Achilles Tendinopathy Toolkit Summary of Interventions

Achilles Tendinopathy Toolkit: Summary of 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.
Related online courses on +Physioplus
Online Course: Managing Tendon Pain Programme
Online Course: Tendinopathy Assessment
Online Course: Tendinopathy
Achilles Tendinopathy (mid-substance): Summary of the Evidence for Physical Therapy Interventions
 Click to go back to the contents page

 Click to go back to the Treatment Algorithm
 Click to continue to Appendix A: Exercise Programs
 Click to continue to Appendix B: Low Level Laser Therapy Dosage Calculation
 Click to continue to: Appendix C: Details of Articles on Interventions
 Click to continue to: Appendix D: Medical and Surgical Interventions
Manual Therapy
Joint mobs
Stage of Acute Chronic

pathology
Clinical No Yes
research 1CS[1]
evidence
Published Yes[2] Yes[2]
expert opinion
Take home There is no clinical evidence but there is expert level consensus There is a small am
message to support the use of joint mobilizations in the acute stage if consensus to supp
assessment reveals joint restriction. if assessment reve
Clinical May consider using manual therapy in the acute stage after undertaking a May consider u
implication comprehensive biomechanical evaluation of the ‐ Joint mobs hip, knee, after undert
foot and ankle. evaluation of the h
Soft-tissue techniques

pathology
Clinical No Yes
research 1
evidence 2 CS[4][5]
Published No Yes[2]
expert opinion
Take home The clinical evidence neither supports nor refutes the use of frictions in There is a small a
message the acute stage. techniques, such a
Clinical May consider using manual therapy in the acute stage after undertaking a May consider a
implication comprehensive biomechanical evaluation of the ‐ Joint mobs hip, knee, frictions, in the ch
foot and ankle. may produce supe
CS ‐ Case studies; SR ‐ Systematic reviews.
Exercise

pathology
Clinical No Yes
research 14
evidence 7
8 RCT[25][26][27][28][29][30][31][32]
Published Yes[33] Yes[33]

expert opinion
Take home There is a small amount of expert opinion There is a large amount of clinical evidence
message to support the use of stretches in the acute precise parameters to ensure effectiveness a
stage. although some protocols use both concentri
resistance training is equally as effective as ec
Clinical May consider using stretching exercises in Strongly consider using eccentric exercise in t

implication acute stage. No prescription parameters are
provided. ACSM recommends 10-30 sec hold, See Appendix A for further details on e
2‐4 repetitions.
OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews.
Low level laser therapy (LLLT)
Stage of Acute C
pathology
Clinical research Yes Y

evidence 2 SR[34][35][36] 1
6
Published expert Yes Y

opinion
Take home There is no clinical evidence, but there is a physiological rationale, to support the use of T
message LLLT in the acute stage. o
Clinical May consider a trial of LLLT in the acute stage at the doses recommended by the World C
implication Association for Laser Therapy (www.walt.nu) i.e., 2‐4 J/point (not per cm2)*, minimum th
2‐3 points. p
*See 'Appendix B 'for further details on calculation of dosage. *

d
MA ‐ Meta‐analyses; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews.
Ultrasound (US)
Stage of Acute C
pathology
Clinical research No N
evidence
Published expert No N
opinion
Take home There is no clinical evidence, but there is physiological rationale, to support the use of US T
message in the acute stage. t
Clinical May consider a trial of US in the acute stage at a low to moderate dose (0.5 ‐ 1.0 W/cm 2, C
implication pulsed 1:4‐1:1, 3 MHz, 5 mins for each treatment area equivalent in size to transducer
head).
Extracorporeal shock wave therapy (ESWT)

pathology
Clinical No Yes
research 4
evidence 1
1SR [49]
Published Yes Yes

expert opinion
Take home There is expert opinion which There is conflicting evidence to support the use of ESWT
message suggests that ESWT be reserved outcomes are dependent upon the dosage of the shock w
for chronic stage. than the type of shock wave generation (focused vs. radia
required in high energy protocols decreases the effect
protocols without the need for anaesthetic are recommen
with equivalent results. Low energy ESWT protocols can
Clinical Consider NOT using Consider a trial of ESWT in the chronic stage,

implication Extracorporeal Shock Wave for following parameters:
the acute stage.
 Low energy SWT: EFD = 0.18 – 0.3 mJ/mm² (2‐4
 2000‐3000 shocks
 15‐30 Hz
 3‐5 sessions, weekly intervals.
ESWT may enhance outcomes compared to exercise alon

well‐designed exercise program.
RCT ‐ Randomized controlled trials; SR - Systematic review
Iontophoresis using dexamethasone

pathology
Clinical research Yes No

evidence 1 RCT [50]
1 SR [51]
Published expert No No
opinion
Take home There is a small amount of evidence to support the application of iontophoresis There i
message using dexamethasone in the acute stage. The role of iontophoresis is iontopho
still investigational. stage.
Clinical May consider, in the acute stage, a trial of iontophoresis, 0.4% dexamethasone Conside
implication (aqueous), 80 mA‐min; 6 sessions over 3 weeks. chronic
A program of concentric‐eccentric exercises should be continued in combination
with iontophoresis, if exercise loading is tolerated.
RCT ‐ Randomized controlled trial; SR - Systematic Review
Taping
Stage of pathology Acute Chronic
Clinical research No Yes

evidence 3
1SR [55]
Published expert Yes Yes

opinion
Take home message There is expert opinion to support the use of antipronation There is expert opinion and
taping in the acute stage. controlled pronation taping in
Clinical implication May consider using antipronation taping in the May consider using antiprona
acute stage.
CS ‐ Case studies; SR - Systematic Review
Orthotics
Clinical research Yes Yes

evidence 2 CS [56][57] 3
2
1 SR [63]

opinion
Take home message There is a small amount of clinical evidence to support the use of There is a mo
orthotics in the acute stage. orthotics in the
Clinical implication Consider using orthotics – perhaps using taping first, in the acute Consider using
stage.
CS ‐ Case studies; RCT ‐ Randomized controlled trials; SR - Systematic Review
Night splints and braces

evidence 3
1 SR [67]

opinion
Take home message There is expert opinion to support the use of night There is a moderate amount of
splints and braces in the acute stage. chronic stage in conjunction wit
Clinical implication Consider a trial of night splints and braces in the acute Consider NOT using night spl
stage. exercise.
RCT ‐ Randomized controlled trials; SR - Systematic Review

Heel raise inserts

evidence 2 RCT[68][69]

opinion
Take home message There is some expert opinion to support the use of heel raise inserts in There is confli
the acute stage. chronic stage.
Clinical implication May consider a trial of inserts in the acute stage. Consider a tria
RCT ‐ Randomized controlled trials.
Needling techniques [70][71]
Acupuncture (trasitional Chinese medicine, anatomical, electrical) and intramuscular stimulation.

pathology
Clinical Yes Yes

research 1 CS 1 CS
evidence
Published No No
expert opinion
Take home There is a small amount of evidence to support the use of Traditional Chinese There is a
message Medicine electroacupuncture in the acute stage. There is expert opinion Chinese Acu
to support the use of other needling techniques in the acute stage. the use of oth
Clinical Consider a trial of electro‐acupuncture in the acute stage. Consider a t

implication May consider a trial of other acupuncture‐related needling techniques in the stage.
acute stage. May conside
the chronic st
CS ‐ Case studies.

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 spe
 Available here
 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
 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 i
Consider NOT: High level/high quality evidence that this should not be included in treatment.

