Achilles Tendinopathy Toolkit: Section C - Summary of Evidence and Recommendations for Interventions: Difference between revisions
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| <u>May consider</u> using manual therapy in the acute stage after undertaking a comprehensive biomechanical&nbsp;evaluation of the ‐ Joint mobs hip, knee, foot and ankle.  
| <u>May consider</u> using manual therapy in the acute stage after undertaking a comprehensive biomechanical&nbsp;evaluation of the ‐ Joint mobs hip, knee, foot and ankle.  
| <u>May consider</u> a trial of soft tissue techniques, such as<br>frictions, in the chronic stage.
| <u>May consider</u> a trial of soft tissue techniques, such as<br>frictions, in the chronic stage.&nbsp;Combining with an eccentric exercise regime may produce superior results.
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CS ‐ Case studies; SR ‐ Systematic reviews.
CS ‐ Case studies; SR ‐ Systematic reviews.  


=== Exercise  ===
=== Exercise  ===
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! scope="row" | Clinical research evidence  
! scope="row" | Clinical research evidence  
| No  
| No  
| Yes<br>14 OS<ref>Gaerdin A, Movin T, Svensson L, Shalabi A. The long‐term clinical andfckLRMRI results following eccentric calf muscle training in chronic Achilles tendinosis. Skeletal Radiol. 2010;39(5):435‐42.</ref><ref>Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy‐load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine. 1998;26(3):360‐66.</ref><ref>Knobloch K, Schreibmueller L, Kraemer R, Jogodzinski M, Vogt PM, Redeker J. Gender and eccentric training in Achilles midportion tendinopathy. Knee Surgery, Sports Traumatology, Arthroscopy. 2010;18(5):648‐55.</ref><ref>Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow‐up. British Journal of Sports Medicine. 2004;38(1):8‐11; discussion 11.</ref><ref>Petersen W, Welp R, Rosenbaum D. Chronic AT: a prospective randomized trial comparing the therapeutic effect of eccentric training, the AirHeel brace, and a combination of both. American Journal of Sports Medicine. 2007;35(10):1659‐67.</ref><ref>Richards PJ, McCall IW, Day C, Belcher J, Maffulli N. Longitiudinal microvascularity in Achilles tendinopathy. Skeletal Radiology. 2010;39(6):509‐21.</ref><ref>Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid portion Achilles tendinopathy: a randomized trial with one year follow‐up. Scandanavian Journal of Medicine and Science in Sports. 2004;14(5):286‐95.</ref><ref>Shalabi A, Kristoffersen‐Wiberg M, Aspelin P, Movin T. Immediate Achilles tendon response after strength training evaluated byfckLRMRI. Medicine and Science in Sports and Exercise. 2004;36(11):1841‐6.</ref><ref>Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated withfckLRexercise alone: a 5 year follow‐up. American Journal of Sports Medicine. 2011;39(3):607‐13.</ref><ref>Silbernagel KG, Thomee R, Eriksson BI, Karlsson, J. Full symptomatic recovery does not ensure full recovery of muscle tendonfckLRfunction in patients with Achilles tendinopathy. British Journal of Sports Medicine. 2007;41(4):276‐80; discussion 280.</ref><ref>Verrall G, Scholfield S, Brustad T. Chronic Achilles tendinopathy treated with eccentric stretching program. Foot Ankle International. 2011;32(9):843‐9.</ref><ref>Westh E, Kongsgaard M, Bojsen‐Moller J, Aagaard P, Hansen M, Kjaer M, Magnuson, S.P. Effect of habitual exercise on the structural and mechanical properties of human tendon, in vivo, in men and women. Scand J Med Sci Sports. 2008;18(1):23‐30.</ref><br>6 SR<ref>Kingma JJ, de Knikker R, Wittink HM, Takken T. Eccentric Overload Training in Patients with Chronic AT: A systematic review. Br J Sports Med. 2007;41(6):e3.</ref><ref>Kraemer R, Lorenzen J, Vogt PM, Knobloch K. Systematic review about eccentric training in chronic achilles tendinopathy. Sportverletz Sportschaden. December. 2010;24(4):204‐11. [Article in German, Abstract translated]</ref><ref>Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achille tendinopathy: a systematic review. Clinical Journal of Sport Medicine. 2009;19(1):54‐64.</ref><ref>Meyer A, Tumility S &amp;amp;amp;amp; Baxter GD. Eccentric exercise protocols for chronic non‐insertional Achilles tendinopathy: how much is enough? Scandanavian Journal of Medicine and Science in Sports. 2009;19(5):609‐15.</ref><ref>Wasielewski NJ &amp;amp;amp;amp; Kotsko KM. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review. Journal of Athletic Training. 2007;42(3):409‐21.</ref><ref>Woodley BL, Newsham‐West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise. British Journal of Sports Medicine. 2007;41(4):188‐98;discussion 199.</ref><br>5 RCT<ref>Backman LJ, Andersson G, Wennstig G, Forsgren S &amp;amp;amp; Danielson P. Endogenous substance P production in the Achilles tendon increases with loading in an in vivo model of tendinopathy ‐ peptidergic elevation preceding tendinosis‐like tissue changes. Journal of Musculoskeletal and Neuronal Interactions. 2011;11(2):133‐40.</ref><ref>Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock‐wave treatment for mid‐portion Achilles tendinopathy: a randomized controlled trial. American Journal of Sports Medicine. 2009;37(3):463‐70.</ref><ref>Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock‐wave treatment, or a wait and see policy for tendinopathy of the main body of tendo Achilles: a randomized controlled trial. American Journal of Sports Medicine. 2007;35(3):374‐83.</ref><ref>Silbernagel K, Thomee P, Karlson J. Eccentric overload training for patients with chronic achilles tendinopathy ‐ a randomised controlled study with reliability testing of the evaluating methods. Scandanavian Journal of Medicine and Science in Sports. 2001;11:197‐206.</ref><ref>Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using a pain‐monitoring model during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. American Journal of Sports Medicine. 2007;35(6):897‐906.</ref>
