sports focus team evidence-based treatment of achilles tendinitis insertional vs non-insertional

Sports Focus Team

Evidence-Based Treatment of Achilles Tendinitis

Insertional vs Non-Insertional

Team Members

bull Eric Williams

bull Barbara Edwards

bull Hung Do

Achilles Tendinopathy

bull McShane et al states that achilles tendinopathy is generally caused by chronic stress to the tendon

bull Ultrasound imaging can help identify the abnormal portion of tendon

bull Khan et al and Maffulli et al popularized the term achilles tendinopathy to describe the triad of tendon pain swelling and impaired performance


bull Cain et classifies achilles tendinopathy as insertional and mid-substance (non-insertional)

bull Insertional ndash within 2 cm of its insertionbull Mid-substance ndash 2-6 cm proximal to its insertion

Achilles Tendinopathybull Maffulli et al used the term ldquotendinopathyrdquo when

referring to diagnosis for pain swelling and impaired performance

bull They reserved more specific terms including tendonitis for cases when inflammation or degeneration has been confirmed

Review of Literature

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

Review of Literature bull There were just as many Level I studies

comparing several treatment options

bull Double blind study of the effects of heel pad on tendinitis

bull Randomized study comparing eccentric training air heel brace and combo of both


bull A randomized controlled trial comparing shockwave treatment with eccentric loading

bull Randomized Placebo ndash Controlled Trial Shock Wave Therapy for chronic Achilles tendon pain

Treatment Comparisonsbull Air Heel Brace

bull Heel PadsSplints

bull ShockWave Therapy

bull Eccentric Exercises

Anatomy of the Achilles Tendon

bull Origin of the Achilles is the thick extension of 3 muscles in the lower leg

bull Gastrocnemiusbull Soleusbull Plantarisbull Achilles tendon is the thickest and strongest tendon in

the bodybull 15 cm long


bull AT begins near the middle of the calf musclebull Insertion ndash middle part of the posterior surface of

the calcaneusbull The small saphenous vein is located on the

lateral side of the Achilles but is superficial to itbull Muscle reflex tests the integrity of the S1 spinal

root

Injuries of the Achilles Tendon

AirHeel Brace

Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace A randomized controlled trial A effects on pain and microcirculation

Knobloch K Schreibmueller L Longo UG Vogt PMDisabil Rehabil 200830(20-22)1685-91

bull Purpose ndash To compare eccentric training and the combination of eccentric training with the AirHeel Brace for the management of tendinopathy of the main body of the Achilles tendon

bull Methods ndash 116 with unilateral tendonitis of the main body (non-insertional) were randomized in two groups



bull Group A ndash performed eccentric training wAirHeel Brace

bull Group B ndash performed the same eccentric training wo the AirHeel Brace

bull Test the null Hypothesis that patients wtendonitis in the main body of the Achilles tendon there is no difference in clinical outcome and micro-vascular parameters

Results

bull The FAOS score and the VAS score showed significant improvements from pre-operative to post-operative values in both groups (A 51 +- 2 vs 29 +- 24 43 reduction and B 54 +- 21 vs 36 +- 24 33 reduction both p = 00001) There were no statistically significant differences in FAOS score and VAS score when comparing the two groups after the end of the intervention

bull In Group A tendon oxygen saturation in the main body of the Achilles tendon showed significant increase from pre- to post-management values (68 +- 12 vs74 +- 8 p = 0003) Post-capillary venous filling pressures showed significant reduction from pre- to post-intervention values

Chronic Achilles tendinopathy a prospective randomized study comparing the therapeutic effect of eccentric training the AirHeel brace and a combination of both

Petersen W Welp R Rosenbaum DAm J Sports Med 2007 Oct35(10)1659-67 Epub 2007 Jun 14

bull Purpose ndash To evaluate 3 different treatment protocols for chronic mid-portion tendinopathy of the Achilles tendon

bull Method ndash One hundred patients were randomly assigned to 1 of 3 different treatment groups

bull Group 1 ndash Eccentric Training (37 patients)bull Group 2 ndash AirHeel Brace (35 patients)bull Group 3 ndash Combination of eccentric training and

the AirHeel Brace (28 patients)

Eccentric Exercises

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

Results

bull VAS score for pain AOFAS score and SF-36 improved significantly in all 3 groups at all 3 follow-up exams

bull At the 3 time points of 612 and 54 weeks of follow-up there was no significant difference between all 3 treatments

