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Is physiotherapy effective for patients with a chronic mid-body Achilles tendinopathy? A systematic review of non-surgical and non-pharmacological interventions
Abstract and Figures
Objective: To assess the effectiveness of physiotherapy interventions (non-surgical and nonpharmacological) for a chronic mid-body Achilles tendinopathy. Materials and methods: A search of published and grey literature databases was undertaken (January 1999 to January 2011). Two reviewers independently assessed the studies for eligibility using a strict inclusion and exclusion criteria. All eligible articles were assessed critically using the PEDro score. Data on cohort characteristics, diagnostic criteria, treatment intervention, outcome measures, and results were extracted. A narrative research synthesis method was adopted since there were insufficient data to conduct a metaanalysis. Results: Two hundred and ninety studies were identified. Nine publications met the review inclusion criteria. Methodological quality was adequate for all nine studies; however, blinding was a limitation for most. Interventions investigated were; exercises (n= 2), low-level laser therapy (n = 1), low-energy shockwave treatment (SWT) (n= 3), air cast brace (n = 2), and insoles (n = 1). Some evidence exists for eccentric exercises in combination with SWT or laser. In contrast to other reviews, eccentric exercises alone were not found to be superior to other physiotherapy treatments. Conclusion: There is an insufficient evidence to determine which method of physiotherapy is most appropriate for a chronic mid-body Achilles tendinopathy. Further well-designed randomized controlled trials assessing physiotherapy interventions with specific diagnostic criteria and appropriate outcome tools are required to determine the efficacy of physiotherapy for the condition. © The Society of Orthopaedic Medicine and the British Institute of Musculoskeletal Medicine 2011.
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... Many modalities are used in the management of this tendon pathology and new innovative treatments are frequently emerging (Hutchison et al., 2011). Patients and clinicians face a range of nonoperative treatment options such as exercise, insoles, electrotherapy and injections. ...
... Many modalities are used in the management of this tendon pathology and new innovative treatments are frequently emerging (Hutchison et al., 2011). Patients and clinicians face a range of nonoperative treatment options such as exercise, insoles, electrotherapy and injections. ...
Background
Achilles tendinopathy is a common pathology that is considered difficult to treat. At a time of austerity in the NHS it is essential to have carefully designed pathways that are monitored in terms of cost and effectiveness. However, a paucity of evidence exists for what the “best value” dedicated “joined up” pathway of care is for this difficult condition.
Objectives
Design, implement and evaluate the impact of a new therapist lead pathway for Tendon- Achilles Pain (TAP).
Methods
Process mapping, driver diagrams, stakeholder analysis and a series of Plan-Do-Study-Act cycles were used to design and implement TAP. To assess the impact of TAP, data was compared on whole system measures for 46 patients treated with referral to the traditional service (without TAP) and 46 patients managed according to the newly designed pathway (with TAP). A cost analysis was also conducted.
Results
A quality improvement approach led to the successful design and implementation of a therapist lead TAP.
The impact of TAP included positive effects on patient satisfaction, a decrease in duplication of treatments, investigations and inappropriate reviews with consultants. No safety concerns were found. TAP was also £44,000 cheaper per annum than the previous service.
Conclusion
Collaboration between orthopaedic and therapy services has resulted in a standardised pathway of care for patients with an Achilles tendinopathy. It has removed unwanted variation, provided an opportunity to monitor the outcomes of treatments and resulted in decreased cost for the health board.
... 1,[5][6][7] Recent reviews have reported a lack of high-quality clinical trials in this area. 8 Although there is some evidence to support the use of eccentric exercises in combination with laser 9 or shock-wave therapy, 10 there is little to suggest which method of physiotherapy is the most appropriate. ...
We conducted a randomised controlled trial to determine whether active intense pulsed light (IPL) is an effective treatment for patients with chronic mid-body Achilles tendinopathy. A total of 47 patients were randomly assigned to three weekly therapeutic or placebo IPL treatments. The primary outcome measure was the Victorian Institute of Sport Assessment – Achilles (VISA-A) score. Secondary outcomes were a visual analogue scale for pain (VAS) and the Lower Extremity Functional Scale (LEFS). Outcomes were recorded at baseline, six weeks and 12 weeks following treatment. Ultrasound assessment of the thickness of the tendon and neovascularisation were also recorded before and after treatment.
There was no significant difference between the groups for any of the outcome scores or ultrasound measurements by 12 weeks, showing no measurable benefit from treatment with IPL in patients with Achilles tendinopathy.
Cite this article: Bone Joint J 2013;95-B:504–9.
Background
Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.
Review questions
(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?
Methods
A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases ( n = 9), trial registries ( n = 6), grey literature databases ( n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.
Results
Scoping review – 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy.
Efficacy reviews – 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect size Resistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect size Resistance:Proprioception = 0.16 [95% CrI −1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect size EccentricOnly:Concentric+Eccentric = 0.48 [95% CrI −0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3).
Mixed-method review – 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients’ and providers’ prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.
