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Objective
To assess the effectiveness of physiotherapy interventions (non-surgical and non-pharmacological) for a chronic mid-body Achilles tendinopathy.
Materials and methods
A search of published and grey literature databases was undertaken (January 1999 to January 2011). Two reviewers independently assessed the studies for eligibility using a strict inclusion and exclusion criteria. All eligible articles were assessed critically using the PEDro score. Data on cohort characteristics, diagnostic criteria, treatment intervention, outcome measures, and results were extracted. A narrative research synthesis method was adopted since there were insufficient data to conduct a meta-analysis.
Results
Two hundred and ninety studies were identified. Nine publications met the review inclusion criteria. Methodological quality was adequate for all nine studies; however, blinding was a limitation for most. Interventions investigated were; exercises (n = 2), low-level laser therapy (n = 1), low-energy shockwave treatment (SWT) (n = 3), air cast brace (n = 2), and insoles (n = 1). Some evidence exists for eccentric exercises in combination with SWT or laser. In contrast to other reviews, eccentric exercises alone were not found to be superior to other physiotherapy treatments.
Conclusion
There is an insufficient evidence to determine which method of physiotherapy is most appropriate for a chronic mid-body Achilles tendinopathy. Further well-designed randomized controlled trials assessing physiotherapy interventions with specific diagnostic criteria and appropriate outcome tools are required to determine the efficacy of physiotherapy for the condition.
INTRODUCTION
This study investigated the effectiveness of two physical therapy interventions for treating chronic insertional Achilles tendinosis (within 2 cm from insertion). Previous studies have found eccentric training to be effective in treating mid-portion Achilles tendinosis (2-6 cm) among athletic persons but are inconclusive for populations with the tendinosis at the insertion or with other dmeographics. This study not only examined the effectiveness of physical therapy intervention, whether eccentric training or conventional, but also the characteristics of patients who had successful outcomes.
METHODS
The study used a single-blinded, randomized experimental design conducted at an outpatient orthopedic clinic. All study participants experienced symptoms within 2 cm of the Achilles insertion > three months. The control group underwent 12 weeks of conventional physical therapy that involved stretching, heel lifts, night splints, and cryotherapy, whereas the experimental group performed eccentric strengthening of the Achilles tendon in addition to the control group’s treatment. Physicians, blinded to the intervention assigned to subjects, collected patient outcome scores on pain (Visual Analog Scale) and function (Foot Ankle Outcome Questionnaire & Short Form-36) at initial evaluation, six weeks, and 12 weeks. Within each protocol, the difference between initial and follow-up outcome scores were compared using Wilcoxon signed ranks tests and between the two protocols, the Mann-Whitney was used. Chi-squares and Spearman’s rho were used to assess patient characteristics.
RESULTS
Fifty-eight patients enrolled in the study, 32 completed the study--15 in the eccentric group and 17 in the traditional group. Overall, there were significant differences (p<0.05) on all measurements for both groups between baseline and 12 weeks. However, there were no significant differences in outcomes between protocols, but a significant higher rate for non-completion of the eccentric protocol among obese subjects (BMI> 30). No statistically significant differences in outcomes were found by age, BMI, duration of symptoms, or prior level of activity. However, persons with a self-reported history of osteoarthritis were statistically significant less likely to report decreased pain and improved function (SF-36). Subjects who reported history of migraines were less likely to experience a decrease in pain (VAS) or improvement in total function (SF-36). Subjects with self reported diabetes were less likely to improve in function (SF-36), and males less likely than females to report decrease in pain per VAS. There was no variable in which subjects failed to improve at a statistically significant level across all scales.
DISCUSSION AND CONCLUSION
Physical therapy intervention that comprises a combination of stretching, heel lifts, night splint, and cryotherapy is an effective treatment for insertional Achilles tendinosis. Physicians may observe slower or less improvement among patients with a history of osteoarthritis, migraines, or diabetes, but it is not unreasonable to still expect both decreased pain and improved function. Patients who are obese also improve, but might need more encouragement to complete the intervention, especially if it includes eccentric training.