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References
Please see Appendix C Achilles Tendinopathy: Details of Individual Articles for the specific details on
each of the articles referenced in this document.
1. Jump up↑ Voorn, R. Case report: can sacroiliac joint dysfunction cause chronic Achilles
tendonitis? JOSPT. 1998;27(6);436 ‐443.
2. ↑ Jump up to:2.0 2.1 2.2
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.
3. Jump up↑ Brosseau L, Casimiro L, Milne S. et al. Deep transverse friction massage for treating
tendinitis. 2002. Cochrane Database Systematic Reviews. 4.
4. Jump up↑ 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.
5. Jump up↑ 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.
6. Jump up↑ Gaerdin A, Movin T, Svensson L, Shalabi A. The long ‐term clinical andfckLRMRI
results following eccentric calf muscle training in chronic Achilles tendinosis. Skeletal Radiol.
2010;39(5):435‐42.
7. Jump up↑ 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.
8. Jump up↑ 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. Jump up↑ 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. Jump up↑ 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. Jump up↑ Richards PJ, McCall IW, Day C, Belcher J, Maffulli N. Longitiudinal
microvascularity in Achilles tendinopathy. Skeletal Radiology. 2010;39(6):509 ‐21.
12. Jump up↑ Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6
weeks of eccentric exercise in patients with mid portion Achilles tendinopathy: a randomized trial with
one year follow ‐up. Scandanavian Journal of Medicine and Science in Sports. 2004;14(5):286 ‐95.
13. Jump up↑ Shalabi A, Kristoffersen ‐Wiberg M, Aspelin P, Movin T. Immediate Achilles tendon
response after strength training evaluated byfckLRMRI. Medicine and Science in Sports and Exercise.
2004;36(11):1841 ‐6.
14. Jump up↑ Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles
tendinopathy recover fully when treated withfckLRexercise alone: a 5 year follow ‐up. American
Journal of Sports Medicine. 2011;39(3):607 ‐13.
15. Jump up↑ Silbernagel KG, Thomee R, Eriksson BI, Karlsson, J. Full symptomatic recovery does
not ensure full recovery of muscle tendonfckLRfunction in patients with Achilles tendinopathy. British
Journal of Sports Medicine. 2007;41(4):276 ‐80; discussion 280.
16. Jump up↑ Verrall G, Scholfield S, Brustad T. Chronic Achilles tendinopathy treated with
eccentric stretching program. Foot Ankle International. 2011;32(9):843 ‐9.
17. Jump up↑ 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.
18. Jump up↑ Kingma JJ, de Knikker R, Wittink HM, Takken T. Eccentric Overload Training in
Patients with Chronic AT: A systematic review. Br J Sports Med. 2007;41(6):e3.
19. Jump up↑ Kraemer R, Lorenzen J, Vogt PM, Knobloch K. Systematic review about eccentric
training in chronic achilles tendinopathy. Sportverletz Sportschaden. December. 2010;24(4):204 ‐11.
[Article in German, Abstract translated]
20. Jump up↑ Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion
Achille tendinopathy: a systematic review. Clinical Journal of Sport Medicine. 2009;19(1):54 ‐64.
21. Jump up↑ Meyer A, Tumility S & Baxter GD. Eccentric exercise protocols for chronic non‐
insertional Achilles tendinopathy: how much is enough? Scandanavian Journal of Medicine and
Science in Sports. 2009;19(5):609 ‐15.
22. Jump up↑ Wasielewski NJ & Kotsko KM. Does eccentric exercise reduce pain and improve
strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review.
Journal of Athletic Training. 2007;42(3):409 ‐21.
23. Jump up↑ Woodley BL, Newsham ‐West RJ, Baxter GD. Chronic tendinopathy: effectiveness of
eccentric exercise. British Journal of Sports Medicine. 2007;41(4):188 ‐98;discussion 199.
24. Jump up↑ Malliaras, P., Barton, C., Reeves, N., & Langberg, H. (2013). Achilles and Patellar
Tendinopathy Loading Programmes. Sports Medicine, 43(4), 267-286. doi: 10.1007/s40279-013-0019-
z
25. Jump up↑ Backman LJ, Andersson G, Wennstig G, Forsgren S & Danielson P. Endogenous
substance P production in the Achilles tendon increases with loading in an in vivo model of
tendinopathy ‐ peptidergic elevation preceding tendinosis ‐like tissue changes. Journal of
Musculoskeletal and Neuronal Interactions. 2011;11(2):133 ‐40.
26. Jump up↑ Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus
shock‐wave treatment for mid ‐portion Achilles tendinopathy: a randomized controlled trial. American
27. Jump up↑ Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock ‐wave treatment, or
a wait and see policy for tendinopathy of the main body of tendo Achilles: a randomized controlled
trial. American Journal of Sports Medicine. 2007;35(3):374 ‐83.
28. Jump up↑ Silbernagel K, Thomee P, Karlson J. Eccentric overload training for patients with
chronic achilles tendinopathy ‐ a randomised controlled study with reliability testing of the evaluating
methods. Scandanavian Journal of Medicine and Science in Sports. 2001;11:197 ‐206.
29. Jump up↑ Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using
a pain‐monitoring model during rehabilitation in patients with Achilles tendinopathy: a randomized
controlled study. American Journal of Sports Medicine. 2007;35(6):897 ‐906.
30. Jump up↑ Beyer, R., Kongsgaard, M., Hougs Kjaer, B., Ohlenschlaeger, T., Kjaer, M., &
Magnusson, S. P. (2015). Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles
Tendinopathy: A Randomized Controlled Trial. Am J Sports Med. doi: 10.1177/0363546515584760
31. Jump up↑ Stevens, M., & Tan, C.-W. (2014). Effectiveness of the alfredson protocol compared
with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled
trial. Journal of Orthopaedic & Sports Physical Therapy, 44(2), 59-67.
32. Jump up↑ Yu, J., Park, D., & Lee, G. (2013). Effect of Eccentric Strengthening on Pain, Muscle
Strength, Endurance, and Functional Fitness Factors in Male Patients with Achilles Tendinopathy.
American Journal of Physical Medicine & Rehabilitation, 92(1), 68-76. doi:
10.1097/PHM.0b013e31826eda63
33. ↑ Jump up to:33.0 33.1
Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy:
balancing the response to loading. Nature Reviews Rheumatology. 2010;6(5):262 ‐8.
34. Jump up↑ Bjordal J, Couppe C. Low Level Laser Therapy for Tendinopathy. Evidence of A
Dose‐Response Pattern. Physical Therapy Reviews. 2001;6:91 ‐99.
35. Jump up↑ Bjordal JM, Lopes ‐Martins RAB, Joensen J, Iversen VV. The anti ‐inflammatory
mechanism of low level laser therapy and its relevance for clinical use in physiotherapy. Physical
Therapy Reviews. 2010;15(4):286–293.
36. Jump up↑ Peplow PV, Chung TY, Baxter GD. Application of low level laser technologies for
pain relief and wound healing: overview of scientific bases. Physical Therapy Reviews.
2010;15(4):253–285.
37. Jump up↑ Tumilty S, Munn J, McDonough S, Hurley D A, Basford JR, Baxter GD. Low level
laser treatment of tendinopathy: a systematic review with meta ‐analysis Photomedicine and Laser
Surgery. 2010;28(1):3–16.
38. Jump up↑ Bjordal, JM. A randomised, placebo controlled trial of low level laser therapy for
activated Achilles tendinitis with micro dialysis measurement of peritendinous prostaglandin E2
concentrations. British Journal of Sports Medicine. 2006;40(1):76–80.
39. Jump up↑ Darre E, Klokker M, Lund P. Laserbehandling af akillessenetendinit. Ugeskr
Laeger.1994;156(45):6680 ‐3. Danish.
40. Jump up↑ Stergioula A, Stergioula M, Aarskog R, Lopes ‐Martins RAB, Bjordal JM. Effects of
low‐level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic
achilles tendinopathy. The American Journal of Sports Medicine. 2008;36(5):881–887.
41. Jump up↑ Tumilty S, Munn J, Abbott JH, McDonough S, Hurley DA, Baxter GD. Laser therapy
in the treatment of Achilles tendinopathy: a pilot study. Photomedicine and Laser Surgery.
2008;26(1):25–30.
42. Jump up↑ Tumilty S, Munn J, Abbott JH, McDonough S, Hurley DA, Basford JR, Baxter G.D.
Laser Therapy in the Treatment of Achilles Tendinopathy: A Randomised Controlled Trial. AIP Conf.
Proc. May 31 2010;Volume 1226:163 ‐169.
43. Jump up↑ Tumilty, S., McDonough, S., Hurley, D. A., & Baxter, G. D. (2012). Clinical
Effectiveness of Low-Level Laser Therapy as an Adjunct to Eccentric Exercise for the Treatment of
Achilles' Tendinopathy: A Randomized Controlled Trial. Archives of Physical Medicine and
Rehabilitation, 93(5), 733-739. doi: http://dx.doi.org/10.1016/j.apmr.2011.08.049
44. Jump up↑ Costa ML, Shepstone L, Donell ST, Thomas TL. Shock WaveTherapy for chronic
Achilles tendon pain: a randomized placebo controlled trial. Clinical Orthopedics and Related
Research. 2005;440:199 ‐204.
45. Jump up↑ Rompe J, Nafe B, Furia J. Eccentric loading, shock wave therapy or ‘wait and see’
policy for tendinopathy of the main body of tendo achillis: a randomized controlled trial. American
46. Jump up↑ Rompe J, Furia J, Maffulli N. Eccentric loading vs eccentric loading plus shock wave
treatment for mid ‐portion Achilles tendinopathy. A randomized controlled trial. American Journal of
Sports Medicine. 2009;37(3):463 ‐470.
47. Jump up↑ Rasmussen S, Christensen M, Mathiesen I, Simonson O. Shock wave therapy for
chronic Achilles tendinopathy: a double ‐blind, randomized clinical trial of efficacy. Acta
Orthopaedica. 2008;79(2):249 ‐256.
48. Jump up↑ Lakshmanan P, O’Doherty D. Chronic Achilles tendinopathy: treatment with extra‐
corporeal shock wave therapy. Foot and Ankle Surgery. 2004;10:125 ‐130.
49. Jump up↑ Al-Abbad, H., & Simon, J. V. (2013). The effectiveness of extracorporeal shock wave
therapy on chronic achilles tendinopathy: a systematic review. Foot Ankle Int, 34(1), 33-41. doi:
10.1177/1071100712464354
50. Jump up↑ Neeter C, Thomee R, Silbernagel K, Thomee P, Karlson J. Iontophoresis with and
without dexamethasone in the treatment of acute Achilles tendon pain. Scandinavian Journal of
Medicine and Science in Sports. 2003;13(6):376 ‐382.
51. Jump up↑ Brown CD, Lauber CA. Evidence ‐based guidelines for utilization of dexamethasone
iontophoresis. International Journal of Athletic Therapy and Training. 2011;16(4):33 ‐36.
52. Jump up↑ Lee, J.-h., & Yoo, W.-g. (2012). Treatment of chronic Achilles tendon pain by
Kinesio taping in an amateur badminton player. Physical Therapy in Sport, 13(2), 115-119.
doi: http://dx.doi.org/10.1016/j.ptsp.2011.07.002
53. Jump up↑ Riddle DL, Freeman DB.(1988). Management of a patient with a diagnosis of
bilateral plantar fasciitis and Achilles tendinitis. A case report. Phys Ther. 68(12): 1913-6
54. Jump up↑ Smith M, Brooker S, Vicenzino B, McPoil T. (2004). Use of anti-pronation taping to
assess suitability of orthotic prescription: case report. Aust J Physiother. 50(2): 111-3.
55. Jump up↑ Scott, L., Munteanu, S., & Menz, H. (2015). Effectiveness of Orthotic Devices in the
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10.1007/s40279-014-0237-z
