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Sports Focus Team
Evidence-Based Treatment of
Achilles Tendinitis
Insertional vs Non-Insertional
Team Members
• Eric Williams
• Barbara Edwards
• Hung Do
Achilles Tendinopathy
• McShane et al. states that achilles tendinopathy is
generally caused by chronic stress to the tendon.
• Ultrasound imaging can help identify the abnormal
portion of tendon.
• Khan et al. and Maffulli et al. popularized the term
achilles tendinopathy to describe the triad of tendon
pain, swelling, and impaired performance.
Achilles Tendinopathy
• Cain et. classifies achilles tendinopathy as
insertional and mid-substance (non-insertional).
• Insertional – within 2 cm of its insertion.
• Mid-substance – 2-6 cm proximal to its insertion.
Achilles Tendinopathy
• Maffulli et al used the term “tendinopathy” when
referring to diagnosis for pain, swelling and
impaired performance.
• They reserved more specific terms including
tendonitis for cases when inflammation or
degeneration has been confirmed.
Review of Literature
• 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
• There were just as many Level I studies
comparing several treatment options.
• Double blind study of the effects of heel
pad on tendinitis.
• Randomized study comparing eccentric
training, air heel brace and combo of both.
Review of Literature
• A randomized controlled trial comparing
shockwave treatment with eccentric loading.
• Randomized Placebo – Controlled Trial: Shock
Wave Therapy for chronic Achilles tendon pain.
Treatment Comparisons
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Air Heel Brace
Heel Pads/Splints
ShockWave Therapy
Eccentric Exercises
Anatomy of the Achilles Tendon
• Origin of the Achilles is the thick extension of 3 muscles
in the lower leg.
• Gastrocnemius
• Soleus
• Plantaris
• Achilles tendon is the thickest and strongest tendon in
the body
• 15 cm long
Anatomy of the Achilles Tendon
• AT begins near the middle of the calf muscle
• Insertion – middle part of the posterior surface of
the calcaneus.
• The small saphenous vein is located on the
lateral side of the Achilles but is superficial to it.
• 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 PM.
Disabil Rehabil. 2008;30(20-22):1685-91.
• Purpose – 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
• Methods – 116 with unilateral tendonitis of
the main body (non-insertional) were
randomized in two groups.
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. 2008;30(20-22):1685-91.
• Group A – performed eccentric training
w/AirHeel Brace.
• Group B – performed the same eccentric
training w/o the AirHeel Brace
• Test the null Hypothesis that patients
w/tendonitis in the main body of the
Achilles tendon there is no difference in
clinical outcome and micro-vascular
parameters .
Results
• The FAOS score and the VAS score showed significant
improvements from pre-operative to post-operative values in both
groups (A 5.1 +/- 2 vs. 2.9 +/- 2.4, 43% reduction and B: 5.4 +/- 2.1
vs. 3.6 +/- 2.4, 33% reduction, both p = 0.0001). There were no
statistically significant differences in FAOS score and VAS score
when comparing the two groups after the end of the intervention.
• In Group A, tendon oxygen saturation in the main body of the
Achilles tendon showed significant increase from pre- to postmanagement values (68 +/- 12 vs.74 +/- 8%, p = 0.003). Postcapillary 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 D.
Am J Sports Med. 2007 Oct;35(10):1659-67. Epub 2007 Jun 14.
• Purpose – To evaluate 3 different treatment
protocols for chronic mid-portion tendinopathy of
the Achilles tendon.
• Method – One hundred patients were randomly
assigned to 1 of 3 different treatment groups.
• Group 1 – Eccentric Training (37 patients)
• Group 2 – AirHeel Brace (35 patients)
• Group 3 – Combination of eccentric training and
the AirHeel Brace. (28 patients)
Eccentric Exercises
• 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
• VAS score for pain, AOFAS score, and
SF-36 improved significantly in all 3
groups at all 3 follow-up exams.
• At the 3 time points of 6,12, 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 AG.
Am J Sports Med. 1984 Nov-Dec;12(6):431-5.
• Purpose - To investigate the efficacy of
heel pads in the treatment of Achilles
tendonitis.
• Methods – 33 patients (26 male, 13
female), ages 11 to 51, were randomly
allocated to one of three treatment groups.
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-Dec;12(6):431-5.
• Group I – was provided w/Sorbothane heel pads
to be worn in all sports and walking for 2
months.
• Group II – was provided with soft sponge rubber
pads of “Molefoam.”
• Group III – received no pads.
• Pt’s in all 3 groups received five consecutive
daily 5 min. ultrasound treatments (0.75 MHz,
pulsed 1:1, w/coupling gel).
Results
• Patients in Group III (ultrasound and
exercise) had the most significant
difference in the reduction of both swelling
and tenderness.
• The study revealed that pt’s 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 JL.
Br J Sports Med. 2007 Jul;41(7):e5. Epub 2006 Dec 18.
• Purpose - To assess whether the use of night
splints is of added benefit on functional
outcomes in treating chronic mid-portion Achilles
tendonitis.
• 70 tendons were included and randomized into
two groups.
• Group A – Eccentric exercise w/ a night splint
(n=36)
• Group B – Eccentric exercise only (n=34).
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 Jul;41(7):e5. Epub 2006 Dec 18.
• Both groups completed a 12 week heavy
load eccentric training program w/ group A
also receiving a night splint to wear at
night.
• Inclusion – age 18 -70 years, active in
sports, and tendon pain localized at 2 7cm from distal insertion.
• Exclusion – insertional disorders, partial or
complete ruptures or systemic illness.
Results
• 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 pt’s satisfaction score.
• Night splints with eccentric training is not
beneficial at short term follow-up.
• 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 Jan;90(1):52-61.
• 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 and/or corticosteroids, a prescription of
nonsteroidal anti-inflammatory drugs, and physiotherapy,
without success for at least three months.
• Group I – 25 patients were allocated to receive eccentric
calf strengthening exercises.
• Group II – 25 patients were allocated to treatment with
repetitive low-energy shock wave therapy.
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 Jan;90(1):52-61.
• 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.
• The patients were assessed for pain, function,
and activity with use of a validated questionnaire
(the Victorian Institute of Sport AssessmentAchilles [VISA-A] questionnaire).
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 Jan;90(1):52-61.
• 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 shockwave treatment).
• 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").
• 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 crossover and with 6 failed patients of group 2 having undergone surgery.
Eccentric Exercises
Chronic Achilles tendon pain treated with eccentric calf-muscle training.
Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):327-33. Epub 2003 Aug 26.
Fahlström M, Jonsson P, Lorentzon R, Alfredson H.
• 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 calfmuscle training in patients with chronic insertional
Achilles tendon pain.
• Methods – 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Chronic Achilles tendon pain treated with eccentric calf-muscle training.
Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):327-33. Epub 2003 Aug 26.
Fahlström M, Jonsson P, Lorentzon R, Alfredson H.
• Results
• 90 of the 101 Achilles tendons (89%) with
chronic painful non-insertional Achilles
tendinosis improved after the 12-week training
program.
• 10/31 tendons (32%) with chronic painful
insertional Achilles tendinosis improved with 12
week program.
Conclusion
• 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
• Shockwave therapy was effective but it is
not being used in the U.S.A. for Achilles
tendonitis.
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