Limitations
Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.
Conclusion
The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.
Future work
There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.
Study registration
This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.
Background
Achilles tendinopathy describes the clinical presentation of pain localised to the Achilles tendon and associated loss of function with tendon loading activities. However, clinicians display differing approaches to the diagnosis of Achilles tendinopathy due to inconsistency in the clinical terminology, an evolving understanding of the pathophysiology, and the lack of consensus on clinical tests which could be considered the gold standard for diagnosing Achilles tendinopathy. The primary aim of this scoping review is to provide a method for clinically diagnosing Achilles tendinopathy that aligns with the nine core health domains.
Methodology
A scoping review was conducted to synthesise available evidence on the clinical diagnosis and clinical outcome measures of Achilles tendinopathy. Extracted data included author, year of publication, participant characteristics, methods for diagnosing Achilles tendinopathy and outcome measures.
Results
A total of 159 articles were included in this scoping review. The most commonly used subjective measure was self-reported location of pain, while additional measures included pain with tendon loading activity, duration of symptoms and tendon stiffness. The most commonly identified objective clinical test for Achilles tendinopathy was tendon palpation (including pain on palpation, localised tendon thickening or localised swelling). Further objective tests used to assess Achilles tendinopathy included tendon pain during loading activities (single-leg heel raises and hopping) and the Royal London Hospital Test and the Painful Arc Sign. The VISA-A questionnaire as the most commonly used outcome measure to monitor Achilles tendinopathy. However, psychological factors (PES, TKS and PCS) and overall quality of life (SF-12, SF-36 and EQ-5D-5L) were less frequently measured.
Conclusions
There is significant variation in the methodology and outcome measures used to diagnose Achilles tendinopathy. A method for diagnosing Achilles tendinopathy is proposed, that includes both results from the scoping review and recent recommendations for reporting results in tendinopathy.
Objective
To summarize evidence in the last decade regarding the efficacy of physical therapy interventions to treat tendinopathy, as a single disease entity, as determined in systematic reviews (SRs) and/or meta-analyses (MAs).
Methods
Electronic search of PubMed, PEDro, and Scopus database was performed from year 2010 to January 2020. The methodological quality of the identified studies was assessed using the AMSTAR 2 tool. Studies scoring 9 points or higher were further analyzed using GRADE principles.
Results
40 SRs and/or MAs were included in qualitative synthesis, whereas only 5 MAs were included in quantitative synthesis. Low-level laser therapy (LLLT) intervention showed a pooled improvement in pain reduction of 1.53 cm; 95% CI, [1.14, 1.91] (I²=1.9%, p=0.361) on visual analogue scale, and grip strength of 9.59 kg; 95% CI, [5.90, 13.27].
Conclusions
Moderate-quality evidence may support these following interventions: LLLT revealed a statistically and potentially clinically significant improvement in pain and function on the short-term. Extracorporeal shockwave therapy showed a statistically significant enhancement in pain and function at all follow-up durations; however, its clinical significance was undetermined. Eccentric exercise was supported by qualitative evidence only. Caution is advised when interpreting results due to possible pathological differences in tendinopathy at each region.
Chronic Achilles tendinosis is commonly seen in clinical practice however the causes are largely unknown. In the last ten years good results have been reported with a range of approaches, one of which is eccentric training. Objective: This study reports on a systematic review of the literature to determine the effectiveness of eccentric training compared with other types of interventions for chronic Achilles tendinosis. Method: A systematic review of the published research literature was conducted to examine the quantity, nature, quality and significance of literature relevant to the effectiveness of eccentric training for chronic Achilles tendinosis. Subject inclusion criteria were being at least 16 years of age, having a minimum of three months of complaints and no other underlying pathologies. Results: Seven databases were searched, and 25 studies were included. They reflected a variety of research designs and study quality. Comparison interventions included surgery, medications and passive treatment. An index combining results and quality showed that the best options for managing Achilles tendinosis were medication and eccentric exercises. Taking account of factors such as cost, safety and inconvenience, eccentric exercises are favoured over drug intervention. Conclusion: Eccentric exercises are simple to perform and provide a cost effective, safe and efficient way to treat Achilles tendinosis. They should be considered first for all patients, before invasive interventions such as surgery and drug therapy.
Achilles tendinopathy is a common overuse injury in athletes, especially older athletes. This condition is difficult to treat and often becomes chronic. This evidence based review summarized the current pathophysiological principles guiding research as well as clinical practice and synthesized the search results to determine if eccentric exercises were effective in the treatment of patients with Achilles tendinopathy. Seven studies were identified, but only two were randomized clinical trials (level A evidence) with the rest controlled clinical studies or prospective cohort studies (level B evidence). Only one study reported follow-up one year beyond the intervention period. Based on a crossectinal analysis of post treatment outcomes, there was modest but significant clinical benefits following eccentric exercise training, but insufficient evidence to predict the long-term effects of eccentric exercise training for the management of Achilles tendinopathy. Although randomized clinical trials with a large subject population are still needed, eccentric exercise paired with biomedical training techniques should be integrated into treatment guidelines for patients with Achilles tendonitis.