| Yes<br>14 OS<ref>Gaerdin A, Movin T, Svensson L, Shalabi A. The long‐term clinical andfckLRMRI results following eccentric calf muscle training in chronic Achilles tendinosis. Skeletal Radiol. 2010;39(5):435‐42.</ref><ref>Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy‐load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine. 1998;26(3):360‐66.</ref><ref>Knobloch K, Schreibmueller L, Kraemer R, Jogodzinski M, Vogt PM, Redeker J. Gender and eccentric training in Achilles midportion tendinopathy. Knee Surgery, Sports Traumatology, Arthroscopy. 2010;18(5):648‐55.</ref><ref>Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow‐up. British Journal of Sports Medicine. 2004;38(1):8‐11; discussion 11.</ref><ref>Petersen W, Welp R, Rosenbaum D. Chronic AT: a prospective randomized trial comparing the therapeutic effect of eccentric training, the AirHeel brace, and a combination of both. American Journal of Sports Medicine. 2007;35(10):1659‐67.</ref><ref>Richards PJ, McCall IW, Day C, Belcher J, Maffulli N. Longitiudinal microvascularity in Achilles tendinopathy. Skeletal Radiology. 2010;39(6):509‐21.</ref><ref>Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid portion Achilles tendinopathy: a randomized trial with one year follow‐up. Scandanavian Journal of Medicine and Science in Sports. 2004;14(5):286‐95.</ref><ref>Shalabi A, Kristoffersen‐Wiberg M, Aspelin P, Movin T. Immediate Achilles tendon response after strength training evaluated byfckLRMRI. Medicine and Science in Sports and Exercise. 2004;36(11):1841‐6.</ref><ref>Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated withfckLRexercise alone: a 5 year follow‐up. American Journal of Sports Medicine. 2011;39(3):607‐13.</ref><ref>Silbernagel KG, Thomee R, Eriksson BI, Karlsson, J. Full symptomatic recovery does not ensure full recovery of muscle tendonfckLRfunction in patients with Achilles tendinopathy. British Journal of Sports Medicine. 2007;41(4):276‐80; discussion 280.</ref><ref>Verrall G, Scholfield S, Brustad T. Chronic Achilles tendinopathy treated with eccentric stretching program. Foot Ankle International. 2011;32(9):843‐9.</ref><ref>Westh E, Kongsgaard M, Bojsen‐Moller J, Aagaard P, Hansen M, Kjaer M, Magnuson, S.P. Effect of habitual exercise on the structural and mechanical properties of human tendon, in vivo, in men and women. Scand J Med Sci Sports. 2008;18(1):23‐30.</ref><br>7 SR<ref>Kingma JJ, de Knikker R, Wittink HM, Takken T. Eccentric Overload Training in Patients with Chronic AT: A systematic review. Br J Sports Med. 2007;41(6):e3.</ref><ref>Kraemer R, Lorenzen J, Vogt PM, Knobloch K. Systematic review about eccentric training in chronic achilles tendinopathy. Sportverletz Sportschaden. December. 2010;24(4):204‐11. [Article in German, Abstract translated]</ref><ref>Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achille tendinopathy: a systematic review. Clinical Journal of Sport Medicine. 2009;19(1):54‐64.</ref><ref>Meyer A, Tumility S &amp;amp;amp;amp;amp; Baxter GD. Eccentric exercise protocols for chronic non‐insertional Achilles tendinopathy: how much is enough? Scandanavian Journal of Medicine and Science in Sports. 2009;19(5):609‐15.</ref><ref>Wasielewski NJ &amp;amp;amp;amp;amp; Kotsko KM. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review. Journal of Athletic Training. 2007;42(3):409‐21.</ref><ref>Woodley BL, Newsham‐West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise. British Journal of Sports Medicine. 2007;41(4):188‐98;discussion 199.</ref><ref>Malliaras, P., Barton, C., Reeves, N., &amp; Langberg, H. (2013). Achilles and Patellar Tendinopathy Loading Programmes. Sports Medicine, 43(4), 267-286. doi: 10.1007/s40279-013-0019-z</ref><br>8 RCT<ref>Backman LJ, Andersson G, Wennstig G, Forsgren S &amp;amp;amp;amp; Danielson P. Endogenous substance P production in the Achilles tendon increases with loading in an in vivo model of tendinopathy ‐ peptidergic elevation preceding tendinosis‐like tissue changes. Journal of Musculoskeletal and Neuronal Interactions. 2011;11(2):133‐40.</ref><ref>Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock‐wave treatment for mid‐portion Achilles tendinopathy: a randomized controlled trial. American Journal of Sports Medicine. 2009;37(3):463‐70.</ref><ref>Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock‐wave treatment, or a wait and see policy for tendinopathy of the main body of tendo Achilles: a randomized controlled trial. American Journal of Sports Medicine. 2007;35(3):374‐83.</ref><ref>Silbernagel K, Thomee P, Karlson J. Eccentric overload training for patients with chronic achilles tendinopathy ‐ a randomised controlled study with reliability testing of the evaluating methods. Scandanavian Journal of Medicine and Science in Sports. 2001;11:197‐206.</ref><ref>Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using a pain‐monitoring model during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. American Journal of Sports Medicine. 2007;35(6):897‐906.</ref><ref>Beyer, R., Kongsgaard, M., Hougs Kjaer, B., Ohlenschlaeger, T., Kjaer, M., &amp; Magnusson, S. P. (2015). Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. Am J Sports Med. doi: 10.1177/0363546515584760</ref><ref>Stevens, M., &amp; Tan, C.-W. (2014). Effectiveness of the alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. Journal of Orthopaedic &amp; Sports Physical Therapy, 44(2), 59-67.</ref><ref>Yu, J., Park, D., &amp; Lee, G. (2013). Effect of Eccentric Strengthening on Pain, Muscle Strength, Endurance, and Functional Fitness Factors in Male Patients with Achilles Tendinopathy. American Journal of Physical Medicine &amp; Rehabilitation, 92(1), 68-76. doi: 10.1097/PHM.0b013e31826eda63</ref>
|-
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! scope="row" | Published expert opinion  
! scope="row" | Published expert opinion  
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! scope="row" | Take home message  
! scope="row" | Take home message  
| There is a small amount of expert opinion to&nbsp;<u>support </u>the use of stretches in the acute stage.  
| There is a small amount of expert opinion to&nbsp;<u>support </u>the use of stretches in the acute stage.  
| There is a large amount of clinical evidence to<br><u>support</u> the use of exercise in the chronic stage but<br>the precise parameters to ensure effectiveness are<br>not clear. Eccentric exercise in particular is<br>supported although some protocols use both<br>concentric and eccentric exercise. Males appear to<br>benefit slightly more than females from eccentric<br>exercise.
| There is a large amount of clinical evidence to&nbsp;<u>support</u> the use of exercise in the chronic stage but&nbsp;the precise parameters to ensure effectiveness are&nbsp;not clear. Eccentric exercise in particular is&nbsp;supported although some protocols use both&nbsp;concentric and eccentric exercise. Males appear to&nbsp;benefit slightly more than females from eccentric&nbsp;exercise.&nbsp;One RCT showed heavy slow resistance training is equally as effective as eccentric training.
|-
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]  
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]  
| <u>May consider</u> using stretching exercises in acute stage. No prescription parameters are provided. ACSM recommends 10-30 sec hold, 2‐4 repetitions.  
| <u>May consider</u> using stretching exercises in acute stage. No prescription parameters are provided. ACSM recommends 10-30 sec hold, 2‐4 repetitions.  
| <u>Strongly consider </u>using eccentric exercise in the chronic stage using the following general parameters of a gradual progression to 3 sets of 15 repetitions, twice per day with the knee extended and with the knee flexed.  
| <u>Strongly consider </u>using eccentric exercise in the chronic stage.
*''See Appendix A for further details on exercise prescription.''
*''See Appendix A for further details on exercise prescription.''


