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ACHILLES TENDINOPATHY (mid-substance): Summary of the Evidence for Physical Therapy Interventions
PURPOSE,SCOPE&DISCLAIMER:ThepurposeofthisdocumentistoprovidephysicaltherapistswithasummaryoftheevidenceforinterventionscommonlyusedtomanagemidsubstanceAchillestendinopathy.Thisdecisionmakingtoolisevidenceinformedandwherethereisinsufficientevidence,expertinformed.Itisnotintendedtoreplacethecliniciansclinicalreasoningskillsandinterprofessionalcollaboration.Acuterefersprimarilytothestagewiththecardinalsignsofheat,redness,pain,swellingandlossoffunctionandaveryrecentonsetofsymptoms.
INTERVENTIONSTAGEOF
PATHOLOGY
CLINICALRESEARCHEVIDENCE
PUBLISHEDEXPERTOPINION TAKEHOMEMESSAGE
CLINICALIMPLICATION*Seefinalpagefordescriptionofcategories
ManualTherapy
Acute Mayconsider usingmanualtherapyintheacutestageafterundertakingacomprehensivebiomechanicalevaluationofthehip,knee,footandankle.
Jointmobs
No
Yes
Thereisnoclinicalevidencebutthereisexpertlevelconsensustosupporttheuseofjointmobilizationsintheacutestageifassessmentrevealsjointrestriction.
Softtissuetechniques
No
No The clinicalevidenceneithersupportsnorrefutestheuseoffrictionsintheacutestage.
Chronic
Jointmobs Yes
1CS
Yes
Thereisasmallamountof clinicalevidenceandmoresubstantialexpertlevelconsensustosupporttheuseofjointmobilizationsinthechronicstageifassessmentrevealsjointrestriction.
Mayconsider usingmanualtherapyinthechronicstageafterundertakingacomprehensivebiomechanicalevaluationofthehip,knee,footandankle.
Softtissuetechniques
Yes
1SR2CS
Yes
Thereisasmallamountofclinicalevidencetosupporttheuseofsofttissuetechniques,suchasfrictions,inthechronicstage.
Mayconsider atrialofsofttissuetechniques,suchasfrictions,inthechronicstage.
Exercise Acute No
Yes
Thereisasmallamountofexpertopiniontosupporttheuseofstretchesintheacutestage.
Mayconsider usingstretchingexercisesinacutestage.Noprescriptionparametersareprovided.ACSMrecommends1030sechold,24repetitions.
Chronic Yes
14OS
6SR
5RCT
Yes
Thereisalargeamountofclinicalevidencetosupporttheuseofexerciseinthechronicstagebutthepreciseparameterstoensureeffectivenessarenotclear.Eccentricexerciseinparticularissupportedalthoughsomeprotocolsusebothconcentricandeccentricexercise.Malesappeartobenefitslightlymorethanfemalesfromeccentricexercise.
Stronglyconsider usingeccentricexerciseinthechronicstageusingthefollowinggeneralparametersofagradualprogressionto3setsof15repetitions,twiceperdaywiththekneeextendedandwiththekneeflexed.
*SeeAppendixAforfurtherdetailsonexerciseprescription.
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INTERVENTION
STAGEOF
HEALING
CLINICALRESEARCHEVIDENCE
PUBLISHEDEXPERTOPINION TAKEHOMEMESSAGE
CLINICALIMPLICATION*Seefinalpagefordescriptionofcategories
Lowlevellasertherapy(LLLT)
Acute Yes
2SR
Yes Thereisnoclinicalevidence,butthereisaphysiologicalrationale,tosupporttheuseofLLLTintheacutestage.
Mayconsider atrialofLLLTintheacutestage atthedosesrecommendedbytheWorldAssociationforLaserTherapy(www.walt.nu)i.e.,24J/point(notpercm2)*,minimum23points.
*SeeAppendixBforfurtherdetailsoncalculationofdosage.
Chronic Yes
1MA
5RCT
Yes Thereisconflicting clinicalevidenceandconflictingexpertopiniontosupporttheuseofLLLTinthechronicstage.
Consider atrialofLLLTinthechronicstage atthefollowingparameters:0.9J/point(notpercm2)*;6pointsontendon.
*SeeAppendixBforfurtherdetailsoncalculationofdosage.