Background —There is no disease specific, reliable, and valid clinical measure of Achilles tendinopathy.
Objective —To develop and test a questionnaire based instrument that would serve as an index of severity of Achilles tendinopathy.
Methods —Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire to assess the severity of Achilles tendinopathy. The final version consisted of eight questions that measured the domains of pain, function in daily living, and sporting activity. Results range from 0 to 100, where 100 represents the perfect score. Its validity and reliability were then tested in a population of non-surgical patients with Achilles tendinopathy (n = 45), presurgical patients with Achilles tendinopathy (n = 14), and two normal control populations (total n = 87).
Results —The VISA-A questionnaire had good test-retest ( r = 0.93), intrarater (three tests, r = 0.90), and interrater ( r = 0.90) reliability as well as good stability when compared one week apart ( r = 0.81). The mean (95% confidence interval) VISA-A score in the non-surgical patients was 64 (59–69), in presurgical patients 44 (28–60), and in control subjects it exceeded 96 (94–99). Thus the VISA-A score was higher in non-surgical than presurgical patients (p = 0.02) and higher in control subjects than in both patient populations (p<0.001).
Conclusions —The VISA-A questionnaire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects. The continuous numerical result of the VISA-A questionnaire has the potential to provide utility in both the clinical setting and research. The test is not designed to be diagnostic. Further studies are needed to determine whether the VISA-A score predicts prognosis.
Tendinitis such as that of the Achilles, lateral elbow, and rotator cuff tendons is a common presentation to family practitioners and various medical specialists.1 Most currently practising general practitioners were taught, and many still believe, that patients who present with overuse tendinitis have a largely inflammatory condition and will benefit from anti-inflammatory medication. Unfortunately this dogma is deeply entrenched. Ten of 11 readily available sports medicine texts specifically recommend non-steroidal anti-inflammatory drugs for treating painful conditions like Achilles and patellar tendinitis despite the lack of a biological rationale or clinical evidence for this approach. 2 3
Instead of adhering to the myths above, physicians should acknowledge that painful overuse tendon conditions have a non-inflammatory pathology. Light …
Achilles tendinitis is one of the most common of all sports injuries. There is no consensus on treatment.
To assess the effectiveness of various treatment interventions for acute and chronic Achilles tendinitis in adults.
The Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2000), Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2000), MEDLINE (1966 to December 2000), EMBASE (1980 to 2001 wk 04), CINAHL (1982 to December 2000), and reference lists of identified trials were searched.
Randomised or quasi-randomised trials of treatment interventions for acute and chronic Achilles tendinitis in adults. Studies focusing on pathological tendinitis were excluded. Excluded were those trials that compared different dosages of the same drug or drugs within the same class of drugs, for example different non-steroidal anti-inflammatory drugs (NSAIDs).
Three reviewers independently assessed trial quality, by use of a ten item check list, and extracted data. Requests were sent for separate data for Achilles tendinitis patients in studies within trials of mixed patient populations. Where possible, quantitative analysis and limited pooling of data were undertaken.
Nine trials, involving 697 patients, met the inclusion criteria of the review. Methodological quality was adequate in most of the trials with regards to blinding but the assessment of outcome was incomplete and short-term.There was weak but not robust evidence from three trials of a modest benefit of NSAIDs for the alleviation of acute symptoms. There was some weak evidence of no difference compared with no treatment of low dose heparin, heel pads, topical laser therapy and peritendonous steroid injection, but this could not be fully evaluated from the reports of four trials. The results of an experimental preparation of a calf-derived deproteinized haemodialysate, Actovegin, were promising but the severity of patient symptoms was questionable in the single small trial testing this comparison. The results of a comparison of glycosaminoglycan sulfate with a NSAID were inconclusive.
There is insufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate for the treatment of acute or chronic Achilles tendinitis. Further research is warranted.
Prognosis and treatment of Achilles tendon pain (achillodynia) has been insufficiently studied. The purpose of the present study was to examine the long-term effect of eccentric exercises compared with stretching exercises on patients with achillodynia.
Patients with achillodynia for at least 3 months were randomly allocated to one of two exercise regimens. Exercise was performed daily for a 3-month period. Symptom severity was evaluated by tendon tenderness, ultrasonography, a questionnaire on pain and other symptoms, and a global assessment of improvement. Follow-up was performed at time points 3, 6, 9, 12 weeks and 1 year.
Of 53 patients with achillodynia 45 patients were randomized to either eccentric exercises or stretching exercises. Symptoms gradually improved during the 1-year follow-up period and were significantly better assessed by pain and symptoms after 3 weeks and all later visits. However, no significant differences could be observed between the two groups. Women and patients with symptoms from the distal part of the tendon had significantly less improvement.
Marked improvement in symptoms and findings could be gradually observed in both groups during the 1-year follow-up period. To that extent this is due to effect of both regimens or the spontaneous improvement is unsettled.