I am reviewing a fairly recent article, 2011, on the conservative treatment of chronic Achilles tendinopathy. This article was published in the Canadian Medical Association Journal, the reference for the paper is CMAJ, July 12, 2011, 183(10) p.1159-65 http://www.cmaj.ca/content/183/10.toc
Why is Achilles tendinopathy an issue? About 52% of former runners had or do have Achilles tendinopathy and the annual incidence is between 7-9% of current runners.
Achilles tendinopathy is different than a partial or complete tear. The tendinopathy means that there is something wrong with the tendon but it is intact. Whereas, a partial or complete tear of a tendon may be in two pieces.
A lot of us are familiar with the term “tendinitis”. It basically means inflammation of the tendon. but tendinopathy, which means “sick tendon”, is when there is no more inflammation in the tendon but the tendon is still painful to touch or causes pain with just about any activity. The word chronic comes from the word of having the tendon issue for greater than 3 months. In medical terms, if you have had just about anything for longer than 3 months it is termed chronic. For example, if you have had pain for longer than 3 months, you are now termed as having chronic pain.
There are many different types of conservative treatment, basically anything that is not conservative treatment = surgery, for example ultrasound, laser, manual therapy… However, this review looked at only conservative treatments that were studied through randomized controlled trials.
Randomized controlled trials (RCT’s) = the group of the people being studied have an equal chance of being the in the treatment group or the control group. This type of study is what we think of as the best type for studying treatments, currently. There is a downside to the randomized controlled trials though. They are expensive, they are best with large groups of people and they take a long time to complete. Anyways, enough with that mumbo-jumbo, let’s get into the meat and potatoes of this study. They talked about: exercise, orthotics/braces/splints, NSAID’s, injection therapies, shockwave therapy and glyceryl trinitrate patches. I will go over what they said about each one.
This was the only intervention in the study with strong scientific evidence to back it up! The basics are to have a “…strong, controlled, mechanical force to the Achilles tendon”. This is usually done through eccentric, lengthening the muscle under tension, exercises. The exercises should be progressed, usually from two feet, one foot, then adding weighted vest or backpack. Rompe and colleagues found this to be superior to wait-and-see, 60%, success rate with exercise, vs 24%, success with wait-and-see.
Eccentric exercises were found to the be the superior exercise. However, it might “…take several weeks or months before a benefit is felt…”.
There is a downside to eccentric exercises. These include DOMS, delayed onset muscle soreness and causing a flare up the tendinopathy. On the bright side, there are no reports of tendon rupture caused by eccentric loading.
My thoughts: New Leaf Physiotherapy has always used eccentric exercises when after someone is assessed and has thought to have a tendinitis/ tendinopathy. It would be interesting to read all the studies used in these review because one thing that some physiotherapists do it give their patient’s 3 sets of 10 reps. New Leaf Physiotherapy likes to give a progression of repetitions so their client’s are always pushing forward with their body, causing it to adapt, with minimal discomfort.
“Orthotics may be helpful in conjunction with other modalities of treatment if there is an identifiable malalignment,, whereas braces and splints do not appear to improve outcomes in Achilles tendinopathy”. There was a study where the male runners had significant improvement however, there might be a little snag. The control group in this study did not get a pair of orthotics. This may possibly cause a placebo effect, where someone sees another runner not getting an orthotic and thinks they are special for getting an orthotic.
The use of an Aircast brace has been studied in two different studies. Both groups did eccentric exercises, one group with the Aircast brace. After 12 weeks, the addition of the Aircast did not improve the chance of success.
Night splints were also investigated. Again, everybody did an eccentric exercises and one group got a night splint. After 12 weeks, 63% of people that just got the exercises were satisfied and only 48% of people that used the night splint and exercises were satisfied.
First off, what the heck does NSAID stand for? NSAID = Nonsteroidal Anti-Inflammatory Drugs. This is a certain class of medications.
There were no RCT’s identified that met the criteria for this study. There was one study that had some clients with chronic Achilles tendinopathy of less than 6 months duration. There were 70 patients in the study and guess what they found? The results were identical for client receiving the NSAID medication and a placebo tablets. There is very little evidence supporting the use of NSAID medication with a chronic tendinopathy.