Heel Pads

The effect of heel pads on the treatment of Achilles tendinitis a double blind trial

Lowdon A Bader DL Mowat AGAm J Sports Med 1984 Nov-Dec12(6)431-5

bull Purpose - To investigate the efficacy of heel pads in the treatment of Achilles tendonitis

bull Methods ndash 33 patients (26 male 13 female) ages 11 to 51 were randomly allocated to one of three treatment groups



bull Group I ndash was provided wSorbothane heel pads to be worn in all sports and walking for 2 months

bull Group II ndash was provided with soft sponge rubber pads of ldquoMolefoamrdquo

bull Group III ndash received no padsbull Ptrsquos in all 3 groups received five consecutive

daily 5 min ultrasound treatments (075 MHz pulsed 11 wcoupling gel)

Results

bull Patients in Group III (ultrasound and exercise) had the most significant difference in the reduction of both swelling and tenderness

bull The study revealed that ptrsquos with relatively short duration of injury were more likely to experience changes in gait parameters of interest

Night Splints

The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy a randomised controlled trial

de Vos RJ Weir A Visser RJ de Winter T Tol JLBr J Sports Med 2007 Jul41(7)e5 Epub 2006 Dec 18

bull Purpose - To assess whether the use of night splints is of added benefit on functional outcomes in treating chronic mid-portion Achilles tendonitis

bull 70 tendons were included and randomized into two groups

bull Group A ndash Eccentric exercise w a night splint (n=36)

bull Group B ndash Eccentric exercise only (n=34)



bull Both groups completed a 12 week heavy load eccentric training program w group A also receiving a night splint to wear at night

bull Inclusion ndash age 18 -70 years active in sports and tendon pain localized at 2 -7cm from distal insertion

bull Exclusion ndash insertional disorders partial or complete ruptures or systemic illness

Results

bull At 12 weeks pt satisfaction in the eccentric group was 63 compared w 48 in the night splint group The VISA-A score in both groups improved and were not significantly different between the two nor in the ptrsquos satisfaction score

bull Night splints with eccentric training is not beneficial at short term follow-up

bull Further research trials needed

Shock WaveTherapy

Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy A randomized controlled trial

Rompe JD Furia J Maffulli N J Bone Joint Surg Am 2008 Jan90(1)52-61

bull METHODS Fifty patients with chronic (six months or more) recalcitrant insertional Achilles tendinopathy were enrolled in a randomized controlled study All patients had received treatment including local injections of an anesthetic andor corticosteroids a prescription of nonsteroidal anti-inflammatory drugs and physiotherapy without success for at least three months

bull Group I ndash 25 patients were allocated to receive eccentric calf strengthening exercises

bull Group II ndash 25 patients were allocated to treatment with repetitive low-energy shock wave therapy



bull Primary follow-up was at four months and afterward patients were allowed to cross over The last follow-up evaluation was at one year after completion of the initial treatment

bull The patients were assessed for pain function and activity with use of a validated questionnaire (the Victorian Institute of Sport Assessment-Achilles [VISA-A] questionnaire)



bull RESULTS At 4 months from baseline the VISA-A score increased in both groups from 50 to 73 points in group 1 (eccentric loading) and from 51 to 87 points in group 2 (eccentric loading plus shock-wave treatment)

bull Pain rating decreased in both groups from 7 to 4 points in group 1 and from 7 to 2 points in group 2 Nineteen of 34 patients in group 1 (56) and 28 of 34 patients in group 2 (82) reported a Likert scale of 1 or 2 points (completely recovered or much improved)

bull For all outcome measures groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up At 1 year from baseline there was no difference any longer with 15 failed patients of group 1 opting for having the combined therapy as cross-over and with 6 failed patients of group 2 having undergone surgery

Eccentric Exercises

Chronic Achilles tendon pain treated with eccentric calf-muscle trainingKnee Surg Sports Traumatol Arthrosc 2003 Sep11(5)327-33 Epub 2003 Aug 26

Fahlstroumlm M Jonsson P Lorentzon R Alfredson H

bull Purpose - The aim of this prospective study was to investigate if the previously achieved good clinical results could be reproduced in a larger group of patients and also to investigate the effects of eccentric calf-muscle training in patients with chronic insertional Achilles tendon pain

bull Methods ndash 78 Patients with chronic painful Achilles tendinosis at the mid-portion (2-6 cm) in a total of 101 tendons (55 unilateral and 23 bilateral) and 30 with chronic insertional Achilles tendon pain in 31 tendons (29 unilateral and one bilateral) were treated with eccentric calf-muscle training for 12 weeks

