Physical therapies for Achilles tendinopathy: systematic review and meta-analysis

Samuel P Sussmilch-Leitch, Natalie J Collins, Andrea E Bialocerkowski, Stuart J Warden, Kay M Crossley, Samuel P Sussmilch-Leitch, Natalie J Collins, Andrea E Bialocerkowski, Stuart J Warden, Kay M Crossley

Abstract

Background: Achilles tendinopathy (AT) is a common condition, causing considerable morbidity in athletes and non-athletes alike. Conservative or physical therapies are accepted as first-line management of AT; however, despite a growing volume of research, there remains a lack of high quality studies evaluating their efficacy. Previous systematic reviews provide preliminary evidence for non-surgical interventions for AT, but lack key quality components as outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement. The aim of this study was to conduct a systematic review and meta-analysis (where possible) of the evidence for physical therapies for AT management.

Methods: A comprehensive strategy was used to search 11 electronic databases from inception to September 2011. Search terms included Achilles, tendinopathy, pain, physical therapies, electrotherapy and exercise (English language full-text publications, human studies). Reference lists of eligible papers were hand-searched. Randomised controlled trials (RCTs) were included if they evaluated at least one non-pharmacological, non-surgical intervention for AT using at least one outcome of pain and/or function. Two independent reviewers screened 2852 search results, identifying 23 suitable studies, and assessed methodological quality and risk of bias using a modified PEDro scale. Effect size calculation and meta-analyses were based on fixed and random effects models respectively.

Results: Methodological quality ranged from 2 to 12 (/14). Four studies were excluded due to high risk of bias, leaving 19 studies, the majority of which evaluated midportion AT. Effect sizes from individual RCTs support the use of eccentric exercise. Meta-analyses identified significant effects favouring the addition of laser therapy to eccentric exercise at 12 weeks (pain VAS: standardised mean difference -0.59, 95% confidence interval -1.11 to -0.07), as well as no differences in effect between eccentric exercise and shock wave therapy at 16 weeks (VISA-A:-0.55,-2.21 to 1.11). Pooled data did not support the addition of night splints to eccentric exercise at 12 weeks (VISA-A:-0.35,-1.44 to 0.74). Limited evidence from an individual RCT suggests microcurrent therapy to be an effective intervention.

Conclusions: Practitioners can consider eccentric exercise as an initial intervention for AT, with the addition of laser therapy as appropriate. Shock wave therapy may represent an effective alternative. High-quality RCTs following CONSORT guidelines are required to further evaluate the efficacy of physical therapies and determine optimal clinical pathways for AT.

Figures

Figure 1
Figure 1
Flow chart of the process and rationale used in selecting studies for inclusion.
Figure 2
Figure 2
Standardised mean differences for outcomes of pain ± function following intervention with exercise modalities. EE = eccentric exercise; SWT = shock wave therapy. * denotes use of conservative therapy in addition to presented modality.
Figure 3
Figure 3
Standardised mean differences for outcomes of pain ± function following electrophysical therapies. SWT = shock wave therapy; EE = eccentric exercise. * denotes use of rehabilitation program in addition to presented modality.
Figure 4
Figure 4
Standardised mean differences for outcomes of pain with braces and splints. EE = eccentric exercise