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


=== Low level laser therapy (LLLT)  ===
=== Low level laser therapy (LLLT)  ===
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! scope="row" | Clinical research evidence  
! scope="row" | Clinical research evidence  
| Yes<br>2 SR<ref>Bjordal J, Couppe C. 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, Iversen VV. 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. 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><br>  
| Yes<br>2 SR<ref>Bjordal J, Couppe C. 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, Iversen VV. 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. 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><br>  
| Yes<br>1 MA<ref>Tumilty S, Munn J, McDonough S, Hurley D A, Basford JR, Baxter GD. Low level laser treatment of tendinopathy: a systematic review with meta‐analysis Photomedicine and Laser Surgery. 2010;28(1):3–16.</ref><br>5 RCT<ref>Bjordal, JM. A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with micro dialysis measurement of peritendinous prostaglandin E2 concentrations. British Journal of Sports Medicine. 2006;40(1):76–80.</ref><ref>Darre E, Klokker M, Lund P. Laserbehandling af akillessenetendinit. Ugeskr Laeger.1994;156(45):6680‐3. Danish.</ref><ref>Stergioula A, Stergioula M, Aarskog R, Lopes‐Martins RAB, Bjordal JM. 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. 2008;36(5):881–887.</ref><ref>Tumilty S, Munn J, Abbott JH, McDonough S, Hurley DA, Baxter GD. Laser therapy in the treatment of Achilles tendinopathy: a pilot study. Photomedicine and Laser Surgery. 2008;26(1):25–30.</ref><ref>Tumilty S, Munn J, Abbott JH, McDonough S, Hurley DA, Basford JR, Baxter G.D. Laser Therapy in the Treatment of Achilles Tendinopathy: A Randomised Controlled Trial. AIP Conf. Proc. May 31 2010;Volume 1226:163‐169.</ref><br>
| Yes<br>1 MA<ref>Tumilty S, Munn J, McDonough S, Hurley D A, Basford JR, Baxter GD. Low level laser treatment of tendinopathy: a systematic review with meta‐analysis Photomedicine and Laser Surgery. 2010;28(1):3–16.</ref><br>6 RCT<ref>Bjordal, JM. A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with micro dialysis measurement of peritendinous prostaglandin E2 concentrations. British Journal of Sports Medicine. 2006;40(1):76–80.</ref><ref>Darre E, Klokker M, Lund P. Laserbehandling af akillessenetendinit. Ugeskr Laeger.1994;156(45):6680‐3. Danish.</ref><ref>Stergioula A, Stergioula M, Aarskog R, Lopes‐Martins RAB, Bjordal JM. 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. 2008;36(5):881–887.</ref><ref>Tumilty S, Munn J, Abbott JH, McDonough S, Hurley DA, Baxter GD. Laser therapy in the treatment of Achilles tendinopathy: a pilot study. Photomedicine and Laser Surgery. 2008;26(1):25–30.</ref><ref>Tumilty S, Munn J, Abbott JH, McDonough S, Hurley DA, Basford JR, Baxter G.D. Laser Therapy in the Treatment of Achilles Tendinopathy: A Randomised Controlled Trial. AIP Conf. Proc. May 31 2010;Volume 1226:163‐169.</ref><ref>Tumilty, S., McDonough, S., Hurley, D. A., &amp; 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. doi: http://dx.doi.org/10.1016/j.apmr.2011.08.049</ref><br>
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! scope="row" | Published expert opinion  
! scope="row" | Published expert opinion  
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MA ‐ Meta‐analyses; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews.
MA ‐ Meta‐analyses; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews.  


=== Ultrasound (US)  ===
=== Ultrasound (US)  ===
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<br>
<br>  


=== Extracorporeal shock wave therapy (SWT)  ===
=== Extracorporeal shock wave therapy (ESWT)  ===