Physical therapies for Achilles tendinopathy: systematic review and meta-analysis
Samuel P Sussmilch-Leitch, Natalie J Collins, Andrea E Bialocerkowski, Stuart J Warden and Kay M Crossley Journal of Foot and Ankle Research 2012, 5:15
Quote:
Achilles tendinopathy (AT) is a common condition, causing considerable morbidity in athletes and non-athletes alike. Conservative or physical therapies are accepted as the first line approach for management of AT. Despite a growing volume of research in AT, there remains a lack of high quality studies evaluating their efficacy. Previous systematic reviews provide preliminary evidence for non-surgical interventions for AT, but lack key quality components as outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement. This study aims to conduct a systematic review and meta-analysis (where possible) of the evidence for physical therapies for AT management. A comprehensive strategy was used to search 11 electronic databases from inception to September 13th 2011. Search terms included Achilles, tendinopathy, pain, physical therapies, electrotherapy and exercise (English language full-text publications, human studies). Reference lists of eligible papers were hand-searched. Randomised controlled trials (RCTs) were included if they evaluated at least one non-pharmacological, non-surgical intervention for AT using at least one outcome of pain and/or function. Two independent reviewers screened 2852 search results, identifying 23 suitable studies. Two independent reviewers assessed methodological quality and risk of bias using a modified PEDro scale. One reviewer extracted study characteristics and data for effect size calculations. Methodological quality ranged from 2 to 12 (/14). Four studies were excluded due to high risk of bias, leaving 19 studies. Evidence from meta-analyses supports the use of shock wave therapy (SWT) for outcomes of pain and function (standardised mean difference -0.46, 95% confidence interval -0.88 to -0.04) and pain (-0.50, -0.90 to -0.10) at 16 weeks, and laser therapy (LT) with eccentric exercise at 12 weeks (-0.51, -0.95 to -0.06), but did not support the addition of night splints to eccentric exercise. Effect sizes from individual studies support the use of eccentric exercise, while limited evidence suggests microcurrent therapy to be an effective intervention. Practitioners should consider SWT and LT as initial interventions for AT, in conjunction with eccentric exercise. Further high-quality RCTs following CONSORT guidelines are required to establish the efficacy of other physical therapies and determine optimal clinical pathways for AT.
Conservative Management of Midportion Achilles Tendinopathy: A Mixed Methods Study, Integrating Systematic Review and Clinical Reasoning.
Rowe V, Hemmings S, Barton C, Malliaras P, Maffulli N, Morrissey D. Sports Med. 2012 Sep 24.
Quote:
Background: Clinicians manage midportion Achilles tendinopathy (AT) using complex clinical reasoning underpinned by a rapidly developing evidence base. Objectives: The objectives of the study were to develop an inclusive, accessible review of the literature in combination with an account of expert therapists' related clinical reasoning to guide clinical practice and future research.
Methods: Searches of the electronic databases, PubMed, ISI Web of Science, PEDro, CINAHL, EMBASE, and Google Scholar were conducted for all papers published from inception to November 2011. Reference lists and citing articles were searched for further relevant articles. Inclusion required studies to evaluate the effectiveness of any conservative intervention for midportion AT. Exclusion criteria included in vitro, animal and cadaver studies and tendinopathies in other locations (e.g. patella, supraspinatus). From a total of 3497 identified in the initial search, 47 studies fulfilled the inclusion criteria. Studies were scored according to the PEDro scale, with a score of ≥8/10 considered of excellent quality, 5-7/10 good, and ≤4/10 poor. The strength of evidence supporting each treatment modality was then rated as 'strong', 'moderate', 'limited', 'conflicting' or 'no evidence' according to the number and quality of articles supporting that modality. Additionally, semi-structured interviews were conducted with physiotherapists to explore clinical reasoning related to the use of various interventions with and without an evidence base, and their perceptions of available evidence.
Results: Evidence was strong for eccentric loading exercises and extracorporeal shockwave therapy; moderate for splinting/bracing, active rest, low-level laser therapy and concentric exercises (i.e. inferior to eccentric exercise). In-shoe foot orthoses and therapeutic ultrasound had limited evidence. There was conflicting evidence for topical glycerin trinitrate. Taping techniques and soft-tissue mobilization were not yet examined but featured in case studies and in the interview data. Framework analysis of interview transcripts yielded multiple themes relating to physiotherapists' clinical reasoning and perceptions of the evidence, including the difficulty in causing pain while treating the condition and the need to vary research protocols for specific client groups - such as those with the metabolic syndrome as a likely etiological factor. Physiotherapists were commonly applying the modality with the strongest evidence base, eccentric loading exercises. Barriers to research being translated into practice identified included the lack of consistency of outcome measures, excessive stringency of some authoritative reviews and difficulty in accessing primary research reports. The broad inclusion criteria meant some lower quality studies were included in this review. However, this was deliberate to ensure that all available research evidence for the management of midportion AT, and all studies were evaluated using the PEDro scale to compensate for the lack of stringent inclusion criteria.
Conclusion: Graded evidence combined with qualitative analysis of clinical reasoning produced a novel and clinically applicable guide to conservative management of midportion AT. This guide will be useful to novice clinicians learning how to manage this treatment-resistant condition and to expert clinicians reviewing their evidence-based practice and developing their clinical reasoning. Important areas requiring future research were identified including the effectiveness of orthoses, the effectiveness of manual therapy, etiological factors, optimal application of loading related to stage of presentation and how to optimize protocols for different types of patients such as the older patient with the metabolic syndrome as opposed to the athletically active.
