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

Manual Therapy

Joint mobs
Stage of pathology	Acute	Chronic
Clinical research evidence	No	Yes
Published expert opinion	Yes	Yes
Take home message	There is no clinical evidence but there is expert level consensus to support	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 2 CS
Published expert opinion	No	Yes
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 <u>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.

CS ‐ Case studies; SR ‐ Systematic reviews.

Exercise

Stage of pathology	Acute	Chronic
Clinical research evidence	No	Yes 14 OS 6 SR 5 RCT
Published expert opinion	Yes	Yes
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.
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 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. See Appendix A for further details on exercise prescription.

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

Ultrasound (US)

CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews

Extracorporeal shock wave therapy (SWT)

CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews

Iontophoresis using dexamethasone

CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews

Taping

CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews

Orthotics

CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews

Night splints and braces

CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews

Heel raise inserts

CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews

Needling techniques

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

CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews

Outcome measures

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
  • Available at: http://www.physther.net/content/79/4/371/F1.large.jpg
• Detailed questionnaire, specific to Achilles tendinopathy e.g. the VISA‐A questionnaire
  • Available at: http://bjsm.bmj.com/content/suppl/2001/11/09/35.5.335.DC1/01055_Fig_1_data_supplement.pdf 
  • 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

• 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.
  

References

References will automatically be added here, see adding references tutorial.

 

Acknowledgements

Developed by the BC Physical Therapy Tendinopathy Task Force: Dr. Joseph Anthony, Allison Ezzat, Diana Hughes, JR Justesen, Dr. Alex Scott, Michael Yates, Alison Hoens.

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.