Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation.] ''Disability and rehabilitation'', ''30''(20-22), 1685–1691. </ref><ref>Petersen, W., Welp, R., & Rosenbaum, D. (2007). [https://doi.org/10.1177/0363546507303558 Chronic Achilles tendinopathy: a prospective randomized study comparing the therapeutic effect of eccentric training, the AirHeel brace, and a combination of both.] ''The American journal of sports medicine'', ''35''(10), 1659–1667. </ref>
|-
|-
! scope="row" | Stage of pathology
!Published Expert Opinion
| '''Acute'''
|Yes
| '''Chronic'''
|Yes
|-
|-
! scope="row" | Clinical research evidence  
!Take Home Message
| Yes<br>1 CS
|There is expert opinion to consider
| Yes<br>1 CS<br>
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.
|-
|-
! scope="row" | Published expert opinion
!Clinical implication
| No
|May consider trialing a brace in the
| No
acute stage.
|-
|May consider trialing a brace in the
! scope="row" | Take home message
chronic stage.
| There is a small amount of evidence to <u>support</u> the use of Traditional Chinese Medicine electroacupuncture in the acute stage. There is expert opinion to&nbsp;<u>support</u> the use of other needling techniques in the acute stage.
| There is a small amount of evidence to <u>support</u> use of Traditional Chinese Acupuncture in the chronic stage. There is expert opinion on the use of other needling techniques in the chronic stage.<br>
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]
| <u></u><u>Consider</u> a trial of electro‐acupuncture in the acute stage. <br><u>May consider</u> a trial of other acupuncture‐related needling techniques in the acute stage.  
| <u></u><u>Consider</u> a trial of Traditional Chinese Acupuncture in the chronic stage.<br><u>May consider</u> a trial of other acupuncture‐related needling techniques in the chronic stage.<br>
|}
|}


CS ‐ Case studies.
=== Heel raise inserts  ===
 
[[Foot Orthoses|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.
<br>
{| class="wikitable"
 
*''Click to go back to the ''[[Achilles Tendinopathy Toolkit|''contents page'']]  
*''Click to go back to the&nbsp;[[Achilles Tendinopathy Toolkit: Treatment Algorithm|Treatment Algorithm]]''
*''Click to continue to ''[[Achilles Tendinopathy Toolkit: Appendix A|''Appendix A: Exercise Programs'']]
*''Click to continue to ''[[Achilles Tendinopathy Toolkit: Appendix B|''Appendix B: Low Level Laser Therapy Dosage Calculation'']]
*''Click to continue to:&nbsp;''[[Achilles Tendinopathy Toolkit: Appendix C|''Appendix C: Details of Articles on Interventions'']]
*''Click to continue to:&nbsp;''[[Achilles Tendinopathy Toolkit: Appendix D|''Appendix D: Medical and Surgical Interventions'']]
 
== Outcome measures  ==
 
For any intervention selected by the clinician, it is strongly recommended that the clinician use one or more of the&nbsp;following outcome measures.<br>
 
{| width="700" border="1" cellpadding="1" cellspacing="1"
|-
|-
| '''A. Patient reported outcome measure'''
! Stage of pathology
! '''Acute'''
! '''Chronic'''
|-
|-
| Such as:
! Clinical research evidence
*A global measure of lower extremity function: e.g., The Lower Extremity Functional Scale (LEFS) ‐ not&nbsp;specific to Achilles tendinopathy
| No
**Available [http://www.physther.net/content/79/4/371/F1.large.jpg here]<br>  
| Yes<br>1 CPG<ref>Martin, R. L., Chimenti, R., Cuddeford, T., Houck, J., Matheson, J. W., McDonough, C. M., Paulseth, S., Wukich, D. K., & Carcia, C. R. (2018). [https://doi.org/10.2519/jospt.2018.0302 Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018.] ''The Journal of orthopaedic and sports physical therapy'', ''48''(5), A1–A38. </ref>
*Detailed questionnaire, specific to Achilles tendinopathy e.g. the VISA‐A questionnaire
2 RCT<ref>Lowdon, A., Bader, D. L., & Mowat, A. G. (1984). [https://doi.org/10.1177/036354658401200605 The effect of heel pads on the treatment of Achilles tendinitis: a double blind trial.] ''The American journal of sports medicine'', ''12''(6), 431–435. </ref><ref name=":7" />
**Available [http://bjsm.bmj.com/content/suppl/2001/11/09/35.5.335.DC1/01055_Fig_1_data_supplement.pdf here]&nbsp;(Click on ‘view questionnaire’)<br>