56. Jump up↑ Gross ML, Davlin L, Evanski PM. (1991). Effectiveness of orthotic shoe inserts in
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57. Jump up↑ Greene BL. (2002). Physical therapist management of fluoroquinolone-induced
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58. Jump up↑ Riddle DL, Freeman DB. (1988). Management of a patient with a diagnosis of
bilateral plantar fasciitis and Achilles tendinitis. A case report. Phys Ther. 68(12): 1913-6
59. Jump up↑ Smith M, Brooker S, Vicenzino B, McPoil T. (2004). Use of anti-pronation taping to
assess suitability of orthotic prescription: case report. Aust J Physiother. 50(2): 111-3.
60. Jump up↑ Donoghue OA, Harrison AJ, Laxton P, Jones RK. (2008). Orthotic control of rear
foot and lower limb motion during running in participants with chronic Achilles tendon injury. Sports
Biomech. 7(2): 194-205.
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term treatment strategies over 4 weeks in Achilles tendinopathy. Br J Sports Med. 41(7): e6
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Brace. A randomized controlled trial. A: effects on pain and microcirculation. Disabil Rehabil.
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65. Jump up↑ Petersen W, Welp R & Rosenbaum D. Chronic Achilles tendinopathy: a prospective
randomized study comparing the therapeuticfckLReffect of eccentric training, the AirHeel brace, and a
combination of both. Am J Sports Med. 2007;35:1659 ‐67.
66. Jump up↑ de Vos RJ, Weir A, Visser RJ et al. The additional value of a night splint to eccentric
exercises in chronic midportion AchillesfckLRtendinopathy: a randomised controlled trial. Br J Sports
Med. 2007;41: e5.
10.1007/s40279-014-0237-z
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tendonitis with visco ‐elastic heel inserts. Br J Sports Med. 1982;15(2):117 ‐21.
69. Jump up↑ Lowdon A, Bader DL, Mowat AG. The effect of heel pads on the treatment of
Achilles tendinitis: a double blind trial. Am J Sports Med. 1984;12(6):431 ‐5.
70. Jump up↑ Jens Foell S. Is electro ‐acupuncture a safe and cost ‐effective treatment for Achilles
tendonopathy in a primary care setting?International Musculoskeletal Medicine. 2010;32( 2):51 ‐54.
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Related articles
Lateral Epicondyle Tendinopathy Toolkit: Summary of the Evidence - Physiopedia by Topic 14.1
Manual Therapy 14.2 Exercise 14.3 Acupuncture 14.4 Low Level Laser Therapy (LLLT) 14.5
Ultrasound (US) 14.6 Extracorporeal Shock Wave Therapy (ESWT) 14.7 Iontophoresis Using
Dexamethasone 14.8 Iontophoresis Using NSAID or Lidocaine 14.9 Orthotic Devices 14.10 Taping
Abbreviations CAT = Critically Appraised Topic CS = Case Study LET = Lateral Epicondyle
Tendinopathy LLLT = Low Level Laser Therapy MA = Meta-Analysis MWM = Mobilization with
Movement NR = Narrative Review NSAID = Non-Steroidal Anti-Inflammatory Drug OS =
Observational Study RCT = Randomized Controlled Trial SR = Systematic Review SWT = Shock
Wave Therapy US = Ultrasound WALT = World Association of Laser Therapy *Numbers in
parentheses in the "Clinical Research Evidence" rows represent the number of individual studies
included in each review article. 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. Manual Therapy Elbow Joint Mobilizations Stage of pathology Acute Chronic Clinical
research evidence* No • 4 RCT • 5 SR (21) • 1 CAT (5) • 1 wrist RCT Published expert opinion No 2
expert opinion narrative reviews Take home message There is no clinical evidence to support or refute
the use of elbow mobilization in the acute stage. There is a large amount of clinical evidence to support
the use of elbow mobilizations for short term effects. There is a small amount of evidence that supports
long-term effects. There is a small amount of clinical evidence to support the use of radial head
mobilization and neural tension techniques. There is weak support for the use of wrist MWM. Clinical
implication There is no direction provided by the literature on the use of elbow mobilization in the
management of acute LET. Strongly consider using MWM of the elbow as part of a multimodal
treatment regime (manual therapy and exercise) in the treatment of chronic LET. The effects should be
apparent within the first few treatments. (See Appendix B for details) Consider using radial head
mobilization and neural tension techniques. Consider using MWM of the wrist as part of multimodal
treatment regime. Spinal Mobilization Techniques Stage of pathology Acute Chronic Clinical research
evidence* No • 3 RCT • 1 RCT pilot • 1 chart review • 1 case series Published expert opinion No ---
Take home message There is no clinical evidence or expert opinion on the use of spinal mobilization
for patients with acute LET. There is clinical evidence to support the use of incorporating cervical and
thoracic mobilizations into the treatment of LET. However, only 1 paper had follow up of ≥ 6/12 - the
others report immediate or very short term responses. Clinical implication There is no direction
provided by the literature on the use of spinal mobilization in the management of acute LET. Consider
using cervical mobilizations as part of a multimodal approach to treatment of chronic LET. Consider
using cervical and thoracic mobilization techniques in those with cervical and/or thoracic signs even if
they do not report spinal symptoms, in addition to local treatment to the elbow. (See Appendix B for
details) Soft Tissue Techniques Stage of pathology Acute Chronic Clinical research evidence* • 1 RCT
• 2 SR (7) • 3 RCT Published expert opinion --- --- Take home message There is weak clinical evidence
to support the use of deep and superficial massage to achieve immediate pain relief. Early SR found
insufficient evidence to make recommendations. More recent SR found there is weak clinical evidence
to support the use of soft tissue techniques, such as frictions. There is a small amount of weak clinical
evidence to support the use of soft tissue techniques in combination with other treatment modalities.
Note: some of the studies which examined the effect of frictions included the use of Mill’s
manipulation. Clinical implication Consider using deep and superficial massage for immediate pain
relieving effect in acute LET. Consider using soft tissue techniques (deep transverse friction massage)
as part of a multimodal treatment regime for chronic LET. (See Appendix B for details) Exercise Stage
of pathology Acute Chronic Clinical research evidence* • 1 RCT • 7 RCT • 1 SR (3) • 2 OS Published
expert opinion --- --- Take home message There is a small amount of clinical evidence to support the
use of exercise in the acute stage. There is a large amount of clinical evidence to support the use of
exercise in the chronic stage. Eccentric exercise seems to be the most effective but almost all exercise
studies showed improvement whether it was concentric, eccentric or isometric strengthening.
Stretching was also found to be effective. Studies that instructed their subjects to exercise even with
pain, as long as it wasn't debilitating, seemed to have better results. Clinical implication Consider using
exercise in the management of acute LET. Strongly consider using exercise in the chronic stage,
especially eccentric exercise. (See Appendix C for details) Consider instructing the patient to exercise
even with mild pain as long as it is not disabling. Acupuncture Stage of pathology Acute Chronic
Clinical research evidence* --- • 1 SR (6) Published expert opinion Yes --- Take home message There
is a plausible physiological rationale (short-term pain reduction) to support the use of acupuncture for
patients with acute LET. There is weak but consistent clinical evidence to support the use of
acupuncture for pain control in patients with chronic LET. Clinical implication May consider the use of
acupuncture for short-term pain relief in patients with acute LET. Consider the use of acupuncture for
short-term pain relief in patients with chronic LET. Low Level Laser Therapy (LLLT) Stage of
pathology Acute Chronic Clinical research evidence* • 1 RCT • 6 SR (+/- MA) (16) • 3 RCT • 1 case
report Published expert opinion --- --- Take home message Laser at 905 nm may be effective when
used in accordance with the WALT guidelines, when used in combination with exercise. Laser at 904
nm and possibly 832 nm or 830 nm may be effective when used in accordance with the WALT
guidelines, and particularly if used in combination with other treatments. The evidence in support of
laser is stronger when only those studies that use an appropriate dose are included. Clinical implication
Consider using laser (LLLT) at 905 nm with dosage as recommended by WALT guidelines. (See
Appendix D for details) Consider using laser (LLLT) at 904 nm with dosage as recommended by
WALT guidelines. (See Appendix D for details) Ultrasound (US) Stage of pathology Acute Chronic
Clinical research evidence* • 2 RCT • 5 RCT • 5 SR (13) • 1 short-cut review Published expert opinion
--- --- Take home message Weak evidence for effectiveness of US in the management of acute LET. 1
MHz or 3 MHz, 0.5 – 1.0 W/cm2 5-10 minutes (pulsed 1:2-1:4 suggested). Weak evidence for
effectiveness of US in the management of chronic LET. 1 MHz or 3 MHz, 1.0 – 1.5 W/cm2 5-10
minutes (continuous suggested). Clinical implication Consider using US in the management of acute
LET. Consider using US in the management of chronic LET. Extracorporeal Shock Wave Therapy
(ESWT): Focused and Radial Stage of pathology Acute Chronic Clinical research evidence* • 1 RCT •
6 RCT • 3 SR (8) • 2 comparative studies Published expert opinion --- --- Take home message Studies
that have included subjects with a short period of lateral elbow pain (e.g., < 1 month) have not shown
any benefit of SWT. The benefits from SWT are dose-dependent. Most studies and reviews of high
energy SWT (> 0.17 mJ/mm²) do not support SWT for lateral elbow pain compared to low energy SWT
(< 0.15 mJ/mm²). Studies suggest that the use of anesthetic at the treatment site diminishes the effect of
SWT. Studies also suggest that the delivery of focused or radial energy sources is equivalent. There is
conflicting evidence for the use of low energy SWT for lateral elbow pain, and a need to create
consistent protocols when comparing treatment outcomes. Qualitative reviews of low energy SWT with
similar study designs support SWT. Systematic reviews that pool data in studies with dissimilar
designs by meta-analysis do not support SWT for lateral elbow pain. An adequate follow-up time >3
months is recommended to measure the benefit of SWT. Clinical implication Consider NOT using
SWT for acute stage. SWT in early onset of symptoms does not improve lateral elbow pain. Consider
using low energy SWT for subjects that have failed to respond to other conservative treatment;