Purpose
Systematically search and analyse the results of surgical and non-surgical treatments for insertional Achilles tendinopathy.
Methods
A structured systematic review of the literature was performed to identify surgical and non-surgical therapeutic studies reporting on ten or more adults with insertional Achilles tendinopathy. MEDLINE, CINAHL, EMBASE (Classic) and the Cochrane database of controlled trials (1945–March 2011) were searched. The Coleman methodology score was used to assess the quality of included articles, and these were analysed with an emphasis on change in pain score, patient satisfaction and complication rate.
Results
Of 451 reviewed abstracts, 14 trials met our inclusion criteria evaluating 452 procedures in 433 patients. Five surgical techniques were evaluated; all had a good patient satisfaction (avg. 89 %). The complication ratio differed substantially between techniques. Two studies analysed injections showing significant decrease in visual analogue scale (VAS). Eccentric exercises showed a significant decrease in VAS, but a large group of patients was unsatisfied. Extracorporeal shockwave therapy (ESWT) was superior to both wait-and-see and an eccentric training regime. One study evaluated laser CO2, TECAR and cryoultrasound, all with significant decrease in VAS.
Conclusions
Despite differences in outcome and complication ratio, the patient satisfaction is high in all surgical studies. It is not possible to draw conclusions regarding the best surgical treatment for insertional Achilles tendinopathy. ESWT seems effective in patients with non-calcified insertional Achilles tendinopathy. Although both eccentric exercises resulted in a decrease in VAS score, full range of motion eccentric exercises shows a low patient satisfaction compared to floor level exercises and other conservative treatment modalities.
Tendons transmit force between muscles and bones and, when stretched, store elastic energy that contributes to movement.(1) The tendinous portion of the gastrocnemius and soleus muscles merge to form the Achilles tendon, which is the largest and strongest in the body, but one of the most frequently injured.(2,3) Conservative management options for chronic Achilles tendinopathy include eccentric (lengthening) exercises, extracorporeal shockwave therapy (ESWT), topical nitroglycerin, low level laser therapy, orthoses, splints or injections (e.g. corticosteroids, hyperosmolar dextrose, polidocanol, platelet-rich plasma), while a minority of patients require surgery (using open, percutaneous or endoscopic methods).(4-8) Here we assess the management options for patients with chronic Achilles tendinopathy (lasting over 6 weeks).
Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning.
Rowe V, Hemmings S, Barton C, Malliaras P, Maffulli N, Morrissey D. Sports Med. 2012 Nov 1;42(11):941-67.
Quote:
BACKGROUND:
Clinicians manage midportion Achilles tendinopathy (AT) using complex clinical reasoning underpinned by a rapidly developing evidence base.
OBJECTIVES:
The objectives of the study were to develop an inclusive, accessible review of the literature in combination with an account of expert therapists' related clinical reasoning to guide clinical practice and future research.
METHODS:
Searches of the electronic databases, PubMed, ISI Web of Science, PEDro, CINAHL, EMBASE, and Google Scholar were conducted for all papers published from inception to November 2011. Reference lists and citing articles were searched for further relevant articles. Inclusion required studies to evaluate the effectiveness of any conservative intervention for midportion AT. Exclusion criteria included in vitro, animal and cadaver studies and tendinopathies in other locations (e.g. patella, supraspinatus). From a total of 3497 identified in the initial search, 47 studies fulfilled the inclusion criteria. Studies were scored according to the PEDro scale, with a score of ≥ 8/10 considered of excellent quality, 5-7/10 good, and ≤ 4/10 poor. The strength of evidence supporting each treatment modality was then rated as 'strong', 'moderate', 'limited', 'conflicting' or 'no evidence' according to the number and quality of articles supporting that modality. Additionally, semi-structured interviews were conducted with physiotherapists to explore clinical reasoning related to the use of various interventions with and without an evidence base, and their perceptions of available evidence.
RESULTS:
Evidence was strong for eccentric loading exercises and extracorporeal shockwave therapy; moderate for splinting/bracing, active rest, low-level laser therapy and concentric exercises (i.e. inferior to eccentric exercise). In-shoe foot orthoses and therapeutic ultrasound had limited evidence. There was conflicting evidence for topical glycerin trinitrate. Taping techniques and soft-tissue mobilization were not yet examined but featured in case studies and in the interview data. Framework analysis of interview transcripts yielded multiple themes relating to physiotherapists' clinical reasoning and perceptions of the evidence, including the difficulty in causing pain while treating the condition and the need to vary research protocols for specific client groups--such as those with the metabolic syndrome as a likely etiological factor. Physiotherapists were commonly applying the modality with the strongest evidence base, eccentric loading exercises. Barriers to research being translated into practice identified included the lack of consistency of outcome measures, excessive stringency of some authoritative reviews and difficulty in accessing primary research reports. The broad inclusion criteria meant some lower quality studies were included in this review. However, this was deliberate to ensure that all available research evidence for the management of midportion AT, and all studies were evaluated using the PEDro scale to compensate for the lack of stringent inclusion criteria.