2 Other*<ref>MacLellan, G. E., & Vyvyan, B. (1981). [https://doi.org/10.1136/bjsm.15.2.117 Management of pain beneath the heel and Achilles tendonitis with visco-elastic heel inserts.] ''British journal of sports medicine'', ''15''(2), 117–121. </ref><ref>Wulf, M., Wearing, S. C., Hooper, S. L., Bartold, S., Reed, L., & Brauner, T. (2016). [https://doi.org/10.2519/jospt.2016.6030 The Effect of an In-shoe Orthotic Heel Lift on Loading of the Achilles Tendon During Shod Walking.] ''The Journal of orthopaedic and sports physical therapy'', ''46''(2), 79–86. </ref><br>
|-
|-
| '''B. Patient specific functional outcome measure'''
! scope="row" | Published expert opinion
| No
| Yes
|-
|-
| Such as:<br>
! Take home message
*How much weight can be applied to the plantar flexed foot on a weighing scale before the onset of pain
| There is physiological rationale that the
*The number of heel raises before the onset of pain
application of heel inserts can reduce load on the Achilles tendon
*The number of heel drops before the onset of pain
| There is conflicting evidence and expert opinion for and against the use of heel inserts in the chronic stage
*The number of heel drops with a specific weight in a backpack before the onset of pain
|-
*How far can the client walk or run before the onset of pain
! 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.
|}  


*''Click to go back to the ''[[Achilles Tendinopathy Toolkit|''contents page'']]
=== Dry Needling Techniques ===
*''Click to go back to the&nbsp;[[Achilles Tendinopathy Toolkit: Treatment Algorithm|Treatment Algorithm]]''
*''Click to continue to ''[[Achilles Tendinopathy Toolkit: Appendix A|''Appendix A: Exercise Programs'']]
*''Click to continue to ''[[Achilles Tendinopathy Toolkit: Appendix B|''Appendix B: Low Level Laser Therapy Dosage Calculation'']]
*''Click to continue to:&nbsp;''[[Achilles Tendinopathy Toolkit: Appendix C|''Appendix C: Details of Articles on Interventions'']]
*''Click to continue to:&nbsp;''[[Achilles Tendinopathy Toolkit: Appendix D|''Appendix D: Medical and Surgical Interventions'']]


== Explanation of clinical implications ==
[[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.


{| width="700" border="1" cellpadding="1" cellspacing="1"
{| class="wikitable"
|-
! Stage of pathology
! '''Acute'''
! '''Chronic'''
|-
|-
| '''Strongly consider:&nbsp;'''High level/high quality evidence that this should be included in treatment.
! Clinical research evidence
| No<br>
| Yes<br>1 RCT<ref>Solomons, L., Lee, J., Bruce, M., White, L. D., & Scott, A. (2020). [https://doi.org/10.1371/journal.pone.0238579 Intramuscular stimulation vs sham needling for the treatment of chronic midportion Achilles tendinopathy: A randomized controlled clinical trial]. ''PloS one'', ''15''(9), e0238579. </ref><br>
|-
|-
| '''Consider:'''&nbsp;Consistent lower level/lower quality or inconsistent evidence that this should be included in treatment.
!  Published expert opinion
| No
| No
|-
|-
| '''May consider:&nbsp;'''No clinical evidence but expert opinion and/or plausible physiological rationale that this should be included in treatment.
! 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.<br>
|-
|-
| '''Consider NOT:&nbsp;'''High level/high quality evidence that this should not be included in treatment.'''<br>'''
! Clinical implication
| <u></u>Consider NOT using dry needling in the acute stage.
| <u></u>No high-quality evidence to support or refute the use dry needling in the chronic stage.<br>
|}
|}