however, the patient should be informed that SWT is experimental. Recommended dosage: • Low
energy SWT (focused or radial) <0.1.5 mJ/mm² • 2,000 shocks • 3 sessions, weekly intervals
Iontophoresis Using Dexamethasone Stage of pathology Acute Chronic Clinical research evidence* • 1
RCT • 1 RCT • 1 comparative study Published expert opinion --- --- Take home message A small
amount of evidence supports the delivery of corticosteroid (Dexamethasone) by iontophoresis to treat
acute lateral elbow pain for short term pain reduction, allowing the subject to participate in an earlier
increase in exercise activity or return to work. Iontophoresis may have advantages over injection (less
pain, decreased trophic changes in tissue), but may not be as cost effective. Application of
iontophoresis with Dexamethasone for degenerative lateral elbow tendon pain has no long term benefit
and may be no better than placebo. Studies comparing the delivery of corticosteroids for lateral elbow
pain by iontophoresis or by injection have similar outcomes. In general, corticosteroids for chronic
lateral elbow tendinopathy are not supported in the literature. (See Appendix C - Medical Interventions
- corticosteroids) Clinical implication Consider a trial of iontophoresis with Dexamethasone for short-
term pain control for acute LET. Recommended dosage: • 0.4% Dexamethasone Sodium Phosphate
(aqueous) • 40-80 mA-min • 4-6 sessions, alternate days Physician prescription required Consider NOT
using iontophoresis with Dexamethasone for the treatment of chronic LET. Iontophoresis Using
NSAID or Lidocaine Stage of pathology Acute Chronic Clinical research evidence* • 2 comparative
studies • 1 experimental study --- Published expert opinion --- Yes Take home message There is a
small amount of weak evidence to support the delivery of NSAID (Diclofenac, Salicylate, Naproxen)
or local analgesic (Lidocaine) by means of iontophoresis for LET. Studies demonstrate short term
benefit in pain management, which may be beneficial in early stages of treatment. No long term benefit
is proven. Studies generally are designed with other concurrent treatment, so that the effects of
iontophoresis of these drugs are inconclusive. In addition, studies of iontophoresis using NSAID
involved a high number of treatments. The studies using iontophoresis to deliver NSAID or Lidocaine
do not adequately differentiate acute versus chronic conditions of LET. The physiological rationale for
using NSAID may be applicable in the acute phase, but inflammatory cells are not considered part of
the pathology in chronic LET. Clinical implication May consider a trial of iontophoresis with NSAIDs
or Lidocaine for short term pain control for acute LET. Physician prescription required. Gel forms of
NSAIDS should not be used for iontophoresis. May consider a trial of iontophoresis with NSAID’s or
Lidocaine for the treatment of chronic LET for short term pain control. Physician prescription required.
Gel forms of NSAIDS should not be used for iontophoresis. Orthotic Devices Stage of pathology Acute
Chronic Clinical research evidence* • 3 RCT • 2 SR (7) • 4 RCT Published expert opinion --- --- Take
home message There is some clinical evidence to support the use of splinting for pain relief for patients
with acute LET. There is some clinical evidence and expert advice to support the use of a counterforce
brace in patients with chronic LET. Clinical implication Consider the use of splinting for patients with
acute LET. Consider the use of a counterforce brace for patients with chronic LET. (See Appendix E
for details) Taping Stage of pathology Acute Chronic Clinical research evidence* No • 2 experimental
studies Published expert opinion No • 1 narrative review Take home message There is no clinical
evidence or expert opinion on the use of taping for patients with acute LET. There is a plausible
physiological rationale to support the use of taping for patients with chronic LET. Clinical implication
There is no direction provided by the literature on the use of taping in the management of acute LET.
May consider a trial of taping for patients with chronic LET. Relevant Outcome Measures See
Appendix F for details. Note: The following outcome measures have been selected as they are
commonly reported in the literature, supported by expert clinical opinion and used extensively
clinically. Performance based impairment measures such as: Pain-free grip strength Pain with isometric
wrist extension (Thomsen test) Pain with isometric middle finger extension (Maudsley test) Pain rating
outcome measures such as: Numeric Pain Rating Scale (NPRS) Visual Analog Scale (VAS) Self-report
questionnaires such as: The Upper Limb Functional Index (ULFI):
http://www.users.muohio.edu/smithdl2/images/articles/UpperLimbFunctionalIndex.pdf Patient Rated
Tennis Elbow Evaluation (PRTEE): http://www.srs-
mcmaster.ca/Portals/20/pdf/research_resources/PRTEE.pdf QuickDASH (Disabilities of the Arm
Shoulder and Hand): http://www.dash.iwh.on.ca/conditions-use Patient Specific Functional Scale
(PSFS): http://www.tac.vic.gov.au/upload/Patient-specific.pdf Although the PSFS has not yet been
validated for lateral epicondylalgia, it has been shown to be valid, reliable and responsive to change in
other conditions such as knee dysfunction, cervical radiculopathy, acute low back pain, mechanical low
back pain, and neck dysfunction. Download Lateral Epicondyle Tendinopathy Toolkit: Summary of the
Evidence http://physicaltherapy.med.ubc.ca/files/2013/07/Lateral-Epicondyle-Tendinopathy-Summary-
of-the-Evidence-June-2013.pdf Acknowledgements Developed by the BC Physical Therapy
Tendinopathy Task Force: Dr. Joseph Anthony, Dr. Angela Fearon, Diana Hughes, Carol Kennedy, 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. June 2013 Achilles Tendinopathy
Toolkit: Appendix A - PhysiopediaAchilles Tendinopathy: Exercise Programs 1. Phased Achilles
Tendon Loading Program (As per Silbernagel et al.[1]) Phase 1: Weeks 1-2 Patient status: Pain and
difficulty with all activities, difficulty performing ten 1 ‐legged heel raises Goal: Start to exercise, gain
understanding of their injury and of pain ‐monitoring model Treatment program: Perform exercises
every day Pain‐monitoring model information and advice on exercise activity Circulation exercises
(moving foot up/down) Two ‐legged heel raises standing on the floor (3 sets of 10 ‐15 repetitions/set)
One‐legged heel raises standing on the floor (3 sets of 10) Sitting heel raises (3 sets of 10) Eccentric
heel raises standing on the floor (3 sets of 10) Phase 2: Weeks 2-5 Patient status: Pain with exercise,
morning stiffness, pain when performing heel raises Goal: Start strengthening Treatment program:
Perform exercises every day Two ‐legged heel raises standing on edge of stair (3 sets of 15) One ‐legged
heel raises standing on edge of stair (3 sets of 15) Sitting heel raises (3 sets of 15) Eccentric heel raises
standing on edge of stair (3 sets of 15) Quick ‐rebounding heel raises (3 sets of 20) Phase 3: Weeks 3–
12 (longer if needed) Patient status: Handled the phase 2 exercise program, no pain distally in tendon
insertion, possibly decreased or increased morning stiffness Goal: Heavier strength training, increase or
start running and/or jumping activity Treatment program: Perform exercises every day and with heavier
load 2‐3 times/week One ‐legged heel raises standing on edge of stair with added weight (3 sets of 15)
Sitting heel raises (3 sets of 15) Eccentric heel raises standing on edge of stair with added weight (3
sets of 15) Quick ‐rebounding heel raises (3 sets of 20) Plyometric training Phase 4: Week 12–6 months
(longer if needed) Patient status: Minimal symptoms, morning stiffness not every day, can participate
in sports without difficulty Goal: Maintenance exercise, no symptoms Treatment program: Perform
exercises 2 ‐3 times/week One ‐legged heel raises standing on edge of stair with added weight (3 sets of
15) Eccentric heel raises standing on edge of stair with added weight (3 sets of 15) Quick ‐rebounding
heel raises (3 sets of 20) 2. 12-Week Eccentric Loading Program (As per Alfredson et al.[2]) 3 x 15
repetitions twice per day with extended knee, and another 3 x 15 repetitions twice per day with a flexed
knee. All exercises were 7 days per week. Patients were told to continue to exercise with pain unless it
became disabling. Patients were allowed to jog during their 12 ‐week rehabilitation so long as it caused
only mild discomfort. A B C Figure 1. From an upright body position and standing with all body
weight on the forefoot and the ankle joint in plantar flexion lifted by the non ‐injured leg (A), the calf
muscle was loaded eccentrically by having the patient lower the heel with the knee straight (B) and
with the knee bent (C). Figure 2. Once the eccentric loads were performed at body weight without any
discomfort, subjects were given a backpack that was successively loaded with weight. In this way their
eccentric loading was gradually increased. If very high weights ended up becoming needed then the
subject used a weight machine. Click to go back to the contents page Click to go back to the Treatment
Algorithm Click to go back to the Summary of Interventions Click to continue to Appendix B: Low
Level Laser Therapy Dosage Calculation Click to continue to: Appendix C: Details of Articles on
Interventions Click to continue to: Appendix D: Medical and Surgical Interventions Download Achilles
Tendinopathy Toolkit: Appendix A File:Download Appendix A - Exercise Programs.pdf Achilles
Tendinopathy Toolkit: Appendix D - Physiopedia4 Acknowledgements Achilles Tendinopathy:
Medical and Surgical Interventions The purpose of this document is to summarize common medical
and surgical interventions which may be considered for the management of Achilles tendinopathy –
particularly if it is not responding adequately to more strongly supported conservative management
strategies (see “Achilles Tendinopathy: Summary of the Evidence for Physical Therapy
Interventions”). Pharmacological Approaches NSAIDS[1][2] Method Short term benefit in the acute
stage of tendinopathy to minimise inflammatory process. Proposed Mechanism Interrupts the chemical
pathway of inflammation. Benefit: Pros/Cons Pros: Inexpensive, easily accessible. Cons: Precautions
and contraindications that accompany specific medications. Inhibition of inflammation may delay
repair of muscle tissue or tendon insertion. Evidence Limited evidence for a modest effect of topical or
oral NSAIDs in acute stage in Achilles tendinopathy. Take Home Message 'Implications for
Physiotherapy PTs are involved in the treatment of tendon pain at all stages of recovery. General
knowledge of commonly used NSAIDS is important for treatment planning. Corticosteroid (injection)