Ultrasound(US) Acute No No Thereisnoclinicalevidence,butthereisphysiologicalrationale,tosupporttheuseofUSintheacutestage.
Mayconsider atrialofUSintheacutestage atalowtomoderatedose(0.51.0W/cm2,pulsed1:41:1,3MHz,5minsforeachtreatmentareaequivalentinsizetotransducerhead).
Chronic No No ThereisnoclinicalevidenceandnophysiologicalrationaletosupporttheuseofUSinthechronicstage.
ConsiderNOT usingUS inthechronicstage.
Extracorporealshockwavetherapy(SWT)
FocusedorradialSWT(lowenergy)
Acute No Yes ThereisexpertopinionwhichsuggeststhatSWTbereservedforchronicstage.
ConsiderNOT usingExtracorporealShockWavefortheacutestage.
Chronic Yes
4RCT
1Cohort
Yes Thereisconflicting evidencetosupporttheuseofSWTinthechronicstage.Thereisevidencesuggestingthattheoutcomesaredependentuponthedosageoftheshockwaveenergy(EFDenergyfluxdensity=mJ/mm),ratherthanthetypeofshockwavegeneration(focusedvs.radialSWT).ThereisalsoevidencethattheuseofanestheticrequiredinhighenergyprotocolsdecreasestheeffectivenessofSWT.Therefore,usinglowenergySWTprotocolswithouttheneedforanestheticarerecommendedasmorepractical,moretolerable,andlessexpensivewithequivalentresults.LowenergySWTprotocolscanapplytobothfocusedandradialSWT.
Consider atrialofSWTinthechronicstage,especiallyifotherinterventionshavefailed,atthefollowingparameters:
LowenergySWT:EFD=0.180.3mJ/mm(24Bars)20003000shocks1530Hz35sessions,weeklyintervals.Advisepatientsthatthisisanexperimentaltechnique.SWTenhancestheoutcomescomparedtoeccentricexercisealone,thereforepatientsshouldbeinstructedtocontinuewithawelldesignedexerciseprogram.
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INTERVENTION
STAGEOF
HEALING
CLINICALRESEARCHEVIDENCE
PUBLISHEDEXPERTOPINION TAKEHOMEMESSAGE
CLINICALIMPLICATION*Seefinalpagefordescriptionofcategories
Iontophoresisusingdexamethasone
Acute Yes
1RCT
1review
No Thereisasmallamountofevidencetosupport theapplicationofiontophoresisusingdexamethasoneintheacutestage.Theroleofiontophoresisisstillinvestigational.
Mayconsider,intheacutestage,atrialofiontophoresis,0.4%dexamethasone(aqueous),80mAmin;6sessionsover3weeks.
Aprogramofconcentriceccentricexercisesshouldbecontinuedincombinationwithiontophoresis,ifexerciseloadingistolerated.
Chronic No No Thereisnoevidencethatantiinflammatoryinterventionwithiontophoresisusingdexamethasonehasausefulroleinthechronicstage.
ConsiderNOT usingiontophoresisusingdexamethasoneinthechronicstage.
Taping Acute No Yes Thereisexpertopiniontosupport theuseofantipronationtapingintheacutestage.
Mayconsider using antipronationtaping intheacutestage.
Chronic Yes
1CS
Yes Thereisexpertopiniontosupport theuseofcontrolledpronationtapinginthechronicstage.
Mayconsider using antipronationtaping inthechronicstage.
Orthotics Acute Yes
2CS
Yes Thereisasmallamountofclinicalevidencetosupporttheuseoforthoticsintheacutestage.
Consider usingorthotics perhapsusingtapingfirst,intheacutestage.
Chronic Yes
2CS
1RCT
Yes Thereisamoderateamountofclinicalevidencetosupporttheuseoforthoticsinthechronicstage.
Consider usingorthotics inthechronicstage.
Nightsplintsandbraces
Acute No Yes Thereisexpertopiniontosupport theuseofnightsplintsandbracesintheacutestage.
Consider atrialofnightsplintsandbraces intheacutestage.
Chronic Yes
3RCT
Yes Thereisamoderateamountofevidenceagainsttheuseofnightsplintsandbracesinthechronicstage.
ConsiderNOT usingnightsplintsandbraces inthechronicstage.
Heelraiseinserts
Acute No Yes Thereissomeexpertopiniontosupporttheuseofheelraiseinsertsintheacutestage.
Mayconsider atrialofinserts intheacutestage.