{| width="700" border="1" cellpadding="1" cellspacing="1"
{| width="700" border="1" cellpadding="1" cellspacing="1"
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! scope="row" | Clinical research evidence  
! scope="row" | Clinical research evidence  
| No  
| No  
| Yes<br>4 RCT<ref>Costa ML, Shepstone L, Donell ST, Thomas TL. Shock WaveTherapy for chronic Achilles tendon pain: a randomized placebo controlled trial. Clinical Orthopedics and Related Research. 2005;440:199‐204.</ref><ref>Rompe J, Nafe B, Furia J. Eccentric loading, shock wave therapy or ‘wait and see’ policy for tendinopathy of the main body of tendo achillis: a randomized controlled trial. American Journal of Sports Medicine. 2007;35(3):374‐383.</ref><ref>Rompe J, Furia J, Maffulli N. Eccentric loading vs eccentric loading plus shock wave treatment for mid‐portion Achilles tendinopathy. A randomized controlled trial. American Journal of Sports Medicine. 2009;37(3):463‐470.</ref><ref>Rasmussen S, Christensen M, Mathiesen I, Simonson O. Shock wave therapy for chronic Achilles tendinopathy: a double‐blind, randomized clinical trial of efficacy. Acta Orthopaedica. 2008;79(2):249‐256.</ref><br>1 Cohort<ref>Lakshmanan P, O’Doherty D. Chronic Achilles tendinopathy: treatment with extra‐corporeal shock wave therapy. Foot and Ankle Surgery. 2004;10:125‐130.</ref><br>
| Yes<br>4 RCT<ref>Costa ML, Shepstone L, Donell ST, Thomas TL. Shock WaveTherapy for chronic Achilles tendon pain: a randomized placebo controlled trial. Clinical Orthopedics and Related Research. 2005;440:199‐204.</ref><ref>Rompe J, Nafe B, Furia J. Eccentric loading, shock wave therapy or ‘wait and see’ policy for tendinopathy of the main body of tendo achillis: a randomized controlled trial. American Journal of Sports Medicine. 2007;35(3):374‐383.</ref><ref>Rompe J, Furia J, Maffulli N. Eccentric loading vs eccentric loading plus shock wave treatment for mid‐portion Achilles tendinopathy. A randomized controlled trial. American Journal of Sports Medicine. 2009;37(3):463‐470.</ref><ref>Rasmussen S, Christensen M, Mathiesen I, Simonson O. Shock wave therapy for chronic Achilles tendinopathy: a double‐blind, randomized clinical trial of efficacy. Acta Orthopaedica. 2008;79(2):249‐256.</ref><br>1 Cohort<ref>Lakshmanan P, O’Doherty D. Chronic Achilles tendinopathy: treatment with extra‐corporeal shock wave therapy. Foot and Ankle Surgery. 2004;10:125‐130.</ref><br>1SR&nbsp;<ref>Al-Abbad, H., &amp; Simon, J. V. (2013). The effectiveness of extracorporeal shock wave therapy on chronic achilles tendinopathy: a systematic review. Foot Ankle Int, 34(1), 33-41. doi: 10.1177/1071100712464354</ref>
|-
|-
! scope="row" | Published expert opinion  
! scope="row" | Published expert opinion  
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|-
|-
! scope="row" | Take home message  
! scope="row" | Take home message  
| There is expert opinion which suggests that SWT be&nbsp;reserved for chronic stage.  
| There is expert opinion which suggests that ESWT be&nbsp;reserved for chronic stage.  
| There is <u>conflicting</u> evidence to support the use of SWT in the chronic stage. There is evidence suggesting that the outcomes are dependent upon the <u>dosage</u> of the shock wave energy (EFD ‐ energy&nbsp;flux density = mJ/mm²), rather than the <u>type</u> of shock wave generation (focused vs. radial SWT). There is also evidence that the use of anaesthetic required in high energy protocols decreases the&nbsp;effectiveness of SWT. Therefore, using low energy SWT protocols without the need for anaesthetic are recommended as more practical, more tolerable, and less expensive with equivalent results. Low energy SWT protocols can apply to both focused&nbsp;and radial SWT.<br>
| There is <u>conflicting</u> evidence to support the use of ESWT in the chronic stage. There is evidence suggesting that the outcomes are dependent upon the <u>dosage</u> of the shock wave energy (EFD ‐ energy&nbsp;flux density = mJ/mm²), rather than the <u>type</u> of shock wave generation (focused vs. radial ESWT). There is also evidence that the use of anaesthetic required in high energy protocols decreases the&nbsp;effectiveness of ESWT. Therefore, using low energy ESWT protocols without the need for anaesthetic are recommended as more practical, more tolerable, and less expensive with equivalent results. Low energy ESWT protocols can apply to both focused&nbsp;and radial ESWT.<br>
|-
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]  
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|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 SWT in the chronic stage, especially if&nbsp;other interventions have failed, at the following&nbsp;parameters:&nbsp;  
<u>Consider</u> a trial of ESWT in the chronic stage, especially if&nbsp;other interventions have failed, at the following&nbsp;parameters:&nbsp;  


*Low energy SWT: EFD = 0.18 – 0.3 mJ/mm² (2‐4 Bars)&nbsp;  
*Low energy SWT: EFD = 0.18 – 0.3 mJ/mm² (2‐4 Bars)&nbsp;  
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*3‐5 sessions, weekly intervals.&nbsp;
*3‐5 sessions, weekly intervals.&nbsp;


Advise patients that this is an experimental technique.&nbsp;SWT enhances the outcomes compared to eccentric&nbsp;exercise alone, therefore patients should be instructed to&nbsp;continue with a well‐designed exercise program.  
ESWT enhances the outcomes compared to eccentric&nbsp;exercise alone, therefore patients should be instructed to&nbsp;continue with a well‐designed exercise program.  


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RCT ‐ Randomized controlled trials.
RCT ‐ Randomized controlled trials; SR - Systematic review


=== Iontophoresis using dexamethasone  ===
=== Iontophoresis using dexamethasone  ===
Line 199: Line 199:
|-
|-
! scope="row" | Clinical research evidence  
! scope="row" | Clinical research evidence  
| Yes<br>1 RCT<ref>Neeter C, Thomee R, Silbernagel K, Thomee P, Karlson J. Iontophoresis with and without dexamethasone in the treatment of acute Achilles tendon pain. Scandinavian Journal of Medicine and Science in Sports. 2003;13(6):376‐382.</ref><br>1 review<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>  
| Yes<br>1 RCT&nbsp;<ref>Neeter C, Thomee R, Silbernagel K, Thomee P, Karlson J. Iontophoresis with and without dexamethasone in the treatment of acute Achilles tendon pain. Scandinavian Journal of Medicine and Science in Sports. 2003;13(6):376‐382.</ref><br>1 SR&nbsp;<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>  
| No
| No
|-
|-
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RCT ‐ Randomized controlled trial.<br>
RCT ‐ Randomized controlled trial; SR - Systematic Review<br>  