Eccentric Training Model







bull Resultsbull 90 of the 101 Achilles tendons (89) with

chronic painful non-insertional Achilles tendinosis improved after the 12-week training program

bull 1031 tendons (32) with chronic painful insertional Achilles tendinosis improved with 12 week program

Conclusion

bull In the majority of the studies we researched comparing eccentric training with other forms of treatments it was agreed that eccentric training was the most effective treatment for insertional and non-insertional Achilles tendonitis

bull Shockwave therapy was effective but it is not being used in the USA for Achilles tendonitis

THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8

Treatment Comparisons


Slide 11

Slide 12


AirHeel Brace

Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace A randomized controlled trial A effects on pain and microcirculation Knobloch K Schreibmueller L Longo UG Vogt PM Disabil Rehabil 200830(20-22)1685-91

Slide 16

Results

Chronic Achilles tendinopathy a prospective randomized study comparing the therapeutic effect of eccentric training the AirHeel brace and a combination of both Petersen W Welp R Rosenbaum D Am J Sports Med 2007 Oct35(10)1659-67 Epub 2007 Jun 14

Eccentric Exercises

Slide 20

Heel Pads

The effect of heel pads on the treatment of Achilles tendinitis a double blind trial Lowdon A Bader DL Mowat AG Am J Sports Med 1984 Nov-Dec12(6)431-5


Slide 24

Night Splints

The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy a randomised controlled trial de Vos RJ Weir A Visser RJ de Winter T Tol JL Br J Sports Med 2007 Jul41(7)e5 Epub 2006 Dec 18

Slide 27

Slide 28

Shock WaveTherapy

Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy A randomized controlled trial Rompe JD Furia J Maffulli N J Bone Joint Surg Am 2008 Jan90(1)52-61

Slide 31

Slide 32

Slide 33

Chronic Achilles tendon pain treated with eccentric calf-muscle training Knee Surg Sports Traumatol Arthrosc 2003 Sep11(5)327-33 Epub 2003 Aug 26 Fahlstroumlm M Jonsson P Lorentzon R Alfredson H


Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU

Team Members

bull Eric Williams

bull Barbara Edwards

bull Hung Do
































root


AirHeel Brace










Results









Eccentric Exercises


Results



Heel Pads











Results



Night Splints












Results




Shock WaveTherapy















Eccentric Exercises















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU
































root


AirHeel Brace










Results









Eccentric Exercises


Results



Heel Pads











Results



Night Splints












Results




Shock WaveTherapy















Eccentric Exercises















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU


AirHeel Brace










Results









Eccentric Exercises


Results



Heel Pads











Results



Night Splints












Results




Shock WaveTherapy















Eccentric Exercises















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU










Results









Eccentric Exercises


Results



Heel Pads











Results



Night Splints












Results




Shock WaveTherapy















Eccentric Exercises















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU







Eccentric Exercises


Results



Heel Pads











Results



Night Splints












Results




Shock WaveTherapy















Eccentric Exercises















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU

Results



Heel Pads











Results



Night Splints












Results




Shock WaveTherapy















Eccentric Exercises















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU

Heel Pads











Results



Night Splints












Results




Shock WaveTherapy















Eccentric Exercises















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU











Results



Night Splints












Results




Shock WaveTherapy















Eccentric Exercises















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU

Night Splints












Results




Shock WaveTherapy















Eccentric Exercises















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU












Results




Shock WaveTherapy















Eccentric Exercises















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU

Shock WaveTherapy















Eccentric Exercises















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU















Eccentric Exercises















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU















Conclusion



THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU

THANK YOU

Sports Focus Team

Team Members



Slide 5



Slide 8



Slide 11

Slide 12


AirHeel Brace


Slide 16

Results


Eccentric Exercises

Slide 20

Heel Pads



Slide 24

Night Splints


Slide 27

Slide 28

Shock WaveTherapy


Slide 31

Slide 32

Slide 33



Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Conclusion

THANK YOU

sports focus team evidence-based treatment of achilles tendinitis insertional vs non-insertional

Documents

achilles tendon slide

achilles tendon methods

achilles tendon origin

term achilles tendinopathy

achilles tendinopathy

chronic achilles tendon

airheel brace slide

long slide