Chronic Yes
2RCT
Yes Thereisconflicting evidenceforandagainsttheuseofheelinsertsinthechronicstage.
Consider atrialofinserts inthechronicstage.
April20,2012 Page4
INTERVENTION
STAGEOF
HEALING
CLINICALRESEARCHEVIDENCE
PUBLISHEDEXPERTOPINION TAKEHOMEMESSAGE
CLINICALIMPLICATION*Seefinalpagefordescriptionofcategories
Needlingtechniques
Acupuncture(TraditionalChinesemedicine,anatomical,electrical)andIntramuscularstimulation
Acute Yes
1CS
No
Thereisasmallamountofevidencetosupport theuseofTraditionalChineseMedicineelectroacupunctureintheacutestage.Thereisexpertopiniontosupporttheuseofotherneedlingtechniquesintheacutestage.
Consider atrialofelectroacupuncture intheacutestage.
Mayconsideratrialofotheracupuncturerelatedneedlingtechniquesintheacutestage.
Chronic Yes
1CS
No
Thereisasmallamountofevidencetosupport useofTraditionalChineseAcupunctureinthechronicstage.Thereisexpertopinionontheuseofotherneedlingtechniquesinthechronicstage.
Consider atrialofTraditionalChineseAcupunctureinthechronicstage.
Mayconsideratrialofotheracupuncturerelatedneedlingtechniquesinthechronicstage.
CSCasestudies;MAMetaanalyses;OSObservationalstudies;RCTRandomizedcontrolledtrials;SRSystematicreviews
Foranyinterventionselectedbytheclinician,itisstronglyrecommendedthattheclinicianuseoneormoreofthefollowingoutcomemeasures:A. Patientreportedoutcomemeasuresuchas:
Aglobalmeasureoflowerextremityfunction:e.g.,TheLowerExtremityFunctionalScale(LEFS)notspecifictoAchillestendinopathy http://www.physther.net/content/79/4/371/F1.large.jpg
Detailedquestionnaire,specifictoAchillestendinopathye.g.theVISAAquestionnaire http://bjsm.bmj.com/content/suppl/2001/11/09/35.5.335.DC1/01055_Fig_1_data_supplement.pdf
(clickonviewquestionnaire)B. Patientspecificfunctionaloutcomemeasuresuchas:
Howmuchweightcanbeappliedtotheplantarflexedfootonaweighingscalebeforethe onsetofpain Thenumberofheelraisesbeforetheonsetofpain Thenumberofheeldropsbeforetheonsetofpain Thenumberofheeldropswithaspecificweightinabackpackbefore
theonsetofpain
Howfarcantheclientwalkorrunbeforetheonsetofpain
ExplanationofClinicalImplications
Stronglyconsider:Highlevel/highqualityevidencethatthisshouldbeincludedintreatment.
Consider:Consistentlowerlevel/lowerqualityorinconsistentevidencethatthisshouldbeincludedintreatment.
Mayconsider:Noclinicalevidencebutexpertopinionand/orplausiblephysiologicalrationalethatthisshouldbeincludedintreatment.
ConsiderNOT:Highlevel/highqualityevidencethatthisshouldnotbeincludedintreatment.
DevelopedbytheBCPhysicalTherapyTendinopathyTaskForce:Dr.JosephAnthony,AllisonEzzat,DianaHughes,JRJustesen,Dr.AlexScott,MichaelYates,AlisonHoens.APhysicalTherapyKnowledgeBrokerprojectsupportedby:UBCDepartmentofPhysicalTherapy,PhysiotherapyAssociationofBC,VancouverCoastalResearchInstituteandProvidenceHealthcareResearchInstitute.
April20,2012 Page5
REFERENCES PleaseseeAppendixCAchillesTendinopathy:DetailsofIndividualArticlesforthespecificdetailsoneachofthearticlesreferencedinthisdocument. MANUAL THERAPY
Casestudies
Voorn,R.(1998).Casereport:cansacroiliacjointdysfunctioncausechronicAchillestendonitis?JOSPT.27(6);436443.
WoodmanRM,PareL.(1982).EvaluationandtreatmentofsofttissuelesionsoftheankleandforefootusingaCyriaxapproach.PhysicalTherapy.62(8);114447.
ChristensonRE.(2007).EffectivenessofspecificsofttissuemobilizationsforthemanagementofAchillestendinosis:SinglecasestudyExperimentaldesign.ManualTherapy,12;6371.