=== Taping<ref>Riddle DL, Freeman DB. Management of a patient with a diagnosis of bilateral plantar fasciitis and Achilles tendinitis. A case report. Phys There. 1988;68(12):1913‐6.</ref><ref>Smith M, Brooker S, Vicenzino B &amp;amp;amp;amp; McPoil T. Use of anti‐pronation taping to assess suitability of orthotic prescription: case report. Aust J Physiother. 2004;50(2):111‐3.</ref>  ===
=== Taping ===


{| width="700" border="1" cellpadding="1" cellspacing="1"
{| width="700" border="1" cellpadding="1" cellspacing="1"
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! scope="row" | Clinical research evidence  
! scope="row" | Clinical research evidence  
| No  
| No  
| Yes<br>1 CS
| Yes<br>3 CS&nbsp;<ref>Lee, J.-h., &amp; Yoo, W.-g. (2012). Treatment of chronic Achilles tendon pain by Kinesio taping in an amateur badminton player. Physical Therapy in Sport, 13(2), 115-119. doi: http://dx.doi.org/10.1016/j.ptsp.2011.07.002</ref><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><br> 1SR&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>
|-
|-
! scope="row" | Published expert opinion  
! scope="row" | Published expert opinion  
Line 243: Line 243:
<br>  
<br>  


| There is expert opinion to <u>support</u> the use of&nbsp;controlled pronation taping in the chronic stage.<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>
|-
|-
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]  
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]  
Line 250: Line 250:
|}
|}


CS ‐ Case studies.
CS ‐ Case studies; SR - Systematic Review


=== Orthotics<ref>Mayer F, Hirschmuller A, Muller S, Schuberth M &amp;amp;amp; Baur H. Effects of short‐term treatment strategies over 4 weeks in AchillesfckLRtendinopathy. Br J Sports Med. 2007;41(7):e6.</ref><ref>Gross ML, Davlin L &amp;amp;amp; Evanski PM. Effectiveness of orthotic shoe inserts in the long‐distance runner. Am J Sports Med. 1991;19:409–412.</ref><ref>Donoghue OA, Harrison AJ, Laxton P &amp;amp;amp; Jones RK. Orthotic control of rear foot and lower limb motion during running in participantsfckLRwith chronic Achilles tendon injury. Sports Biomech. 2008;7(2):194‐205.</ref><ref>Greene BL. Physical therapist management of fluoroquinolone‐induced Achilles tendinopathy. Phys Ther. 2002;82(12):1224‐31.</ref><ref>Riddle DL &amp;amp;amp; Freeman DB. Management of a patient with a diagnosis of bilateral plantar fasciitis and Achilles tendinitis. A casefckLRreport. Phys Ther. 1988;68(12):1913‐6.</ref>  ===
=== Orthotics ===


{| width="700" border="1" cellpadding="1" cellspacing="1"
{| width="700" border="1" cellpadding="1" cellspacing="1"
Line 262: Line 262:
! scope="row" | Clinical research evidence  
! scope="row" | Clinical research evidence  
| Yes<br>2 CS<br>  
| Yes<br>2 CS<br>  
| Yes<br>2 CS<br>1 RCT<br>
| Yes<br>2 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><br>1 RCT<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>
|-
|-
! scope="row" | Published expert opinion  
! scope="row" | Published expert opinion  
Line 274: Line 274:
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]  
! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]  
|  
|  
<u>Consider</u> using orthotics – perhaps using taping first, in the acute stage.<br>
<u>Consider</u> using orthotics – perhaps using taping first, in the acute stage.<br>  


| <u>Consider</u> using orthotics in the chronic stage.<br>
| <u>Consider</u> using orthotics in the chronic stage.<br>
|}
|}


CS ‐ Case studies; RCT ‐ Randomized controlled trials.
CS ‐ Case studies; RCT ‐ Randomized controlled trials.  


=== Night splints and braces  ===
=== Night splints and braces  ===
Line 291: Line 291:
! scope="row" | Clinical research evidence  
! scope="row" | 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;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>
| 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;amp;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>
|-
|-
! scope="row" | Published expert opinion  
! scope="row" | Published expert opinion  
Line 333: Line 333:
|}
|}


RCT ‐ Randomized controlled trials.
RCT ‐ Randomized controlled trials.  


=== 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>  ===
=== 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>  ===
Line 442: Line 442:
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.  
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.  


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.
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>

Revision as of 00:39, 4 June 2015

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.

Achilles Tendinopathy (mid-substance): 
Summary of the Evidence for Physical Therapy Interventions
[edit | edit source]

Manual Therapy
[edit | edit source]

Joint mobs

Stage of pathology Acute Chronic
Clinical research evidence No

Yes

1CS[1]

Published expert opinion Yes[2] Yes[2]
Take home message There is no clinical evidence but there is expert level consensus to support the use of joint mobilizations in the acute stage if assessment reveals joint restriction. There is a small amount of clinical evidence and more substantial expert level consensus to support the use of joint mobilizations in the chronic stage if assessment reveals joint restriction.
Clinical implication May consider using manual therapy in the acute stage after undertaking a comprehensive biomechanical evaluation of the ‐ Joint mobs hip, knee, foot and ankle. May consider using manual therapy in the chronic stage
after undertaking a comprehensive biomechanical
evaluation of the hip, knee, foot and ankle.

Soft-tissue techniques

Stage of pathology Acute Chronic
Clinical research evidence No Yes
1 SR[3]
2 CS[4][5]
Published expert opinion No Yes[2]
Take home message The clinical evidence neither supports nor refutes the use of frictions in the acute stage. There is a small amount of clinical evidence to support the use of soft tissue techniques, such as frictions, in the chronic stage.

Clinical implication

May consider using manual therapy in the acute stage after undertaking a comprehensive biomechanical evaluation of the ‐ Joint mobs hip, knee, foot and ankle. May consider a trial of soft tissue techniques, such as
frictions, in the chronic stage. Combining with an eccentric exercise regime may produce superior results.

CS ‐ Case studies; SR ‐ Systematic reviews.

Exercise[edit | edit source]

Stage of pathology Acute Chronic
Clinical research evidence No Yes
14 OS[6][7][8][9][10][11][12][13][14][15][16][17]
7 SR[18][19][20][21][22][23][24]
8 RCT[25][26][27][28][29][30][31][32]
Published expert opinion Yes[33] Yes[33]
Take home message There is a small amount of expert opinion to support the use of stretches in the acute stage. There is a large amount of clinical 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. Males appear to benefit slightly more than females from eccentric exercise. One RCT showed heavy slow resistance training is equally as effective as eccentric training.
Clinical implication May consider using stretching exercises in acute stage. No prescription parameters are provided. ACSM recommends 10-30 sec hold, 2‐4 repetitions. Strongly consider using eccentric exercise in the chronic stage.
  • See Appendix A for further details on exercise prescription.