[3][4][5][6] Method Short ‐term benefit in acute stage. In chronic tendinopathy, the rationale for the use
of anti-inflammatory injections is controversial. Proposed Mechanism Injection into the paratendon to
interrupt the inflammatory process. Benefit: Pros/Cons Pros: Easily accessible. Careful administration
outside the structure of the tendon is considered ‘safe’ i.e., in the paratendon sheath. Cons: Risk of
infection (1%) ‘universal precautions’ required. Destructive; risk of tendon rupture; impairs tendon
tissue repair mechanism. Evidence There is a lack of high quality evidence to support the use of local
corticosteroid injections in chronic Achilles tendon lesions. Generally, lack of well ‐designed clinical
trials. Take Home Message 'Implications for Physiotherapy PTs are involved in the treatment of tendon
pain at all stages of recovery. There are animal studies that suggest risk of tendon rupture after
corticosteroid injection. Caution is recommended in progressing the loading of the tendon within two
weeks of a corticosteroid injection (exercise precautions). Glycerol Trinitrate (GTN)[7][8][9][10][11]
Method Nitro ‐glycerine patches applied over tendon to enhance healing. Proposed Mechanism Nitric
oxide may increase blood flow to the tendon and stimulate repair by enhancing fibroblast proliferation.
Benefit: Pros/Cons Pros: GTN may improve outcomes compared to exercise alone. Increased
compliance because of ease of application. Selfapplied. Non ‐invasive. Cons: Labour ‐ intensive;
requires repeated applications over 12 weeks. Potential headache as a side-effect of nitro patch.
Evidence Conflicting evidence limits conclusions and widespread use. Take Home Message
'Implications for Physiotherapy If prescribed by a physician, may be applied by a physiotherapist and
used in conjunction with an eccentric exercise program. Click to go back to the contents page Click to
go back to the Treatment Algorithm Click to go back to the Summary of Interventions Click to go back
to Appendix A: Exercise Programs Click to go back to Appendix B: Low Level Laser Therapy Dosage
Calculation Click to go back to: Appendix C: Details of Articles on Interventions Injection Therapies
Chronic Achilles tendinopathy is associated with abnormal proliferation of neovessels in the ventral
portion of the tendon, and along with accompanying neural tissue, is associated with pain in
tendinopathy. The presence of neovessels can be visualized by use of ultrasound (US) (sonography).
Grey‐scale US is a reliable method to assess tendon structure. Color Doppler or power Doppler has
also been used to visualize blood flow. Conservative treatment for Achilles tendinopathy is
unsuccessful in 24 ‐45% of cases. US ‐guided injections are becoming increasingly considered as part of
‘best practice’ for treatment of tendinopathies that have failed to respond to other conservative
treatment. Polidocanol[12][13][14][15][16][17] Method Originally developed as an anaesthetic, and
widely used as a sclerosing agent in the treatment of varicose veins. Proposed Mechanism There is a
body of literature that supports the use of US-guided injections of polidocanol to disrupt neovessels
and accompanying nerve structures associated with chronic tendinopathy. Benefit: Pros/Cons Pros:
Increasingly used, registered drug with few side ‐effects. No need to use additional anaesthetic, as it has
its own aesthetic properties. Cons: Expensive sonography equipment, requiring an experienced
operator. Evidence Conflicting evidence limits conclusions and widespread use. Take Home Message
'Implications for Physiotherapy PTs should have knowledge of more invasive techniques to help to
facilitate referral of patients to other procedures when conventional treatment fails to result in a
sufficient positive response. Prolotherapy[18][19][20] Method Injecting a small volume of an irritant
solution at multiple sites around a tendon insertion to induce a ‘pro-inflammatory’ proliferative cell
response. One study used hyperosmolar dextrose while another used hypertonic glucose, both with a
small amount of anaesthetic. Proposed Mechanism Fibroblast proliferation, collagen maturation and
resolution of neovessels are observed, with near normal appearance of tendon tissue structure observed
with US. New viable tissue hypothesised to result from local release of cell growth factors. Medical
dextrose also has a weak sclerosing effect on vessels. Benefit: Pros/Cons Pros: Can be performed with
or without US ‐guided localisation. Cons: Not covered by medical plans (BC); usually requires a
private fee that reflects the expertise of the practitioner. Requires three or more repeated treatments.
Evidence Limited evidence suggests that prolotherapy combined with eccentric exercise for Achilles
tendon loading may provide more rapid improvement in symptoms than eccentrics alone, although
long‐term VISA ‐A scores are similar. Take Home Message 'Implications for Physiotherapy
Prolotherapy may enhance outcomes compared to using eccentric exercise, alone. Platelet Rich Plasma
(PRP) and Autologous whole blood[19][21][22][23][24] Method Autologous blood injections involve
the reinjection of a patient’s own whole blood. In PRP the autologous blood is centrifuged to collect a
concentrate of the platelets and plasma. This is then injected back into the patient’s tendon. Proposed
Mechanism Cellular and humoral (blood) mediators promote healing in areas of tendon degeneration.
Benefit: Pros/Cons Pros: Non-surgical option Can be performed with or without US-guided
localization Cons: RCT-level evidence of lack of effectiveness Requires expensive blood processing
equipment and centrifuge. Also, it is a US-guided technique requiring sonography and an experienced
operator. Evidence Two high-quality RCTs have shown both PRP and autologous whole blood
injection to be ineffective. Take Home Message 'Implications for Physiotherapy PTs are part of a
treatment team when treating tendon injury. General knowledge of PRP and relevant high quality RCTs
is important to assist patients in decision-making. High volume injection (HVI) or Hydrostatic
dissection[25][26][27] Method Small volume of anaesthetic/steroid and high volume of saline,
delivered by US ‐guided imaging. Proposed Mechanism The pressure created by the volume of
substance into the tendon sheath is proposed to disrupt the neovessel ingrowth in Achilles
tendinopathy. Benefit: Pros/Cons Pros: Non ‐surgical option. Cons: Requires sonography equipment.
Evidence Limited evidence of effectiveness. Take Home Message 'Implications for Physiotherapy
Potential treatment option for Achilles tendinopathy that has failed to respond to a more conservative
approach. Click to go back to the contents page Click to go back to the Treatment Algorithm Click to
go back to the Summary of Interventions Click to go back to Appendix A: Exercise Programs Click to
go back to Appendix B: Low Level Laser Therapy Dosage Calculation Click to go back to: Appendix
C: Details of Articles on Interventions Dry Needling The term ‘dry needling’ has been used to describe
several techniques that involve insertion of a needle without injection of a substance. Needling of the
tendon has been described by a number of practitioners using a hypodermic needle. Similar results
using acupuncture needles have become more common. The technique is described below. Dry
Needline using a Hypordermic Needle ("tendon fenestration")[28] Method Tissue trauma from the
cutting edge of the needle/lumen. Proposed Mechanism Repeated lancing of abnormal tendon tissue
creates haemorrhage followed by an inflammatory response, granulation and healing. Some needling
techniques employ US to guide the needle (percutaneous needle tenotomy). Benefit: Pros/Cons Pros:
Invasive treatment that avoids full surgical exposure and risks. Cons: Requires sonography equipment.
Potential to permanently injure the tendon Evidence Limited evience of effectiveness. Take Home
Message 'Implications for Physiotherapy An invasive treatment with limited evidence. Click to go back
to the contents page Click to go back to the Treatment Algorithm Click to go back to the Summary of
Interventions Click to go back to Appendix A: Exercise Programs Click to go back to Appendix B:
Low Level Laser Therapy Dosage Calculation Click to go back to: Appendix C: Details of Articles on
Interventions Surgical Approaches Surgical success rates are reported at 85% for Achilles tendinopathy
that have failed to respond to conservative measures. Percutaneous tenetomy[29][30] Method
Techniques include closed dissection of the tendon sheath by US ‐guided percutaneous longitudinal
internal tenotomy; or open surgical exposure of the tendon. Proposed Mechanism Surgical trauma
creates granulation and repair, and interrupts fibrous adhesions. Benefit: Pros/Cons Pros: Simple
procedure that can be done as an outpatient. Cons: Risk of infection. Evidence Satisfactory outcomes
for selected patients that do not have complicated Achilles pathology, and have failed to respond to a
conservative treatment approach. Treatment seems to be effective in the long-term with regard to
returning to pre-injury level of functioning. Paratendinopathy is a negative prognostic factor. Take
Home Message 'Implications for Physiotherapy PT may be involved in the post ‐op rehabilitation
following surgery. Surgical debridement[31][32] Method Central longitudinal incision to expose the
tendon, with excision of disorganised and fibrotic tendon tissue and adhesions. Additional diathermy to
destroy neovessels. Proposed Mechanism Surgery creates granulation and repair, and removes fibrotic
tissue. Benefit: Pros/Cons Pros: High success rates reported by some centres in terms of reducing pain
and improving functionality Cons: Risk of infection. Long post ‐op recovery of 3 ‐6 months. Evidence
Surgery may be a successful option for patients that have failed to respond to conservative treatment,
or have complicated Achilles tendon pathology. Take Home Message 'Implications for Physiotherapy
PT may be involved in the post ‐op rehabilitation following surgery. Minimally invasive stripping[33]
Method Small incision in made allowing a probe or scapel to be inserted ventral to the tendon. The area
of neovascularisation is stripped. Proposed Mechanism Disrupts abnormal blood/nerve supply, releases
adhesions. Benefit: Pros/Cons Pros: High success rate reported. Minimal trauma to tendon Quick return
to sport Reduced risk of infection comparing to open surgery Cons: Risk of infection. Potential loss of
gliding function due to long term increased Evidence Retrospective, short-term studies only Take
Home Message 'Implications for Physiotherapy PT may be involved in the post ‐op rehabilitation
following surgery. Download Achilles Tendinopathy Toolkit: Appendix D File:Download Appendix D