References

    1. Holmes GB, Lin J. Etiologic factors associated with symptomatic achilles tendinopathy. Foot Ankle Int. 2006;27:952–959.
    1. Kujala UM, Sarna S, Kaprio J. Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med. 2005;15:133–135. doi: 10.1097/01.jsm.0000165347.55638.23.
    1. Del Buono A, Battery L, Denaro V, Maccauro G, Maffulli N. Tendinopathy and inflammation: some truths. Int J Immunopathol Pharmacol. 2011;24:45–50.
    1. Battery L, Maffulli N. Inflammation in overuse tendon injuries. Sports Med Arthrosc. 2011;19:213–217. doi: 10.1097/JSA.0b013e31820e6a92.
    1. Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med. 1999;27:393–408. doi: 10.2165/00007256-199927060-00004.
    1. Khan KM, Bonar F, Desmond PM, Cook JL, Young DA, Visentini PJ, Fehrmann MW, Kiss ZS, O’Brien PA, Harcourt PR. et al.Patellar tendinosis (jumper’s knee): findings at histopathologic examination, US, and MR imaging. Victorian Institute of Sport Tendon Study Group. Radiology. 1996;200:821–827.
    1. Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy. 1998;14:840–843. doi: 10.1016/S0749-8063(98)70021-0.
    1. Paavola M, Kannus P, Paakkala T, Pasanen M, Jarvinen M. Long-term prognosis of patients with achilles tendinopathy. An observational 8-year follow-up study. Am J Sports Med. 2000;28:634–642.
    1. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991;73:1507–1525.
    1. Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med. 2007;41:211–216. doi: 10.1136/bjsm.2007.035543.
    1. Kearney R, Costa ML. Insertional achilles tendinopathy management: a systematic review. Foot Ankle Int. 2010;31:689–694. doi: 10.3113/FAI.2010.0689.
    1. Maffulli N, Longo UG, Denaro V. Novel approaches for the management of tendinopathy. J Bone Joint Surg Am. 2010;92:2604–2613. doi: 10.2106/JBJS.I.01744.
    1. McLauchlan GJ, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev. 2001;2:CD000232.
    1. Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med. 2009;19:54–64. doi: 10.1097/JSM.0b013e31818ef090.
    1. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med. 2009;151:W65–W94.
    1. NHMRC. How to review the evidence: systematic identification and review of the scientific literature. Biotext, Canberra; 1999.
    1. Physiotherapy Evidence Database. [ ]
    1. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005;39:411–422. doi: 10.1136/bjsm.2004.016170. discussion 411–422.
    1. Collins N, Bisset L, McPoil T, Vicenzino B. Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis. Foot Ankle Int. 2007;28:396–412. doi: 10.3113/FAI.2007.0396.
    1. Collins NJ, Bisset LM, Crossley KM, Vicenzino B. Efficacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomized trials. Sports Med. 2012;42:31–49. doi: 10.2165/11594460-000000000-00000.
    1. Higgins J, Green S. In Cochrane Handbook for Systematic Reviews of Interventions Version 502 (updated September 2009) 2009.
    1. A new view of statistics. [ ]
    1. Review Manager (RevMan) [computer programme] Version 42 for Windows edition. City: The Cochrane Collaboration; 2003.
    1. Higgins PTJ, Green S. Cochrane Handbook for Systematic Reviews of Interventions. The Cochrance Collaboration & John Wiley & Sons Ltd, West Sussex; 2008.
    1. 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 Achillis: a randomized controlled trial. Am J Sports Med. 2007;35:374–383.
    1. Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional Achilles tendinopathy. a randomized, controlled trial. J Bone Joint Surg Am. 2008;90:52–61.
    1. Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2009;37:463–470. doi: 10.1177/0363546508326983.
    1. Mayer F, Hirschmuller A, Muller S, Schuberth M, Baur H. Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy. Br J Sports Med. 2007;41:e6. doi: 10.1136/bjsm.2006.031732.
    1. Knobloch K, Kraemer R, Jagodzinkski M, Zeichen J, Meller R, Vogt P. Eccentric training decreases paratendon capillary blood flow and preserves paratendon oxygen saturation in chronic Achilles tendinopathy. J Orthop Sports Phys Ther. 2007;37:269–276.
    1. Knobloch K, Schreibmueller L, Longo UG, Vogt PM. 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. 2008;30:1685–1691. doi: 10.1080/09638280701786658.
    1. Petersen W, Welp R, Rosenbaum D. 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. 2007;35:1659–1667. doi: 10.1177/0363546507303558.
    1. Costa ML, Shepstone L, Donell ST, Thomas TL. Shock wave therapy for chronic Achilles tendon pain. Clin Orthop Relat Res. 2005;440:199–204. doi: 10.1097/01.blo.0000180451.03425.48.
    1. Herrington L, McCulloch R. The role of eccentric training in the management of Achilles tendinopathy: A pilot study. Phys Ther Sport. 2007;8:191–196. doi: 10.1016/j.ptsp.2007.07.001.