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

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

Stage of pathology Acute Chronic
Clinical research evidence Yes
2 SR[34][35][36]

 Yes
1 MA[37]
6 RCT[38][39][40][41][42][43]
Published expert opinion Yes Yes
Take home message There is no clinical evidence, but there is a physiological rationale, to support the use of LLLT in the acute stage.
 There is conflicting clinical evidence and conflicting expert opinion to support the use of LLLT in the chronic stage.
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 'Appendix B '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.

*See Appendix B 'for further details on calculation of dosage.

MA ‐ Meta‐analyses; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews.

Ultrasound (US)[edit | edit source]

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). Consider NOT using US in the chronic stage.


Extracorporeal shock wave therapy (ESWT)[edit | edit source]

Stage of pathology Acute Chronic
Clinical research evidence No Yes
4 RCT[44][45][46][47]
1 Cohort[48]
1SR [49]
Published expert opinion Yes Yes
Take home message There is expert opinion which suggests that ESWT be reserved for chronic stage. There is conflicting evidence to support the use of ESWT in the chronic stage. There is evidence suggesting that the outcomes are dependent upon the dosage of the shock wave energy (EFD ‐ energy flux density = mJ/mm²), rather than the type of shock wave generation (focused vs. radial ESWT). There is also evidence that the use of anaesthetic required in high energy protocols decreases the effectiveness of ESWT. Therefore, using low energy ESWT protocols without the need for anaesthetic are recommended as more practical, more tolerable, and less expensive with equivalent results. Low energy ESWT protocols can apply to both focused and radial ESWT.
Clinical implication Consider NOT using Extracorporeal Shock Wave for the acute stage.

Consider a trial of ESWT in the chronic stage, especially if other interventions have failed, at the following parameters: 

  • Low energy SWT: EFD = 0.18 – 0.3 mJ/mm² (2‐4 Bars) 
  • 2000‐3000 shocks 
  • 15‐30 Hz 
  • 3‐5 sessions, weekly intervals. 

ESWT enhances the outcomes compared to eccentric exercise alone, therefore patients should be instructed to continue with a well‐designed exercise program.

RCT ‐ Randomized controlled trials; SR - Systematic review

Iontophoresis using dexamethasone[edit | edit source]

Stage of pathology Acute Chronic
Clinical research evidence Yes
1 RCT [50]
1 SR [51] 		No
Published expert opinion No No
Take home message

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

There is no evidence that anti‐inflammatory intervention with iontophoresis using dexamethasone has a useful role in the chronic stage.
Clinical implication

May 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.

Consider NOT using iontophoresis using dexamethasone in the chronic stage.

RCT ‐ Randomized controlled trial; SR - Systematic Review

Taping[edit | edit source]

Stage of pathology Acute Chronic
Clinical research evidence No Yes
3 CS [52][53][54]
1SR [55]
Published expert opinion Yes Yes
Take home message There is expert opinion to support the use of antipronation taping in the acute stage.


 There is expert opinion and a small amount of clinical evidence to support the use of controlled pronation taping in the chronic stage.
Clinical implication May consider using antipronation taping in the acute stage. May consider using antipronation taping in the chronic stage.

CS ‐ Case studies; SR - Systematic Review

Orthotics[edit | edit source]

Stage of pathology Acute Chronic
Clinical research evidence Yes
2 CS
 Yes
2 CS [56][57]
1 RCT
1 SR [58]
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. There is a moderate amount of clinical evidence tosupport the use of orthotics in the chronic stage.
Clinical implication

Consider using orthotics – perhaps using taping first, in the acute stage.

 Consider using orthotics in the chronic stage.

CS ‐ Case studies; RCT ‐ Randomized controlled trials.

Night splints and braces[edit | edit source]

Stage of pathology Acute Chronic
Clinical research evidence No Yes
3 RCT[59][60][61]
Published expert opinion Yes Yes
Take home message There is expert opinion to support the use of night splints and braces in the acute stage. There is a moderate amount of evidence against the use of night splints and braces in the chronic stage.
Clinical implication Consider a trial of night splints and braces in the acute stage. Consider NOT using night splints and braces in the chronic stage.

RCT ‐ Randomized controlled trials.

Heel raise inserts[edit | edit source]

Stage of pathology Acute Chronic
Clinical research evidence No Yes
2 RCT[62][63]
Published expert opinion Yes Yes
Take home message There is some expert opinion to support the use of heel raise inserts in the acute stage. There is conflicting evidence for and against the use of heel inserts in the chronic stage.
Clinical implication May consider a trial of inserts in the acute stage. Consider a trial of inserts in the chronic stage.

RCT ‐ Randomized controlled trials.

Needling techniques[64][65][edit | edit source]

Acupuncture (trasitional Chinese medicine, anatomical, electrical) and intramuscular stimulation.

Stage of pathology Acute Chronic
Clinical research evidence Yes
1 CS 		Yes
1 CS
Published expert opinion No No
Take home message There is a small amount of evidence to support the use of Traditional Chinese Medicine electroacupuncture in the acute stage. There is expert opinion to support the use of other needling techniques in the acute stage. There is a small amount of evidence to support use of Traditional Chinese Acupuncture in the chronic stage. There is expert opinion on the use of other needling techniques in the chronic stage.
Clinical implication Consider a trial of electro‐acupuncture in the acute stage.
May consider a trial of other acupuncture‐related needling techniques in the acute stage. 		Consider a trial of Traditional Chinese Acupuncture in the chronic stage.
May consider a trial of other acupuncture‐related needling techniques in the chronic stage.

CS ‐ Case studies.


Outcome measures[edit | edit source]

For any intervention selected by the clinician, it is strongly recommended that the clinician use one or more of the following outcome measures.