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


*''Click to go back to the ''[[Achilles Tendinopathy Toolkit|''contents page'']]
<nowiki>*</nowiki>Other study designs (e.g. Cohort, case control, case series, quasi-experimental studies, etc).
*''Click to go back to the&nbsp;[[Achilles Tendinopathy Toolkit: Treatment Algorithm|Treatment Algorithm]]''
*''Click to continue to ''[[Achilles Tendinopathy Toolkit: Appendix A|''Appendix A: Exercise Programs'']]
*''Click to continue to ''[[Achilles Tendinopathy Toolkit: Appendix B|''Appendix B: Low Level Laser Therapy Dosage Calculation'']]
*''Click to continue to:&nbsp;''[[Achilles Tendinopathy Toolkit: Appendix C|''Appendix C: Details of Articles on Interventions'']]
*''Click to continue to:&nbsp;''[[Achilles Tendinopathy Toolkit: Appendix D|''Appendix D: Medical and Surgical Interventions'']]


== Download&nbsp;Achilles Tendinopathy Toolkit: Summary of Interventions  ==
<nowiki>**</nowiki>“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


[[Image:Download Achilles Tendinopathy - Summary of Interventions.pdf]]  
== Resources ==
*Click to go back to the [[Achilles Tendinopathy Toolkit|Main Achilles Tendinopathy Toolkit page]]
* Click to go back to [[Achilles Tendinopathy Toolkit: Section A - Clinical Evaluation|Section A - Clinical Evaluation]]
* Click to go back to [[Achilles Tendinopathy Toolkit: Section B - Outcome Measures|Section B - Outcome Measures]]
* Click to continue to [[Achilles Tendinopathy Toolkit: Section D - Exercise Programs|Section D - Exercise Programs]]
* Click to continue to [[Achilles Tendinopathy Toolkit: Section E - Low Level Laser Therapy Dosage Calculation|Section E - Low Level Laser Therapy Dosage Calculation]]
* Click to continue to [[Achilles Tendinopathy Toolkit: Section F - Medical and Surgical Interventions|Section F - Medical and Surgical Interventions]]
 
* [https://physicaltherapy.med.ubc.ca/physical-therapy-knowledge-broker/tendinopathy-toolkit/?utm_source=Physiopedia&utm_medium=Link+in+text&utm_id=Physiopedia+Toolkit+Link+-+Achilles&utm_term=Physiopedia%2C+PT+Knowledge+Broker+toolkit UBC Achilles Tendinopathy Toolkit]


== References  ==
== References  ==


Please see [[Achilles Tendinopathy Toolkit: Appendix C|Appendix C Achilles Tendinopathy: Details of Individual Articles]] for the specific details on each of the articles referenced in this document.
<references />&nbsp;<br>
 
<references />&nbsp;  
 
== Acknowledgements  ==
 
Developed by the BC Physical Therapy Tendinopathy Task Force: Dr. Joseph Anthony, Allison Ezzat, Diana Hughes, JR Justesen, Dr. Alex Scott, Michael Yates, Alison Hoens. April 2012.
 
Updated by Alexandra Kobza, Dr. Alex Scott. June 2015.
 
A Physical Therapy Knowledge Broker project supported by: UBC Department of Physical Therapy, Physiotherapy Association of BC, Vancouver Coastal Research Institute and Providence Healthcare Research Institute.<br>
[[Category:Sports Medicine]]
[[Category:Sports Medicine]]
[[Category:Tendinopathy]]
[[Category:Tendinopathy]]
[[Category:Course Pages]]
[[Category:PT Knowledge Broker Project]]

Latest revision as of 13:53, 29 January 2024

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, Cindy John-Chu, Olajumoke Ogunleye, Alex Scott, Wanda van Niekerk, Admin, Rishika Babburu and 127.0.0.1

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]

References[edit | edit source]

