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]

Manual Therapy
[edit | edit source]

Joint mobs

Stage of pathology Acute Chronic
Clinical research evidence No Yes[1]
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]
2 CS[3][4]
Published expert opinion No Yes[5]
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[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]
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.

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

Stage of pathology Acute Chronic
Clinical research evidence Yes
2 SR

Yes
1 MA
5 RCT
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 Bfor 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 Bfor 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 Consider NOT using US in the chronic stage.


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

Stage of pathology Acute Chronic
Clinical research evidence No Yes
4 RCT
1 Cohort
Published expert opinion Yes Yes
Take home message There is expert opinion which suggests that SWT be reserved for chronic stage. There is conflicting evidence to support the use of SWT 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 SWT). There is also evidence that the use of anaesthetic required in high energy protocols decreases the 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 and radial SWT.
Clinical implication Consider NOT using Extracorporeal Shock Wave for the acute stage. Consider a trial of SWT 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. Advise patients that this is an experimental technique. SWT 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.

Iontophoresis using dexamethasone[edit | edit source]

Stage of pathology Acute Chronic
Clinical research evidence Yes
1 RCT
1 review
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.

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.
Clinical implication There is no evidence that anti‐inflammatory intervention with iontophoresis using dexamethasone has a useful role in the chronic stage Consider NOT using iontophoresis using dexamethasone in the chronic stage.

RCT ‐ Randomized controlled trial.

Taping[edit | edit source]

Stage of pathology Acute Chronic
Clinical research evidence No Yes
1 CS
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 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.

Orthotics[edit | edit source]

Stage of pathology Acute Chronic
Clinical research evidence Yes
2 CS
Yes
2 CS
1 RCT
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. Consider using orthotics – perhaps using taping first, in the acute stage.
Clinical implication There is a moderate amount of clinical evidence to support the use of orthotics in the chronic 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
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
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[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 tosupport 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[edit | edit source]

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:[edit | edit source]

  • 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.

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. Brosseau L, Casimiro L, Milne S. et al. Deep transverse friction massage for treating tendinitis. 2002. Cochrane Database Systematic Reviews. 4.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. Gaerdin A, Movin T, Svensson L & Shalabi A. The long‐term clinical and MRI results following eccentric calf muscle training in chronic Achilles tendinosis. Skeletal Radiology. 2010;39(5):435‐42.
  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 midportion 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 by MRI. 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 with exercise 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 tendon function 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.

 

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.