A. Patient reported outcome measure
Such as:
  • A global measure of lower extremity function: e.g., The Lower Extremity Functional Scale (LEFS) ‐ not specific to Achilles tendinopathy
  • Detailed questionnaire, specific to Achilles tendinopathy e.g. the VISA‐A questionnaire
    • Available here (Click on ‘view questionnaire’)
B. Patient specific functional outcome measure
Such as:
  • How much weight can be applied to the plantar flexed foot on a weighing scale before the onset of pain
  • The number of heel raises before the onset of pain
  • The number of heel drops before the onset of pain
  • 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

Explanation of clinical implications[edit | edit source]

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.

Download Achilles Tendinopathy Toolkit: Summary of Interventions[edit | edit source]

File:Download Achilles Tendinopathy - Summary of Interventions.pdf

References[edit | edit source]

Please see Appendix C Achilles Tendinopathy: Details of Individual Articles for the specific details on each of the articles referenced in this document.

  1. ↑ Voorn, R. Case report: can sacroiliac joint dysfunction cause chronic Achilles tendonitis? JOSPT. 1998;27(6);436‐443.
  2. ↑ 2.0 2.1 2.2 Carcia CR, Martin RL, Houck J, Wukich DK. Achilles pain, stiffness, and muscle power deficits: achilles tendinitis. J Orthop Sports Phys Therapy. 2010;40(9)A1‐A26.
  3. ↑ Brosseau L, Casimiro L, Milne S. et al. Deep transverse friction massage for treating tendinitis. 2002. Cochrane Database Systematic Reviews. 4.
  4. ↑ Woodman RM, Pare L. Evaluation and treatment of soft tissue lesions of the ankle and forefoot using a Cyriax approach. Physical Therapy. 1982;62(8);1144‐47.
  5. ↑ Christenson RE. Effectiveness of specific soft tissue mobilizations for the management of Achilles tendinosis: Single case study‐ Experimental design. Manual Therap. 2007;12;63‐71.
  6. ↑ Gaerdin A, Movin T, Svensson L, Shalabi A. The long‐term clinical andfckLRMRI results following eccentric calf muscle training in chronic Achilles tendinosis. Skeletal Radiol. 2010;39(5):435‐42.
  7. ↑ Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy‐load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine. 1998;26(3):360‐66.
  8. ↑ Knobloch K, Schreibmueller L, Kraemer R, Jogodzinski M, Vogt PM, Redeker J. Gender and eccentric training in Achilles midportion tendinopathy. Knee Surgery, Sports Traumatology, Arthroscopy. 2010;18(5):648‐55.
  9. ↑ Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow‐up. British Journal of Sports Medicine. 2004;38(1):8‐11; discussion 11.
  10. ↑ Petersen W, Welp R, Rosenbaum D. Chronic AT: a prospective randomized trial comparing the therapeutic effect of eccentric training, the AirHeel brace, and a combination of both. American Journal of Sports Medicine. 2007;35(10):1659‐67.
  11. ↑ Richards PJ, McCall IW, Day C, Belcher J, Maffulli N. Longitiudinal microvascularity in Achilles tendinopathy. Skeletal Radiology. 2010;39(6):509‐21.
  12. ↑ Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid portion Achilles tendinopathy: a randomized trial with one year follow‐up. Scandanavian Journal of Medicine and Science in Sports. 2004;14(5):286‐95.
  13. ↑ Shalabi A, Kristoffersen‐Wiberg M, Aspelin P, Movin T. Immediate Achilles tendon response after strength training evaluated byfckLRMRI. Medicine and Science in Sports and Exercise. 2004;36(11):1841‐6.
  14. ↑ Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated withfckLRexercise alone: a 5 year follow‐up. American Journal of Sports Medicine. 2011;39(3):607‐13.
  15. ↑ Silbernagel KG, Thomee R, Eriksson BI, Karlsson, J. Full symptomatic recovery does not ensure full recovery of muscle tendonfckLRfunction in patients with Achilles tendinopathy. British Journal of Sports Medicine. 2007;41(4):276‐80; discussion 280.
  16. ↑ Verrall G, Scholfield S, Brustad T. Chronic Achilles tendinopathy treated with eccentric stretching program. Foot Ankle International. 2011;32(9):843‐9.
  17. ↑ Westh E, Kongsgaard M, Bojsen‐Moller J, Aagaard P, Hansen M, Kjaer M, Magnuson, S.P. Effect of habitual exercise on the structural and mechanical properties of human tendon, in vivo, in men and women. Scand J Med Sci Sports. 2008;18(1):23‐30.
  18. ↑ Kingma JJ, de Knikker R, Wittink HM, Takken T. Eccentric Overload Training in Patients with Chronic AT: A systematic review. Br J Sports Med. 2007;41(6):e3.
  19. ↑ Kraemer R, Lorenzen J, Vogt PM, Knobloch K. Systematic review about eccentric training in chronic achilles tendinopathy. Sportverletz Sportschaden. December. 2010;24(4):204‐11. [Article in German, Abstract translated]
  20. ↑ Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achille tendinopathy: a systematic review. Clinical Journal of Sport Medicine. 2009;19(1):54‐64.
  21. ↑ Meyer A, Tumility S &amp;amp;amp;amp; Baxter GD. Eccentric exercise protocols for chronic non‐insertional Achilles tendinopathy: how much is enough? Scandanavian Journal of Medicine and Science in Sports. 2009;19(5):609‐15.
  22. ↑ Wasielewski NJ &amp;amp;amp;amp; Kotsko KM. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review. Journal of Athletic Training. 2007;42(3):409‐21.
  23. ↑ Woodley BL, Newsham‐West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise. British Journal of Sports Medicine. 2007;41(4):188‐98;discussion 199.
  24. ↑ Malliaras, P., Barton, C., Reeves, N., & Langberg, H. (2013). Achilles and Patellar Tendinopathy Loading Programmes. Sports Medicine, 43(4), 267-286. doi: 10.1007/s40279-013-0019-z
  25. ↑ Backman LJ, Andersson G, Wennstig G, Forsgren S &amp;amp;amp; Danielson P. Endogenous substance P production in the Achilles tendon increases with loading in an in vivo model of tendinopathy ‐ peptidergic elevation preceding tendinosis‐like tissue changes. Journal of Musculoskeletal and Neuronal Interactions. 2011;11(2):133‐40.
  26. ↑ Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock‐wave treatment for mid‐portion Achilles tendinopathy: a randomized controlled trial. American Journal of Sports Medicine. 2009;37(3):463‐70.
