Achilles Tendinopathy Toolkit: Section C - Summary of Evidence and Recommendations for Interventions
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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]
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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 |
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.
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).
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. |
Therapeutic 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
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]
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | Yes
1 CPG |
Yes
1 CPG 1 SR 2 Other* |
| 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]
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | Yes
1 CPG 1 Other* |
Yes
1 CPG 2 SR 2 RCT 6 Other*
|
| 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]
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | No
1 CPG |
Yes
1 CPG 2 SR 3 RCT 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]
| State of Pathology |
|
Chronic |
|---|---|---|
| Clinical research evidence | No
1 CPG |
Yes
1 CPG 1 SR 3 RCT |
| 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]
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | No | Yes 1 CPG 2 RCT 2 Other* |
| 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]
Acupuncture (trasitional Chinese medicine, anatomical, electrical) and intramuscular stimulation.
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | No |
Yes 1 RCT |
| 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
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 Main Achilles Tendinopathy Toolkit page
- Click to go back to Section A - Clinical Evaluation
- Click to go back to Section B - Outcome Measures
- Click to continue to Section D - Exercise Programs
- Click to continue to Section E - Low Level Laser Therapy Dosage Calculation
- Click to continue to Section F - 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]
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.