- Medical and Surgical Interventions.pdfMicrosoft Word - Achilles Tendinopathy - Summary of
Interventions - FINAL (April 20, 2012).docxACHILLES TENDINOPATHY (mid-substance):
Summary of the Evidence for Physical Therapy Interventions PURPOSE, SCOPE & 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. INTERVENTION Manual Therapy STAGE OF PATHOLOGY
CLINICAL RESEARCH EVIDENCE PUBLISHED EXPERT OPINION TAKE HOME MESSAGE
CLINICAL IMPLICATION *See final page for description of categories Acute May consider using
manual therapy in the acute stage after undertaking a comprehensive biomechanical evaluation of the
hip, knee, foot and ankle. ‐ Joint mobs No Yes There is no clinical evidence but there is expert level
consensus to support the use of joint mobilizations in the acute stage if assessment reveals joint
restriction. ‐ Soft tissue techniques No No The clinical evidence neither supports nor refutes the use of
frictions in the acute stage. Chronic ‐ Joint mobs Yes ‐ Soft tissue techniques 1 CS Yes 1 SR 2 CS Yes
Yes 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. There
is a small amount of clinical evidence to support the use of soft tissue techniques, such as frictions, in
the chronic stage. Exercise Acute No Yes There is a small amount of expert opinion to support the use
of stretches in the acute stage. Chronic Yes 14 OS 6 SR 5 RCT Yes 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. May consider using manual therapy in the chronic stage after undertaking a
comprehensive biomechanical evaluation of the hip, knee, foot and ankle. May consider a trial of soft
tissue techniques, such as frictions, in the chronic stage. 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. April 20, 2012
Page 1 INTERVENTION STAGE OF HEALING CLINICAL RESEARCH EVIDENCE PUBLISHED
EXPERT OPINION TAKE HOME MESSAGE CLINICAL IMPLICATION *See final page for
description of categories Low level laser therapy (LLLT) Acute Yes 2 SR Yes There is no clinical
evidence, but there is a physiological rationale, to support the use of LLLT in the acute stage. 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 cm 2 )*, minimum 2 ‐ 3 points. *See Appendix
B for further details on calculation of dosage. Chronic Yes 1 MA 5 RCT Yes There is conflicting
clinical evidence and conflicting expert opinion to support the use of LLLT in the chronic stage.
Consider a trial of LLLT in the chronic stage at the following parameters: 0.9 J/point (not per cm 2 )*;
6 points on tendon. *See Appendix B for further details on calculation of dosage. Ultrasound (US)
Acute No No There is no clinical evidence, but there is physiological rationale, to support the use of
US in the acute stage. Chronic No No There is no clinical evidence and no physiological rationale to
support the use of US in the chronic stage. May consider a trial of US in the acute stage at a low to
moderate dose (0.5 ‐ 1.0 W/cm 2 , pulsed 1:4 ‐1:1, 3 MHz, 5 mins for each treatment area equivalent in
size to transducer head). Consider NOT using US in the chronic stage. Extracorporeal shock wave
therapy (SWT) Acute No Yes There is expert opinion which suggests that SWT be reserved for chronic
stage. Consider NOT using Extracorporeal Shock Wave for the acute stage. Focused or radial SWT
(low energy) Chronic Yes 4 RCT 1 Cohort Yes 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 anesthetic required in
high energy protocols decreases the effectiveness of SWT. Therefore, using low energy SWT protocols
without the need for anesthetic 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.
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. April 20, 2012 Page 2 INTERVENTION
Iontophoresis using dexamethasone STAGE OF HEALING Acute CLINICAL RESEARCH
EVIDENCE Yes 1 RCT 1 review PUBLISHED EXPERT OPINION 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. Chronic No No There is no
evidence that anti ‐inflammatory intervention with iontophoresis using dexamethasone has a useful role
in the chronic stage. Taping Acute No Yes There is expert opinion to support the use of antipronation
taping in the acute stage. Chronic Yes 1 CS Yes There is expert opinion to support the use of
controlled pronation taping in the chronic stage. CLINICAL IMPLICATION *See final page for
description of categories 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.
Consider NOT using iontophoresis using dexamethasone in the chronic stage. May consider using
antipronation taping in the acute stage. May consider using antipronation taping in the chronic stage.
Orthotics Acute Yes 2 CS Yes 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.
Chronic Yes 2 CS Yes 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. 1 RCT Night splints and braces Heel
raise inserts Acute No Yes There is expert opinion to support the use of night splints and braces in the
acute stage. Chronic Yes 3 RCT Yes There is a moderate amount of evidence against the use of night
splints and braces in the chronic stage. Acute No Yes There is some expert opinion to support the use
of heel raise inserts in the acute stage. Chronic Yes 2 RCT Yes There is conflicting evidence for and
against the use of heel inserts in the chronic stage. Consider a trial of night splints and braces in the
acute stage. Consider NOT using night splints and braces in the chronic stage. May consider a trial of
inserts in the acute stage. Consider a trial of inserts in the chronic stage. April 20, 2012 Page 3
INTERVENTION STAGE OF HEALING CLINICAL RESEARCH EVIDENCE PUBLISHED
EXPERT OPINION TAKE HOME MESSAGE CLINICAL IMPLICATION *See final page for
description of categories Needling techniques Acupuncture (Traditional Chinese medicine, anatomical,
electrical) and Intramuscular stimulation Acute Chronic Yes 1 CS Yes 1 CS No No There is a small
amount of evidence to support the use of Traditional Chinese Medicine electroacupuncture in the acute
stage. There is expert opinion to support 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. 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; MA ‐ Meta ‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐
Systematic reviews 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 • http://www.physther.net/content/79/4/371/F1.large.jpg
� Detailed questionnaire, specific to Achilles tendinopathy e.g. the VISA ‐A questionnaire •
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. 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. April 20, 2012 Page 4 REFERENCES Please see Appendix C Achilles
Tendinopathy: Details of Individual Articles for the specific details on each of the articles referenced in
this document. MANUAL THERAPY Case studies Voorn, R. (1998). Case report: can sacroiliac joint
dysfunction cause chronic Achilles tendonitis? JOSPT. 27(6); 436 ‐443. Woodman RM, Pare L. (1982).
Evaluation and treatment of soft tissue lesions of the ankle and forefoot using a Cyriax approach.
Physical Therapy. 62 (8); 1144 ‐47. Christenson RE. (2007). Effectiveness of specific soft tissue
mobilizations for the management of Achilles tendinosis: Single case study ‐ Experimental design.
Manual Therapy,12; 63 ‐71. Expert Opinion Carcia CR, Martin RL, Houck J, Wukich DK. (2010).
Achilles pain, stiffness, and muscle power deficits: achilles tendinitis. J Orthop Sports Phys Therapy:
40 (9) A1‐A26. Systematic Reviews Brosseau L, Casimiro L, Milne S. et al. (2002). Deep transverse
friction massage for treating tendinitis. Cochrane Database Systematic Reviews. 4. EXERCISE
Observational Studies Alfredson H, Pietila T, Jonsson P & Lorentzon R. (1998). Heavy ‐load eccentric
calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports
Medicine. 26(3), 360 ‐66. Gaerdin A, Movin T, Svensson L & Shalabi A. (2010). The long ‐term clinical
and MRI results following eccentric calf muscle training in chronic Achilles tendinosis. Skeletal
Radiology. May, 39(5), 435 ‐42. Knobloch K, Schreibmueller L, Kraemer R, Jogodzinski M, Vogt, PM
& Redeker J. (2010). Gender and eccentric training in Achilles midportion tendinopathy. Knee
Surgery, Sports Traumatology, Arthroscopy. May, 18(5), 648 ‐55. Ohberg L, Lorentzon R & Alfredson
H. (2004). Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure
and decreased thickness at follow ‐up. British Journal of Sports Medicine. February, 38(1), 8 ‐11;
discussion 11. Petersen W, Welp R & Rosenbaum D. (2007). 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. October, 35(10), 1659 ‐67. Richards PJ, McCall IW, Day
C, Belcher J & Maffulli N. (2010). Longitiudinal microvascularity in Achilles tendinopathy. Skeletal
Radiology. June, 39(6), 509 ‐21. Roos EM, Engstrom M, Lagerquist A & Soderberg B. (2004). 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.
October, 14(5), 286 ‐95. Shalabi A, Kristoffersen ‐Wiberg M, Aspelin P & Movin T. (2004). Immediate
Achilles tendon response after strength training evaluated by MRI. Medicine and Science in Sports and
Exercise. November, 36(11), 1841 ‐6. Silbernagel KG, Brorsson A & Lundberg M. (2011). The
majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5 year
follow‐up. American Journal of Sports Medicine. March, 39(3), 607 ‐13. Silbernagel KG, Thomee R,
Eriksson BI & Karlsson, J. (2007). Full symptomatic recovery does not ensure full recovery of muscle
tendon function in patients with Achilles tendinopathy. British Journal of Sports Medicine. April,
41(4), 276 ‐80; discussion 280. Verrall G, Scholfield, S & Brustad T. (2011). Chronic Achilles
tendinopathy treated with eccentric stretching program. Foot Ankle International. September, 32(9),
843‐9. Westh E, Kongsgaard M, Bojsen ‐Moller J, Aagaard P, Hansen M, Kjaer M & Magnuson, S.P.
(2008). Effect of habitual exercise on the structural and mechanical properties of human tendon, in
vivo, in men and women. Scandinavian Journal of Medicine and Science in Sports. Feb;18(1):23 ‐30.
RCTs Backman LJ, Andersson G, Wennstig G, Forsgren S & Danielson P. (2011). Endogenous
substance P production in the Achilles tendon increases with loading in an in vivo model of
tendinopathy ‐ peptidergic elevation preceding tendinosis ‐like tissue changes. Journal of
Musculoskeletal and Neuronal Interactions, June, 11(2), 133 ‐40. Rompe JD, Furia J & Maffulli N.
(2009). Eccentric loading versus eccentric loading plus shock ‐wave treatment for mid ‐portion Achilles
tendinopathy: a randomized controlled trial. American Journal of Sports Medicine, March, 37(3), 463 ‐
70. Rompe JD, Nafe B, Furia JP & Maffulli N. (2007). Eccentric loading, shock ‐wave treatment, or a
wait and see policy for tendinopathy of the main body of tendo Achilles: a randomized controlled trial.
American Journal of Sports Medicine, March, 35(3): 374 ‐83. Silbernagel K, Thomee P & Karlson J.
(2001). Eccentric overload training for patients with chronic achilles tendinopathy ‐ a randomized