    1. Chapman-Jones D, Hill D. Novel microcurrent treatment is more effective than conventional therapy for chronic Achilles tendinopathy: randomised comparative trial. Physiotherapy. 2002;88:471–480. doi: 10.1016/S0031-9406(05)60849-8.
    1. Chester R, Costa ML, Shepstone L, Cooper A, Donell ST. Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain- A pilot study. Man Ther. 2008;13:484–491. doi: 10.1016/j.math.2007.05.014.
    1. 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;12:431–435. doi: 10.1177/036354658401200605.
    1. 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 1-year follow-up. Scand J Med Sci Sports. 2004;14:286–295. doi: 10.1111/j.1600-0838.2004.378.x.
    1. Silbernagel KG, Thomee R, Thomee P, Karlsson J. Eccentric overload training for patients with chronic Achilles tendon pain - a randomised controlled study with reliability testing of the evluation methods. Scand J Med Sci Sports. 2001;11:197–206. doi: 10.1034/j.1600-0838.2001.110402.x.
    1. 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. Am J Sports Med. 2007;35:897–906. doi: 10.1177/0363546506298279.
    1. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2001;9:42–47. doi: 10.1007/s001670000148.
    1. Norregaard J, Larsen CC, Bieler T, Langberg H. Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports. 2007;17:133–138.
    1. Rasmussen S, Christensen M, Mathiesen I, Simonsen O. Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy. Acta Orthop. 2008;79:249–256. doi: 10.1080/17453670710015058.
    1. Tumilty S, Munn J, Abbott JH, McDonough S, Hurley DA, Baxter GD. Laser therapy in the treatment of Achilles tendinopathy: a pilot study. Photomed Laser Surg. 2008;26:25–30. doi: 10.1089/pho.2007.2126.
    1. McAleenan M, McVeigh JG, Cullen M, Sayers M, McCrea K, Baxter D. The effectiveness of night splints in achilles tendinopathy: a pilot study. Physiotherapy Ireland. 2010;31:29–33.
    1. Stergioulas 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. Am J Sports Med. 2008;36:881–887. doi: 10.1177/0363546507312165.
    1. Niesen-Vertommen SL, Taunton JE, Clement DB, Mosher RE. The effect of eccentric versus concentric exercise in the management of Achilles tendonitis. Clin J Sport Med. 1992;2:109–113. doi: 10.1097/00042752-199204000-00006.
    1. de Jonge S, de Vos RJ, Van Schie HT, Verhaar JA, Weir A, Tol JL. One-year follow-up of a randomised controlled trial on added splinting to eccentric exercises in chronic midportion Achilles tendinopathy. Br J Sports Med. 2010;44:673–677. doi: 10.1136/bjsm.2008.052142.
    1. Boonstra AM, Schiphorst Preuper HR, Reneman MF, Posthumus JB, Stewart RE. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. Int J Rehabil Res. 2008;31:165–169. doi: 10.1097/MRR.0b013e3282fc0f93.
    1. Robinson JM, Cook JL, Purdam C, Visentini PJ, Ross J, Maffulli N, Taunton JE, Khan KM. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med. 2001;35:335–341. doi: 10.1136/bjsm.35.5.335.
    1. Salen BA, Spangfort EV, Nygren AL, Nordemar R. The Disability Rating Index: an instrument for the assessment of disability in clinical settings. J Clin Epidemiol. 1994;47:1423–1435. doi: 10.1016/0895-4356(94)90086-8.
    1. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26:360–366.
    1. Rees JD, Lichtwark GA, Wolman RL, Wilson AM. The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. Rheumatology (Oxford) 2008;47:1493–1497. doi: 10.1093/rheumatology/ken262.
    1. Rompe JD, Meurer A, Nafe B, Hofmann A, Gerdesmeyer L. Repetitive low-energy shock wave application without local anesthesia is more efficient than repetitive low-energy shock wave application with local anesthesia in the treatment of chronic plantar fasciitis. J Orthop Res. 2005;23:931–941.
    1. Solan M, Davies M. Management of insertional tendinopathy of the Achilles tendon. Foot Ankle Clin. 2007;12:597–615. doi: 10.1016/j.fcl.2007.07.005. vi.
    1. Krishna Sayana M, Maffulli N. Insertional Achilles tendinopathy. Foot Ankle Clin. 10;10:309–320.
    1. Rufai A, Ralphs JR, Benjamin M. Structure and histopathology of the insertional region of the human Achilles tendon. J Orthop Res. 1995;13:585–593. doi: 10.1002/jor.1100130414.
    1. Tuite DJ, Renstrom PA, O’Brien M. The aging tendon. Scand J Med Sci Sports. 1997;7:72–77.
    1. Kjaer M, Magnusson P, Krogsgaard M, Boysen Moller J, Olesen J, Heinemeier K, Hansen M, Haraldsson B, Koskinen S, Esmarck B, Langberg H. Extracellular matrix adaptation of tendon and skeletal muscle to exercise. J Anat. 2006;208:445–450. doi: 10.1111/j.1469-7580.2006.00549.x.
    1. Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. Ann Intern Med. 2001;134:657–662.
    1. Cohn LD, Becker BJ. How meta-analysis increases statistical power. Psychol Methods. 2003;8:243–253.

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