  1. ↑ 1.0 1.1 de Vos RJ, van der Vlist AC, Zwerver J, Meuffels DE, Smithuis F, van Ingen R, van der Giesen F, Visser E, Balemans A, Pols M, Veen N, den Ouden M, Weir A. Dutch multidisciplinary guideline on Achilles tendinopathy. Br J Sports Med. 2021 Oct;55(20):1125-1134.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther. 2018 May;48(5):A1-A38.
  3. ↑ Silbernagel KG, et al. Continued Sports Activity, Using a Pain-monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy: a Randomized Controlled Study. Am J Sports Med. 2007;35(6):897-906. PubMed PMID: 17307888.
  4. ↑ 4.0 4.1 Silbernagel KG, Crossley KM. A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation. J Orthop Sports Phys Ther. 2015 Nov;45(11):876-86.
  5. ↑ Habets B, van Cingel REH. Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review of different protocols. Scand J Med Sci Sports. 2015: 25: 3–15
  6. ↑ Murphy MC, Travers MJ, Chivers P, Debenham JR, Docking SI, Rio EK, Gibson W. Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis. Br J Sports Med. 2019 Sep;53(17):1070-1077
  7. ↑ Kingma JJ, de Knikker R, Wittink HM, Takken T. Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. Br J Sports Med. 2007 Jun;41(6):e3.
  8. ↑ Kraemer R, Lorenzen J, Vogt PM, et al. Systematic review about eccentric training in chronic achilles tendinopathy. Sportverletz Sportschaden. 2010, 24(4): 204-11
  9. ↑ Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med. 2009 Jan;19(1):54-64
  10. ↑ Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013 Apr;43(4):267-86.
  11. ↑ Meyer A, Tumilty S, Baxter GD. Eccentric exercise protocols for chronic non-insertional Achilles tendinopathy: how much is enough? Scand J Med Sci Sports. 2009 Oct;19(5):609-15.
  12. ↑ Wasielewski NJ, Kotsko KM. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review. J Athl Train. 2007 Jul-Sep;42(3):409-21
  13. ↑ Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med. 2007 Apr;41(4):188-98.
  14. ↑ Silbernagel KG, Thomeé R, Thomeé P, Karlsson J. Eccentric overload training for patients with chronic Achilles tendon pain--a randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports. 2001 Aug;11(4):197-206.
  15. ↑ 15.0 15.1 Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nature Reviews Rheumatology. 2010;6(5):262‐8.
  16. ↑ Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther. 2018 May;48(5):A1-A38.
  17. ↑ Stefansson SH, Brandsson S, Langberg H, Arnason A. Using Pressure Massage for Achilles Tendinopathy: A Single-Blind, Randomized Controlled Trial Comparing a Novel Treatment Versus an Eccentric Exercise Protocol. Orthop J Sports Med. 2019 Mar 21;7(3):2325967119834284.
  18. ↑ Christenson RE. Effectiveness of specific soft tissue mobilizations for the management of Achilles tendinosis: single case study--experimental design. Man Ther. 2007 Feb;12(1):63-71.
  19. ↑ 19.0 19.1 Tumilty, S., Munn, J., McDonough, S., Hurley, D. A., Basford, J. R., & Baxter, G. D. (2010). Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomedicine and laser surgery, 28(1), 3–16.
  20. ↑ Bjordal, J. M., Lopes-Martins, R. A., & Iversen, V. V. (2006). A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 concentrations. British journal of sports medicine, 40(1), 76–80.
  21. ↑ Darre E, Klokker M, Lund P. Laserbehandling af akillessenetendinit. Ugeskr Laeger. 1994; Nov 7; 15
  22. ↑ Mårdh, A., & Lund, I. (2016). High Power Laser for Treatment of Achilles Tendinosis - a Single Blind Randomized Placebo Controlled Clinical Study. Journal of lasers in medical sciences, 7(2), 92–98.
  23. ↑ Stergioulas, A., Stergioula, M., Aarskog, R., Lopes-Martins, R. A., & Bjordal, J. M. (2008). Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles tendinopathy. The American journal of sports medicine, 36(5), 881–887.