CONCLUSION:
Graded evidence combined with qualitative analysis of clinical reasoning produced a novel and clinically applicable guide to conservative management of midportion AT. This guide will be useful to novice clinicians learning how to manage this treatment-resistant condition and to expert clinicians reviewing their evidence-based practice and developing their clinical reasoning. Important areas requiring future research were identified including the effectiveness of orthoses, the effectiveness of manual therapy, etiological factors, optimal application of loading related to stage of presentation and how to optimize protocols for different types of patients such as the older patient with the metabolic syndrome as opposed to the athletically active.
Introduction
Achilles and patellar tendinopathy are overuse injuries that are common among athletes. Isolated eccentric muscle training has become the dominant conservative management strategy for Achilles and patellar tendinopathy but, in some cases, up to 45 % of patients may not respond. Eccentric-concentric progressing to eccentric (Silbernagel combined) and eccentric-concentric isotonic (heavy-slow resistance; HSR) loading have also been investigated. In order for clinicians to make informed decisions, they need to be aware of the loading options and comparative evidence. The mechanisms of loading also need to be elucidated in order to focus treatment to patient deficits and refine loading programmes in future studies.
Objectives
The objectives of this review are to evaluate the evidence in studies that compare two or more loading programmes in Achilles and patellar tendinopathy, and to review the non-clinical outcomes (potential mechanisms), such as improved imaging outcomes, associated with clinical outcomes.
Methods
Comprehensive searching (MEDLINE, EMBASE, CINAHL, Current Contents and SPORTDiscus™) identified 403 studies. Two authors independently reviewed studies for inclusion and quality. The final yield included 32 studies; ten compared loading programmes and 28 investigated at least one potential mechanism (six studies compared loading programmes and investigated potential mechanisms).
Results
This review has identified limited (Achilles) and conflicting (patellar) evidence that clinical outcomes are superior with eccentric loading compared with other loading programmes, questioning the currently entrenched clinical approach to these injuries. There is equivalent evidence for Silbernagel combined (Achilles) and greater evidence for HSR loading (patellar). The only potential mechanism that was consistently associated with improved clinical outcomes in both Achilles and patellar tendon rehabilitation was improved neuromuscular performance (e.g. torque, work, endurance), and Silbernagel-combined (Achilles) HSR loading (patellar) had an equivalent or higher level of evidence than isolated eccentric loading. In the Achilles tendon, a majority of studies did not find an association between improved imaging (e.g. reduced anteroposterior diameter, proportion of tendons with Doppler signal) and clinical outcomes, including all high-quality studies. In contrast, HSR loading in the patellar tendon was associated with reduced Doppler area and anteroposterior diameter, as well as greater evidence of collagen turnover, and this was not seen following eccentric loading. HSR seems more likely to lead to tendon adaptation and warrants further investigation. Improved jump performance was associated with Achilles but not patellar tendon clinical outcomes. The mechanisms associated with clinical benefit may vary between loading interventions and tendons.
Conclusion
There is little clinical or mechanistic evidence for isolating the eccentric component, although it should be made clear that there is a paucity of good quality evidence and several potential mechanisms have not been investigated, such as neural adaptation and central nervous system changes (e.g. cortical reorganization). Clinicians should consider eccentric-concentric loading alongside or instead of eccentric loading in Achilles and patellar tendinopathy. Good-quality studies comparing loading programmes and evaluating clinical and mechanistic outcomes are needed in both Achilles and patellar tendinopathy rehabilitation.
Intense pulsed light treatment of chronic mid-body Achilles tendinopathy
A double blind randomised placebo-controlled trial
A. M. Hutchison, et al Bone Joint J April 2013 vol. 95-B no. 4 504-509
Quote:
We conducted a randomised controlled trial to determine whether active intense pulsed light (IPL) is an effective treatment for patients with chronic mid-body Achilles tendinopathy. A total of 47 patients were randomly assigned to three weekly therapeutic or placebo IPL treatments. The primary outcome measure was the Victorian Institute of Sport Assessment – Achilles (VISA-A) score. Secondary outcomes were a visual analogue scale for pain (VAS) and the Lower Extremity Functional Scale (LEFS). Outcomes were recorded at baseline, six weeks and 12 weeks following treatment. Ultrasound assessment of the thickness of the tendon and neovascularisation were also recorded before and after treatment.
There was no significant difference between the groups for any of the outcome scores or ultrasound measurements by 12 weeks, showing no measurable benefit from treatment with IPL in patients with Achilles tendinopathy.
Physical therapy for achilles tendinopathy
Horsepower is how fast you hit the wall, Torque is how far you move it
Hybrid Mode
