Sports Focus Team Evidence-Based Treatment of Achilles Tendinitis Insertional vs Non-Insertional

Team Members Eric Williams Barbara Edwards Hung Do

Achilles Tendinopathy McShane et al. states that achilles tendinopathy is generally caused by chronic stress to the tendon. Ultrasound imaging can help identify the abnormal portion of tendon. Khan et al. and Maffulli et al. popularized the term achilles tendinopathy to describe the triad of tendon pain, swelling, and impaired performance.

Achilles Tendinopathy Cain et. classifies achilles tendinopathy as insertional and mid-substance (non-insertional). Insertional – within 2 cm of its insertion. Mid-substance – 2-6 cm proximal to its insertion.

Achilles Tendinopathy Maffulli et al used the term “tendinopathy” when referring to diagnosis for pain, swelling and impaired performance. They reserved more specific terms including tendonitis for cases when inflammation or degeneration has been confirmed.

Review of Literature There were several level II and III studies comparing other treatment options ie, shockwave therapy, corticosteriods, heel lifts, iontophoresis, night splints, cross friction massage, ultrasound, and eccentric exercises.

Review of Literature There were just as many Level I studies comparing several treatment options. Double blind study of the effects of heel pad on tendinitis. Randomized study comparing eccentric training, air heel brace and combo of both.

Review of Literature A randomized controlled trial comparing shockwave treatment with eccentric loading. Randomized Placebo – Controlled Trial: Shock Wave Therapy for chronic Achilles tendon pain.

Treatment Comparisons Air Heel Brace Heel Pads/Splints ShockWave Therapy Eccentric Exercises

Anatomy of the Achilles Tendon Origin of the Achilles is the thick extension of 3 muscles in the lower leg. Gastrocnemius Soleus Plantaris Achilles tendon is the thickest and strongest tendon in the body 15 cm long

Anatomy of the Achilles Tendon AT begins near the middle of the calf muscle Insertion – middle part of the posterior surface of the calcaneus. The small saphenous vein is located on the lateral side of the Achilles but is superficial to it. Muscle reflex tests the integrity of the S1 spinal root.

Injuries of the Achilles Tendon

AirHeel Brace

Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation. Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation. Knobloch K, Schreibmueller L, Longo UG, Vogt PM. Disabil Rehabil. 2008;30(20-22): Purpose – To compare eccentric training and the combination of eccentric training with the AirHeel Brace for the management of tendinopathy of the main body of the Achilles tendon Methods – 116 with unilateral tendonitis of the main body (non-insertional) were randomized in two groups.

Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation. Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation. Knobloch K, Schreibmueller L, Longo UG, Vogt PM. Disabil Rehabil. 2008;30(20-22): Group A – performed eccentric training w/AirHeel Brace. Group B – performed the same eccentric training w/o the AirHeel Brace Test the null Hypothesis that patients w/tendonitis in the main body of the Achilles tendon there is no difference in clinical outcome and micro-vascular parameters.

Results The FAOS score and the VAS score showed significant improvements from pre-operative to post-operative values in both groups (A 5.1 +/- 2 vs /- 2.4, 43% reduction and B: 5.4 +/- 2.1 vs /- 2.4, 33% reduction, both p = ). There were no statistically significant differences in FAOS score and VAS score when comparing the two groups after the end of the intervention. In Group A, tendon oxygen saturation in the main body of the Achilles tendon showed significant increase from pre- to post- management values (68 +/- 12 vs.74 +/- 8%, p = 0.003). Post- capillary venous filling pressures showed significant reduction from pre- to post-intervention values.

Chronic Achilles tendinopathy: a prospective randomized study comparing the therapeutic effect of eccentric training, the AirHeel brace, and a combination of both. Petersen W, Welp R, Rosenbaum D. Am J Sports Med Oct;35(10): Epub 2007 Jun 14. Petersen WWelp RRosenbaum D Purpose – To evaluate 3 different treatment protocols for chronic mid-portion tendinopathy of the Achilles tendon. Method – One hundred patients were randomly assigned to 1 of 3 different treatment groups. Group 1 – Eccentric Training (37 patients) Group 2 – AirHeel Brace (35 patients) Group 3 – Combination of eccentric training and the AirHeel Brace. (28 patients)

Eccentric Exercises Eccentric training. From an upright body position and standing with the whole body weight on the forefoot, with the ankle joint in plantar flexion (A), the calf muscles were loaded by lowering the heel (B). Two types of exercises were used. The calf muscle was eccentrically loaded both with the knee straight (C) and, to maximize the activation of the soleus muscle, with the knee slightly bent.

Results VAS score for pain, AOFAS score, and SF-36 improved significantly in all 3 groups at all 3 follow-up exams. At the 3 time points of 6,12, and 54 weeks of follow-up, there was no significant difference between all 3 treatments

Heel Pads

The effect of heel pads on the treatment of Achilles tendinitis: a double blind trial. Lowdon A, Bader DL, Mowat AG. Am J Sports Med Nov-Dec;12(6): Lowdon ABader DLMowat AG Purpose - To investigate the efficacy of heel pads in the treatment of Achilles tendonitis. Methods – 33 patients (26 male, 13 female), ages 11 to 51, were randomly allocated to one of three treatment groups.