  24. ↑ Tumilty, S., McDonough, S., Hurley, D. A., & Baxter, G. D. (2012). Clinical effectiveness of low-level laser therapy as an adjunct to eccentric exercise for the treatment of Achilles' tendinopathy: a randomized controlled trial. Archives of physical medicine and rehabilitation, 93(5), 733–739.
  25. ↑ Tumilty, S., Munn, J., Abbott, J. H., McDonough, S., Hurley, D. A., & Baxter, G. D. (2008). Laser therapy in the treatment of achilles tendinopathy: a pilot study. Photomedicine and laser surgery, 26(1), 25–30.
  26. ↑ Tumilty, S., Mani, R., & Baxter, G. D. (2016). Photobiomodulation and eccentric exercise for Achilles tendinopathy: a randomized controlled trial. Lasers in medical science, 31(1), 127–135.
  27. ↑ Bjordal JM, Couppe C and Ljunggren. Low Level Laser Therapy for Tendinopathy. Evidence of A Dose-Response Pattern. Physical Therapy Reviews. 2001; 6: 91-99.
  28. ↑ Bjordal JM, Lopes-Martins RAB, Joensen J, et al. The anti-inflammatory mechanism of low level laser therapy and its relevance for clinical use in physiotherapy. Physical Therapy Reviews. 2010; 15(4): 286–293.
  29. ↑ Peplow PV, Chung TY & Baxter GD. Application of low level laser technologies for pain relief and wound healing: overview of scientific bases. Physical Therapy Reviews. 2010; 15(4): 253–285.
  30. ↑ National Institute for Health and Care Excellence-NICE (2016). Extracorporeal shock- wave therapy for refractory Achilles tendinopathy: guidance. Available at: http://www.nice.org.uk/guidance/IPG312/Guidance/pdf
  31. ↑ Fan, Y., Feng, Z., Cao, J., & Fu, W. (2020). Efficacy of Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Meta-analysis. Orthopaedic journal of sports medicine, 8(2), 2325967120903430.
  32. ↑ Al-Abbad, H., & Simon, J. V. (2013). The effectiveness of extracorporeal shock wave therapy on chronic achilles tendinopathy: a systematic review. Foot & ankle international, 34(1), 33–41.
  33. ↑ Stania, M., Juras, G., Chmielewska, D., Polak, A., Kucio, C., & Król, P. (2019). Extracorporeal Shock Wave Therapy for Achilles Tendinopathy. BioMed research international, 2019, 3086910.
  34. ↑ Brown CD, Lauber CA. Evidence-based guidelines for utilization of dexamethasone iontophoresis. International Journal of Athletic Therapy and Training. 2011. 16(4): 33-36.
  35. ↑ Neeter, C., Thomeé, R., Silbernagel, K. G., Thomeé, P., & Karlsson, J. (2003). Iontophoresis with or without dexamethazone in the treatment of acute Achilles tendon pain. Scandinavian journal of medicine & science in sports, 13(6), 376–382.
  36. ↑ 36.0 36.1 36.2 Scott, L. A., Munteanu, S. E., & Menz, H. B. (2015). Effectiveness of orthotic devices in the treatment of Achilles tendinopathy: a systematic review. Sports medicine (Auckland, N.Z.), 45(1), 95–110.
  37. ↑ 37.0 37.1 Riddle, D. L., & Freeman, D. B. (1988). Management of a patient with a diagnosis of bilateral plantar fasciitis and Achilles tendinitis. A case report. Physical therapy, 68(12), 1913–1916.
  38. ↑ 38.0 38.1 Smith, M., Brooker, S., Vicenzino, B., & McPoil, T. (2004). Use of anti-pronation taping to assess suitability of orthotic prescription: case report. The Australian journal of physiotherapy, 50(2), 111–113.
  39. ↑ 39.0 39.1 Wilson, F., Walshe, M., O'Dwyer, T., Bennett, K., Mockler, D., & Bleakley, C. (2018). Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta-analysis. British journal of sports medicine, 52(24), 1564–1574.
  40. ↑ Mayer, F., Hirschmüller, A., Müller, S., Schuberth, M., & Baur, H. (2007). Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy. British journal of sports medicine, 41(7), e6.