  27. ↑ Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock‐wave treatment, or a wait and see policy for tendinopathy of the main body of tendo Achilles: a randomized controlled trial. American Journal of Sports Medicine. 2007;35(3):374‐83.
  28. ↑ Silbernagel K, Thomee P, Karlson J. Eccentric overload training for patients with chronic achilles tendinopathy ‐ a randomised controlled study with reliability testing of the evaluating methods. Scandanavian Journal of Medicine and Science in Sports. 2001;11:197‐206.
  29. ↑ Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using a pain‐monitoring model during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. American Journal of Sports Medicine. 2007;35(6):897‐906.
  30. ↑ Beyer, R., Kongsgaard, M., Hougs Kjaer, B., Ohlenschlaeger, T., Kjaer, M., & Magnusson, S. P. (2015). Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. Am J Sports Med. doi: 10.1177/0363546515584760
  31. ↑ Stevens, M., & Tan, C.-W. (2014). Effectiveness of the alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy, 44(2), 59-67.
  32. ↑ Yu, J., Park, D., & Lee, G. (2013). Effect of Eccentric Strengthening on Pain, Muscle Strength, Endurance, and Functional Fitness Factors in Male Patients with Achilles Tendinopathy. American Journal of Physical Medicine & Rehabilitation, 92(1), 68-76. doi: 10.1097/PHM.0b013e31826eda63
  33. ↑ 33.0 33.1 Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nature Reviews Rheumatology. 2010;6(5):262‐8.
  34. ↑ Bjordal J, Couppe C. Low Level Laser Therapy for Tendinopathy. Evidence of A Dose‐Response Pattern. Physical Therapy Reviews. 2001;6:91‐99.
  35. ↑ Bjordal JM, Lopes‐Martins RAB, Joensen J, Iversen VV. 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.
  36. ↑ 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.
  37. ↑ Tumilty S, Munn J, McDonough S, Hurley D A, Basford JR, Baxter GD. Low level laser treatment of tendinopathy: a systematic review with meta‐analysis Photomedicine and Laser Surgery. 2010;28(1):3–16.
  38. ↑ Bjordal, JM. A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with micro dialysis measurement of peritendinous prostaglandin E2 concentrations. British Journal of Sports Medicine. 2006;40(1):76–80.
  39. ↑ Darre E, Klokker M, Lund P. Laserbehandling af akillessenetendinit. Ugeskr Laeger.1994;156(45):6680‐3. Danish.
  40. ↑ Stergioula A, Stergioula M, Aarskog R, Lopes‐Martins RAB, Bjordal JM. 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. 2008;36(5):881–887.
  41. ↑ Tumilty S, Munn J, Abbott JH, McDonough S, Hurley DA, Baxter GD. Laser therapy in the treatment of Achilles tendinopathy: a pilot study. Photomedicine and Laser Surgery. 2008;26(1):25–30.
  42. ↑ Tumilty S, Munn J, Abbott JH, McDonough S, Hurley DA, Basford JR, Baxter G.D. Laser Therapy in the Treatment of Achilles Tendinopathy: A Randomised Controlled Trial. AIP Conf. Proc. May 31 2010;Volume 1226:163‐169.
  43. ↑ 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. doi: http://dx.doi.org/10.1016/j.apmr.2011.08.049
  44. ↑ Costa ML, Shepstone L, Donell ST, Thomas TL. Shock WaveTherapy for chronic Achilles tendon pain: a randomized placebo controlled trial. Clinical Orthopedics and Related Research. 2005;440:199‐204.
  45. ↑ Rompe J, Nafe B, Furia J. Eccentric loading, shock wave therapy or ‘wait and see’ policy for tendinopathy of the main body of tendo achillis: a randomized controlled trial. American Journal of Sports Medicine. 2007;35(3):374‐383.
  46. ↑ Rompe J, Furia J, Maffulli N. Eccentric loading vs eccentric loading plus shock wave treatment for mid‐portion Achilles tendinopathy. A randomized controlled trial. American Journal of Sports Medicine. 2009;37(3):463‐470.
  47. ↑ Rasmussen S, Christensen M, Mathiesen I, Simonson O. Shock wave therapy for chronic Achilles tendinopathy: a double‐blind, randomized clinical trial of efficacy. Acta Orthopaedica. 2008;79(2):249‐256.
  48. ↑ Lakshmanan P, O’Doherty D. Chronic Achilles tendinopathy: treatment with extra‐corporeal shock wave therapy. Foot and Ankle Surgery. 2004;10:125‐130.
  49. ↑ Al-Abbad, H., & Simon, J. V. (2013). The effectiveness of extracorporeal shock wave therapy on chronic achilles tendinopathy: a systematic review. Foot Ankle Int, 34(1), 33-41. doi: 10.1177/1071100712464354
  50. ↑ Neeter C, Thomee R, Silbernagel K, Thomee P, Karlson J. Iontophoresis with and without dexamethasone in the treatment of acute Achilles tendon pain. Scandinavian Journal of Medicine and Science in Sports. 2003;13(6):376‐382.
  51. ↑ Brown CD, Lauber CA. Evidence‐based guidelines for utilization of dexamethasone iontophoresis. International Journal of Athletic Therapy and Training. 2011;16(4):33‐36.
  52. ↑ Lee, J.-h., & Yoo, W.-g. (2012). Treatment of chronic Achilles tendon pain by Kinesio taping in an amateur badminton player. Physical Therapy in Sport, 13(2), 115-119. doi: http://dx.doi.org/10.1016/j.ptsp.2011.07.002
  53. ↑ 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
  54. ↑ 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.
  55. ↑ Scott, L., Munteanu, S., & 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
  56. ↑ 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
  57. ↑ 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.
  58. ↑ Scott, L., Munteanu, S., & 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
  59. ↑ 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.
  60. ↑ Petersen W, Welp R &amp;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.
  61. ↑ 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.
  62. ↑ 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.
  63. ↑ 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.
  64. ↑ 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.
  65. ↑ Fagan N, Staten P. An audit of self‐acupuncture in primary care. Acupunct Med. 2003;21:28‐31.

 

Acknowledgements[edit | edit source]

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.

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.

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