controlled study with reliability testing of the evaluating methods. Scandanavian Journal of Medicine
and Science in Sports, 11: 197 ‐206. Silbernagel KG, Thomee R, Eriksson BI & Karlsson J. (2007).
Continued sports activity, using a pain ‐monitoring model during rehabilitation in patients with Achilles
tendinopathy: a randomized controlled study. American Journal of Sports Medicine, June, 35(6): 897 ‐
906. Systematic Reviews Kingma JJ, de Knikker R, Wittink HM,& Takken T. (2007). Eccentric
Overload Training in Patients with Chronic AT: A systematic review. British Journal of Sports
Medicine. June, 41(6): e3. Kraemer R, Lorenzen J, Vogt PM & Knobloch K . (2010). Systematic
review about eccentric training in chronic achilles tendinopathy. Sportverletz Sportschaden. December,
24(4): 204 ‐11. [Article in German, Abstract translated] Magnussen RA, Dunn WR & Thomson AB.
(2009). Nonoperative treatment of midportion Achille tendinopathy: a systematic review. Clinical
Journal of Sport Medicine. January, 19(1): 54 ‐64. Meyer A, Tumility S & Baxter GD. (2009).
Eccentric exercise protocols for chronic non ‐insertional Achilles tendinopathy: how much is enough?
Scandanavian Journal of Medicine and Science in Sports. October, 19(5), 609 ‐15. Wasielewski NJ &
Kotsko KM. (2007). Does eccentric exercise reduce pain and improve strength in physically active
adults with symptomatic lower extremity tendinosis? A systematic review. Journal of Athletic
Training. Jul‐Sep, 42(3): 409 ‐21. Woodley BL, Newsham ‐West RJ & Baxter GD. (2007). Chronic
tendinopathy: effectiveness of eccentric exercise. British Journal of Sports Medicine. April, 41(4): 188 ‐
98; discussion 199. Expert Opinion Magnusson SP, Langberg H & Kjaer M. (2010). The pathogenesis
of tendinopathy: balancing the response to loading. Nature Reviews Rheumatology. May, 6(5): 262 ‐8.
LASER RCTs Bjordal, JM. (2006). A randomised, placebo controlled trial of low level laser therapy
for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2
concentrations. British Journal of Sports Medicine, 40(1): 76–80. Darre E, Klokker M & Lund P.
(1994). Laserbehandling af akillessenetendinit. Ugeskr Laeger. Nov 7; 156 (45): 6680 ‐3. Danish.
Stergioula A, Stergioula M, Aarskog R, Lopes ‐Martins RAB & Bjordal JM (2008). Effects of low ‐level
laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles
tendinopathy. The American Journal of Sports Medicine, 36(5): 881–887. Tumilty S, Munn J, Abbott
JH, McDonough S, Hurley DA & Baxter GD. (2008). Laser therapy in the treatment of Achilles
tendinopathy: a pilot study. Photomedicine and Laser Surgery, 26(1): 25–30. Tumilty S, Munn J,
Abbott JH, McDonough S, Hurley DA, Basford JR & Baxter G.D. (2010). Laser Therapy in the
Treatment of Achilles Tendinopathy: A Randomised Controlled Trial. AIP Conf. Proc.May 31. Volume
1226, pp. 163 ‐169. Systematic Reviews Bjordal J & Couppe C. (2001). Low Level Laser Therapy for
Tendinopathy. Evidence of A Dose ‐Response Pattern. Physical Therapy Reviews, 6: 91 ‐99. Bjordal
JM, Lopes‐Martins RAB, Joensen J & Iversen VV. (2010). The anti ‐inflammatory mechanism of low
level laser therapy and its relevance for clinical use in physiotherapy. Physical Therapy Reviews,
15(4): 286–293. Peplow PV, Chung TY & Baxter GD. (2010). Application of low level laser
technologies for pain relief and wound healing: overview of scientific bases. Physical Therapy
Reviews, 15(4): 253–285. Meta ‐analysis Tumilty S, Munn J, McDonough S, Hurley D A, Basford JR &
Baxter GD. (2010). Low level laser treatment of tendinopathy: a systematic review with meta ‐analysis
Photomedicine and Laser Surgery, 28(1): 3–16. April 20, 2012 Page 5 EXTRA-CORPOREAL SHOCK
WAVE THERAPY – LOW ENERGY (FOCUSED AND RADIAL) Cohort Lakshmanan P, O’Doherty
D. (2004). Chronic Achilles tendinopathy: treatment with extra ‐corporeal shock wave therapy. Foot
and Ankle Surgery. 10: 125 ‐130. RCTs Costa ML, Shepstone L, Donell ST, Thomas TL. (2005). Shock
WaveTherapy for chronic Achilles tendon pain: a randomized placebo controlled trial. Clinical
Orthopedics and Related Research. 440: 199 ‐204. Rompe J, Nafe B, Furia J. (2007). Eccentric loading,
shock wave therapy or ‘wait and see’ policy for tendinopathy of the main body of tendo achillis: a
randomized controlled trial. American Journal of Sports Medicine. 35(3): 374 ‐383. Rompe J, Furia J,
Maffulli N. (2009). Eccentric loading vs eccentric loading plus shock wave treatment for mid ‐portion
Achilles tendinopathy. A randomized controlled trial. American Journal of Sports Medicine. 37(3):
463‐470. Rasmussen S, Christensen M, Mathiesen I, Simonson O. (2008). Shock wave therapy for
chronic Achilles tendinopathy: a double ‐blind, randomized clinical trial of efficacy. Acta
Orthopaedica. 79(2): 249 ‐256. BRACES AND NIGHT SPLINTS Knobloch K, Schreibmueller L,
Longo UG et al. (2008). 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. Disabil Rehabil 30: 1685 ‐91. Petersen W, Welp R & Rosenbaum D. (2007).
Chronic Achilles tendinopathy: a prospective randomized study comparing the therapeutic effect of
eccentric training, the AirHeel brace, and a combination of both. Am J Sports Med; 35: 1659 ‐67. de
Vos RJ, Weir A, Visser RJ et al. (2007). The additional value of a night splint to eccentric exercises in
chronic midportion Achilles tendinopathy: a randomised controlled trial. Br J Sports Med; 41: e5.
HEEL RAISE INSERTS MacLellan GE & Vyvyan B.(1981). Management of pain beneath the heel and
Achilles tendonitis with visco ‐elastic heel inserts. Br J Sports Med. Jun; 15(2): 117 ‐21. Lowdon A,
Bader DL & Mowat AG (1984). The effect of heel pads on the treatment of Achilles tendinitis: a
double blind trial. Am J Sports Med. Nov ‐Dec; 12(6): 431 ‐5. IONTOPHORESIS WITH
DEXAMETHASONE RCTs Neeter C, Thomee R, Silbernagel K, Thomee P, Karlson J. (2003).
Iontophoresis with and without dexamethasone in the treatment of acute Achilles tendon pain.
Scandinavian Journal of Medicine and Science in Sports. 13(6): 376 ‐382. NEEDLING
TECHNIQUES/ACUPUNCTURE Jens Foell S (2010). Is electro ‐acupuncture a safe and cost ‐effective
treatment for Achilles tendonopathy in a primary care setting? International Musculoskeletal Medicine.
32( 2) 51 ‐54. Fagan N & Staten P. (2003). An audit of self ‐acupuncture in primary care. Acupunct
Med; 21 :28‐31. Review Brown CD, Lauber CA. (2011). Evidence ‐based guidelines for utilization of
dexamethasone iontophoresis. International Journal of Athletic Therapy and Training. 16(4): 33 ‐36.
TAPING Riddle DL & Freeman DB. (1988). Management of a patient with a diagnosis of bilateral
plantar fasciitis and Achilles tendinitis. A case report. Phys Ther. Dec; 68(12): 1913 ‐6. Smith M,
Brooker S, Vicenzino B & McPoil T. (2004). Use of anti ‐pronation taping to assess suitability of
orthotic prescription: case report. Aust J Physiother.; 50(2): 111 ‐3. ORTHOTICS Mayer F,
Hirschmuller A, Muller S, Schuberth M & Baur H. (2007). Effects of short ‐term treatment strategies
over 4 weeks in Achilles tendinopathy. Br J Sports Med, 41(7): e6. Gross ML, Davlin L & Evanski PM
(1991). Effectiveness of orthotic shoe inserts in the long ‐distance runner. Am J Sports Med 19: 409–
412. Donoghue OA, Harrison AJ, Laxton P & Jones RK.(2008). Orthotic control of rear foot and lower
limb motion during running in participants with chronic Achilles tendon injury. Sports Biomech. May;
7(2): 194 ‐205. Greene BL. (2002). Physical therapist management of fluoroquinolone ‐induced Achilles
tendinopathy. Phys Ther. Dec; 82(12): 1224 ‐31. Riddle DL & Freeman DB. (1988). Management of a
patient with a diagnosis of bilateral plantar fasciitis and Achilles tendinitis. A case report. Phys Ther.
Dec; 68(12): 1913 ‐6. April 20, 2012 Page 6 Achilles Tendinopathy Toolkit - PhysiopediaIntroduction to
the Achilles Tendinopathy Project The Achilles Tendinopathy Toolkit is an evidence based clinical
decision making aid to assist clinicians in their management of achilles tendinopathy. Background to
the Project Translation of knowledge to practice in health care is a significant challenge[1][2][3]. A
project was undertaken by a unique partnership of physical therapy researchers, educators and expert
clinicians to address the gap between evidence and practice in the management of Achilles
Tendinopathy. Physiotherapy clinicians in British Columbia requested evidence-informed guidance on
the management of tendinopathy. To address this need the provincial Physical Therapy Knowledge
Broker assembled a team of researchers, educators and expert clinicians with the mandate to develop,
disseminate and implement a toolkit of decision aids to guide clinical decision-making for Achilles
Tendinopathy. Toolkit Development The process to develop the toolkit involved the following
components[1][2][3][4]: Identification of the purpose and scope of the project Agreement on the
processes for selection of content and format Creation of a mechanism for resolution of conflicting
opinion An iterative feedback process with stakeholders The incorporation of concepts and strategies
from the knowledge translation and implementation science literature to support the stages of
knowledge synthesis, dissemination and implementation. The Achilles Tendionopathy Toolkit The
‘Tendinopathy Toolkit’[5] included: A tabulated summary of the evidence for manual therapy,
exercise, low level laser therapy, ultrasound, extracorporeal shock wave therapy, iontophoresis using
dexamethasone, taping, orthotics, night splints and braces, heel raise inserts, needling techniques, and
the appropriate outcome measures for this population [targeted ‘take home messages’ and clinical
implications for each were also included] An algorithm to guide the sequence of interventions
Appendices including: a) exercise programs b) low level laser dosage calculation c) tabulated details
for each article reviewed and d) a review of common medical interventions. The second phase of the
initiative – utilization of strategies to enhance implementation and uptake of the toolkit - is currently
being undertaken. Clinicians want to provide evidence-informed management of tendinopathy but
many struggle with accessing, appraising and synthesizing the vast array of literature available on this
topic. This KT initiative highlights the need for, challenges associated with, evidence-informed process
for and positive response to the development of decision aids synthesizing the current evidence to
guide clinical management of this patient population. Access the Achilles Tendinopathy Toolkit
Treatment Algorithm Summary of Interventions Appendix A: Exercise Programs Appendix B: Low
Level Laser Therapy Dosage Calculation Appendix C: Details of Articles on Interventions Appendix
D: Medical and Surgical Interventions
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. 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.