The effect of heel pads on the treatment of Achilles tendinitis: a double blind trial. Lowdon A, Bader DL, Mowat AG. Am J Sports Med Nov-Dec;12(6): Lowdon ABader DLMowat AG Group I – was provided w/Sorbothane heel pads to be worn in all sports and walking for 2 months. Group II – was provided with soft sponge rubber pads of “Molefoam.” Group III – received no pads. Pt’s in all 3 groups received five consecutive daily 5 min. ultrasound treatments (0.75 MHz, pulsed 1:1, w/coupling gel).

Results Patients in Group III (ultrasound and exercise) had the most significant difference in the reduction of both swelling and tenderness. The study revealed that pt’s with relatively short duration of injury were more likely to experience changes in gait parameters of interest.

Night Splints

The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. de Vos RJ, Weir A, Visser RJ, de Winter T, Tol JL. Br J Sports Med Jul;41(7):e5. Epub 2006 Dec 18. de Vos RJWeir AVisser RJde Winter TTol JL Purpose - To assess whether the use of night splints is of added benefit on functional outcomes in treating chronic mid-portion Achilles tendonitis. 70 tendons were included and randomized into two groups. Group A – Eccentric exercise w/ a night splint (n=36) Group B – Eccentric exercise only (n=34).

The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. de Vos RJ, Weir A, Visser RJ, de Winter T, Tol JL. Br J Sports Med Jul;41(7):e5. Epub 2006 Dec 18. de Vos RJWeir AVisser RJde Winter TTol JL Both groups completed a 12 week heavy load eccentric training program w/ group A also receiving a night splint to wear at night. Inclusion – age years, active in sports, and tendon pain localized at 2 - 7cm from distal insertion. Exclusion – insertional disorders, partial or complete ruptures or systemic illness.

Results At 12 weeks, pt satisfaction in the eccentric group was 63% compared w/ 48% in the night splint group. The VISA-A score in both groups improved and were not significantly different between the two nor in the pt’s satisfaction score. Night splints with eccentric training is not beneficial at short term follow-up. Further research trials needed.

Shock WaveTherapy

Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy. A randomized, controlled trial. Rompe JD, Furia J, Maffulli N. J Bone Joint Surg Am Jan;90(1): Rompe JDFuria JMaffulli N METHODS: Fifty patients with chronic (six months or more) recalcitrant insertional Achilles tendinopathy were enrolled in a randomized, controlled study. All patients had received treatment, including local injections of an anesthetic and/or corticosteroids, a prescription of nonsteroidal anti-inflammatory drugs, and physiotherapy, without success for at least three months. Group I – 25 patients were allocated to receive eccentric calf strengthening exercises. Group II – 25 patients were allocated to treatment with repetitive low-energy shock wave therapy.

Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy. A randomized, controlled trial. Rompe JD, Furia J, Maffulli N. J Bone Joint Surg Am Jan;90(1): Rompe JDFuria JMaffulli N Primary follow-up was at four months, and afterward patients were allowed to cross over. The last follow-up evaluation was at one year after completion of the initial treatment. The patients were assessed for pain, function, and activity with use of a validated questionnaire (the Victorian Institute of Sport Assessment- Achilles [VISA-A] questionnaire).

Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy. A randomized, controlled trial. Rompe JD, Furia J, Maffulli N. J Bone Joint Surg Am Jan;90(1): Rompe JDFuria JMaffulli N RESULTS: At 4 months from baseline, the VISA-A score increased in both groups, from 50 to 73 points in group 1 (eccentric loading) and from 51 to 87 points in group 2 (eccentric loading plus shock- wave treatment). Pain rating decreased in both groups, from 7 to 4 points in group 1 and from 7 to 2 points in group 2. Nineteen of 34 patients in group 1 (56%) and 28 of 34 patients in group 2 (82%) reported a Likert scale of 1 or 2 points ("completely recovered" or "much improved"). For all outcome measures, groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up. At 1 year from baseline, there was no difference any longer, with 15 failed patients of group 1 opting for having the combined therapy as cross- over and with 6 failed patients of group 2 having undergone surgery.

Eccentric Exercises

Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc Sep;11(5): Epub 2003 Aug 26. Fahlström M, Jonsson P, Lorentzon R, Alfredson H. Fahlström MJonsson PLorentzon RAlfredson H Purpose - The aim of this prospective study was to investigate if the previously achieved good clinical results could be reproduced in a larger group of patients, and also to investigate the effects of eccentric calf- muscle training in patients with chronic insertional Achilles tendon pain. Methods – 78 Patients with chronic painful Achilles tendinosis at the mid-portion (2-6 cm) in a total of 101 tendons (55 unilateral and 23 bilateral), and 30 with chronic insertional Achilles tendon pain in 31 tendons (29 unilateral and one bilateral) were treated with eccentric calf-muscle training for 12 weeks.

Eccentric Training Model

Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc Sep;11(5): Epub 2003 Aug 26. Fahlström M, Jonsson P, Lorentzon R, Alfredson H. Fahlström MJonsson PLorentzon RAlfredson H Results 90 of the 101 Achilles tendons (89%) with chronic painful non-insertional Achilles tendinosis improved after the 12-week training program. 10/31 tendons (32%) with chronic painful insertional Achilles tendinosis improved with 12 week program.

Conclusion In the majority of the studies we researched comparing eccentric training with other forms of treatments, it was agreed that eccentric training was the most effective treatment for insertional and non-insertional Achilles tendonitis Shockwave therapy was effective but it is not being used in the U.S.A. for Achilles tendonitis.

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