  41. ↑ Munteanu, S. E., Scott, L. A., Bonanno, D. R., Landorf, K. B., Pizzari, T., Cook, J. L., & Menz, H. B. (2015). Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial. British journal of sports medicine, 49(15), 989–994.
  42. ↑ 42.0 42.1 Lee, K., Ling, S., & Yung, P. (2019). Controlled trial to compare the Achilles tendon load during running in flatfeet participants using a customized arch support orthoses vs an orthotic heel lift. BMC musculoskeletal disorders, 20(1), 535.
  43. ↑ Hannigan, J. J., & Pollard, C. D. (2020). Differences in running biomechanics between a maximal, traditional, and minimal running shoe. Journal of science and medicine in sport, 23(1), 15–19.
  44. ↑ Greene B. L. (2002). Physical therapist management of fluoroquinolone-induced Achilles tendinopathy. Physical therapy, 82(12), 1224–1231.
  45. ↑ Donoghue, O. A., Harrison, A. J., Laxton, P., & Jones, R. K. (2008). Orthotic control of rear foot and lower limb motion during running in participants with chronic Achilles tendon injury. Sports biomechanics, 7(2), 194–205.
  46. ↑ Sussmilch-Leitch, S. P., Collins, N. J., Bialocerkowski, A. E., Warden, S. J., & Crossley, K. M. (2012). Physical therapies for Achilles tendinopathy: systematic review and meta-analysis. Journal of foot and ankle research, 5(1), 15.
  47. ↑ de Jonge, S., de Vos, R. J., Van Schie, H. T., Verhaar, J. A., Weir, A., & Tol, J. L. (2010). One-year follow-up of a randomised controlled trial on added splinting to eccentric exercises in chronic midportion Achilles tendinopathy. British journal of sports medicine, 44(9), 673–677.
  48. ↑ de Vos, R. J., Weir, A., Visser, R. J., de Winter, T., & Tol, J. L. (2007). The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. British journal of sports medicine, 41(7), e5.
  49. ↑ McAleenan M, McVeigh JG, Cullen M, et al. The effectiveness of night splints in Achilles tendinopathy: a pilot study. Physiotherapy Ireland. 2010;31:29–33
  50. ↑ Knobloch, K., Schreibmueller, L., Longo, U. G., & Vogt, P. M. (2008). Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation. Disability and rehabilitation, 30(20-22), 1685–1691.
  51. ↑ Petersen, W., Welp, R., & Rosenbaum, D. (2007). Chronic Achilles tendinopathy: a prospective randomized study comparing the therapeutic effect of eccentric training, the AirHeel brace, and a combination of both. The American journal of sports medicine, 35(10), 1659–1667.
  52. ↑ Martin, R. L., Chimenti, R., Cuddeford, T., Houck, J., Matheson, J. W., McDonough, C. M., Paulseth, S., Wukich, D. K., & Carcia, C. R. (2018). Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. The Journal of orthopaedic and sports physical therapy, 48(5), A1–A38.
  53. ↑ Lowdon, A., Bader, D. L., & Mowat, A. G. (1984). The effect of heel pads on the treatment of Achilles tendinitis: a double blind trial. The American journal of sports medicine, 12(6), 431–435.
  54. ↑ MacLellan, G. E., & Vyvyan, B. (1981). Management of pain beneath the heel and Achilles tendonitis with visco-elastic heel inserts. British journal of sports medicine, 15(2), 117–121.
  55. ↑ Wulf, M., Wearing, S. C., Hooper, S. L., Bartold, S., Reed, L., & Brauner, T. (2016). The Effect of an In-shoe Orthotic Heel Lift on Loading of the Achilles Tendon During Shod Walking. The Journal of orthopaedic and sports physical therapy, 46(2), 79–86.
  56. ↑ Solomons, L., Lee, J., Bruce, M., White, L. D., & Scott, A. (2020). Intramuscular stimulation vs sham needling for the treatment of chronic midportion Achilles tendinopathy: A randomized controlled clinical trial. PloS one, 15(9), e0238579.

 

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