My thoughts: this is actually a good thing because by definition a tendinopathy is not inflamed, so they should not work. NSAIDs do also have a side effect that not many people talk about. After a client takes some NSAIDs, the quality of tissue laid down in the injured area is of lesser quality. I have heard more than a few stories from physiotherapists working with high level track athletes, taking NSAIDs to compete at a high level track meet, i.e. Olympics, only to have an injury after in the same area, sometimes worse. The physiotherapist thought the injuries had been caused by the poor quality of the tissue being laid down after taking the NSAIDs.
The two injection therapies discussed in the article,are corticosteroid vs. placebo and platelet-rich plasma injections.
Platelet-rich plasma injections were performed on patients with acute Achilles tendinopathy, some people had it for only 2 months (this review did not mention the outcome for the platelet-rich plasma injections on acute Achilles tendinopathy). For chronic Achilles tendinopathy, there is no evidence that supports or refutes the use of platelet-rich plasma injections.
Corticosteroid injections were performed in a randomized controlled trial, 24 patients. 12 got the placebo and 12 got the real thing,corticosteroid injection. Initially the patients that got the corticosteroid injection had improvements but more of them relapsed. This is not surprising, see my thoughts below.
My thoughts: Platelet-rich plasma injections have increased in popularity. This review is almost 5 years old now, so there may be some newer evidence supporting its use in chronic Achilles tendinopathy.
The corticosteroid injections initially felt better but then had a relapse of the symptoms. This is not too surprising for me. One of the things that corticosteroid injections do is break down collagen. Collagen is the building block of the human body. There are many different types of collagen, for example, muscle fibres are made of a certain type of collagen, bone is made from a different type and tendon is made from yet another type. When corticosteroids are injected, there is an initial breakdown of tissue for 1-2 weeks post injection. The strength returns to normal about 3-4 weeks post injection. If injecting into the Achilles tendon, most likely the patients were told to decrease their activity, as it is known that injecting corticosteroids into the Achilles tendon leads to increased ruptures of the Achilles tendon. The practice of injecting there has decreased in the past 10-15 years. Here is what I see as happening: injection, rest, feels better, four weeks pass, increased activity and symptoms return.
There is only one study that compares shockwave therapy and eccentric exercises vs. eccentric exercises. It is stated that the shockwave and exercise group did slightly better than the exercise group in terms of pain, activity level and satisfaction with treatment after four months of the start of the study. However, “[although] statistically significant, these values may be clinically insignificant”.
My thoughts: there is more research coming out on shockwave therapy. It would be interesting to see what the newer research has to say about this modality.
Glyceryl trinitrate patches
These studies put patches of glyceryl trinitrate on the sore area of the Achilles tendon. The thought was that these would help with the nitric oxide, which is essential to achieve normal healing.
One of the studies used eccentric exercises (see a pattern here), plus patches, either gylceryl trinitrate or placebo. After 6 months, there was a significant decrease in pain with activity, with the gylceryl trinitrate patch group compared to the eccentric exercise and placebo group.
The other study was the exact same, eccentric exercises and either gylceryl trinitrate vs. placebo. At 6 months, both groups were significantly decreased but the average scores between the groups were close to being equal (no significant difference).
My thoughts: this treatment makes sense, increasing the nitric oxide in the blood right around the injury site. Maybe the dose will have to be changed for each individual person, as a regular patch might work for a smaller person but not a person with a larger body mass.
What does the above information tell you? To me, it simply reinforces that New Leaf Physiotherapy is on the right track with using eccentric exercises. Every study tries to add something to the eccentric exercises and nothing yet really seems to act synergistically with them.
One thing that I have not seen in the literature is the use of heat on a chronic tendinitis. To me it makes theoretical sense. The skin is really thin around the Achilles tendon. Adding heat, will increase the temperature, which will increase the temperature of the area, in turn increasing the blood flow to the area. When blood flow is increased to an area of the body, it brings more oxygen in the blood. This O2 is used to help repair injured areas. I have used this with a number of clients and they seem to respond to it favourably. Maybe it is simply luck that the clients find that it helped to decrease Achilles stiffness and pain.
Below is a summary list of the studies used in the review: