Achilles Tendinopathy Toolkit: Section C - Summary of Evidence and Recommendations for Interventions
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]
- Click to go back to the contents page
- Click to go back to the Treatment Algorithm
- Click to continue to Appendix A: Exercise Programs
- Click to continue to Appendix B: Low Level Laser Therapy Dosage Calculation
- Click to continue to: Appendix C: Details of Articles on Interventions
- Click to continue to: Appendix D: Medical and Surgical Interventions
Load Management[edit | edit source]
| State of pathology | Acute | Chronic |
|---|---|---|
| Clinical Research Evidence | No | Yes
2 CPG 1 RCT |
| Published Expert Opinion | Yes
2 CPG |
Yes |
| Take Home Message | Expert opinion 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 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 |
Manual Therapy[edit | edit source]
|
Joint mobs | ||
|---|---|---|
| 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 1 RCT 1 Other* |
| 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. |
| 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).
Exercise[edit | edit source]
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | No | Yes 9 SR 1 RCT |
| Published expert opinion | Yes[1] | Yes[1] |
| 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.
Low level laser therapy (LLLT)[edit | edit source]
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | Yes 2 Other |
Yes 1 MA 8 RCT 3 Other |
| 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 '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.
If Class III, may consider a tial of LLT in the chronic stage at 450J _ 520J per treatment over the whole tendon. |
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). | 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]
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | No | Yes 2 CPG 1 MA 1 SR 1 Other* |
| 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 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
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]
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | Yes 2 CPG 1 RCT |
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 thqt qn |
| 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. |
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]
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | Yes | Yes
|
| 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 [2][3] |
Yes 3 CS [4][5][6] 2 RCT[7][8] 1 SR [9] |
| 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; SR - Systematic Review
Night splints and braces[edit | edit source]
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | No | Yes 3 RCT[10][11][12] 1 SR [13] |
| 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 in conjunction with eccentric exercise. |
| 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 in conjunction with exercise. |
RCT ‐ Randomized controlled trials; SR - Systematic Review
Heel raise inserts[edit | edit source]
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | No | Yes 2 RCT[14][15] |
| 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[16][17][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.
- Click to go back to the contents page
- Click to go back to the Treatment Algorithm
- Click to continue to Appendix A: Exercise Programs
- Click to continue to Appendix B: Low Level Laser Therapy Dosage Calculation
- Click to continue to: Appendix C: Details of Articles on Interventions
- Click to continue to: Appendix D: Medical and Surgical Interventions
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: |
| B. Patient specific functional outcome measure |
Such as:
|
- Click to go back to the contents page
- Click to go back to the Treatment Algorithm
- Click to continue to Appendix A: Exercise Programs
- Click to continue to Appendix B: Low Level Laser Therapy Dosage Calculation
- Click to continue to: Appendix C: Details of Articles on Interventions
- Click to continue to: Appendix D: Medical and Surgical Interventions
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. |
- Click to go back to the contents page
- Click to go back to the Treatment Algorithm
- Click to continue to Appendix A: Exercise Programs
- Click to continue to Appendix B: Low Level Laser Therapy Dosage Calculation
- Click to continue to: Appendix C: Details of Articles on Interventions
- Click to continue to: Appendix D: Medical and Surgical Interventions
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.
- ↑ 1.0 1.1 Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nature Reviews Rheumatology. 2010;6(5):262‐8.
- ↑ Gross ML, Davlin L, Evanski PM. (1991). Effectiveness of orthotic shoe inserts in the long-distance runner. Am J Sports Med. 19: 409–412.
- ↑ Greene BL. (2002). Physical therapist management of fluoroquinolone-induced Achilles tendinopathy. Phys Ther. 82(12): 1224-31.
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ Munteanu, S. E., Scott, L. A., Bonanno, D. R., Landorf, K. B., Pizzari, T., Cook, J. L., & 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
- ↑ 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
- ↑ 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.
- ↑ Petersen W, Welp R & 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.
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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. 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.