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Stage of Acute Chronic

Stage of Acute Chronic

CS ‐ Case studies; SR ‐ Systematic reviews.

Stage of Acute Chronic

Published Yes[33] Yes[33]

Clinical May consider using stretching exercises in Strongly consider using eccentric exercise in t

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

Low level laser therapy (LLLT)

Clinical research Yes Y

Published expert Yes Y

*See 'Appendix B 'for further details on calculation of dosage. *

MA ‐ Meta‐analyses; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews.

Extracorporeal shock wave therapy (ESWT)

Stage of Acute Chronic

Published Yes Yes

Clinical Consider NOT using Consider a trial of ESWT in the chronic stage,

ESWT may enhance outcomes compared to exercise alon

Iontophoresis using dexamethasone

Stage of Acute Chronic

Clinical research Yes No

Stage of pathology Acute Chronic

Clinical research No Yes

Published expert Yes Yes

CS ‐ Case studies; SR - Systematic Review

Clinical research Yes Yes

Published expert Yes Yes

Night splints and braces

Stage of pathology Acute Chronic

Clinical research No Yes

Published expert Yes Yes

RCT ‐ Randomized controlled trials; SR - Systematic Review

Stage of pathology Acute Chronic

Clinical research No Yes

Published expert Yes Yes

RCT ‐ Randomized controlled trials.

Needling techniques [70][71]

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

Stage of Acute Chronic

Clinical Yes Yes

Clinical Consider a trial of electro‐acupuncture in the acute stage. Consider a t

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A. Patient reported outcome measure

B. Patient specific functional outcome measure

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Explanation of clinical implications

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See 'Appendix B 'for further details on calculation of dosage.