ExpertOpinion
CarciaCR,MartinRL,HouckJ,WukichDK.(2010).Achillespain,stiffness,andmusclepowerdeficits:achillestendinitis.JOrthopSportsPhysTherapy:40(9)A1A26.
SystematicReviews
BrosseauL,CasimiroL,MilneS.etal.(2002).Deeptransversefrictionmassagefortreatingtendinitis.CochraneDatabaseSystematicReviews.4.
EXERCISE
ObservationalStudies
AlfredsonH,PietilaT,JonssonP&LorentzonR.(1998).HeavyloadeccentriccalfmuscletrainingforthetreatmentofchronicAchillestendinosis.AmericanJournalofSportsMedicine.26(3),36066.
GaerdinA,MovinT,SvenssonL&ShalabiA.(2010).ThelongtermclinicalandMRIresultsfollowingeccentriccalfmuscletraininginchronicAchillestendinosis.SkeletalRadiology.May,39(5),43542.
KnoblochK,SchreibmuellerL,KraemerR,JogodzinskiM,Vogt,PM&RedekerJ.(2010).GenderandeccentrictraininginAchillesmidportiontendinopathy.KneeSurgery,SportsTraumatology,Arthroscopy.May,18(5),64855.
OhbergL,LorentzonR&AlfredsonH.(2004).EccentrictraininginpatientswithchronicAchillestendinosis:normalisedtendonstructureanddecreasedthicknessatfollowup.BritishJournalofSportsMedicine.February,38(1),811;discussion11.
PetersenW,WelpR&RosenbaumD.(2007).ChronicAT:aprospectiverandomizedtrialcomparingthetherapeuticeffectofeccentrictraining,theAirHeelbrace,andacombinationofboth.AmericanJournalofSportsMedicine.October,35(10),165967.
RichardsPJ,McCallIW,DayC,BelcherJ&MaffulliN.(2010).LongitiudinalmicrovascularityinAchillestendinopathy.SkeletalRadiology.June,39(6),50921.
RoosEM,EngstromM,LagerquistA&SoderbergB.(2004).Clinicalimprovementafter6weeksofeccentricexerciseinpatientswithmidportionAchillestendinopathy:arandomizedtrialwithoneyearfollowup.ScandanavianJournalofMedicineandScienceinSports.October,14(5),28695.
ShalabiA,KristoffersenWibergM,AspelinP&MovinT.(2004).ImmediateAchillestendonresponseafterstrengthtrainingevaluatedbyMRI.MedicineandScienceinSportsandExercise.November,36(11),18416.
SilbernagelKG,BrorssonA&LundbergM.(2011).ThemajorityofpatientswithAchillestendinopathyrecoverfullywhentreatedwithexercisealone:a5yearfollowup.AmericanJournalofSportsMedicine.March,39(3),60713.
SilbernagelKG,ThomeeR,ErikssonBI&Karlsson,J.(2007).FullsymptomaticrecoverydoesnotensurefullrecoveryofmuscletendonfunctioninpatientswithAchillestendinopathy.BritishJournalofSportsMedicine.April,41(4),27680;discussion280.
VerrallG,Scholfield,S&BrustadT.(2011).ChronicAchillestendinopathytreatedwitheccentricstretchingprogram.FootAnkleInternational.September,32(9),8439.
WesthE,KongsgaardM,BojsenMollerJ,AagaardP,HansenM,KjaerM&Magnuson,S.P.(2008).Effectofhabitualexerciseonthestructuralandmechanicalpropertiesofhumantendon,invivo,inmenandwomen.ScandinavianJournalofMedicineandScienceinSports.Feb;18(1):2330.
RCTs
BackmanLJ,AnderssonG,WennstigG,ForsgrenS&DanielsonP.(2011).EndogenoussubstancePproductionintheAchillestendonincreaseswithloadinginaninvivomodeloftendinopathypeptidergicelevationprecedingtendinosisliketissuechanges.JournalofMusculoskeletalandNeuronalInteractions,June,11(2),13340.
RompeJD,FuriaJ&MaffulliN.(2009).EccentricloadingversuseccentricloadingplusshockwavetreatmentformidportionAchillestendinopathy:arandomizedcontrolledtrial.AmericanJournalofSportsMedicine,March,37(3),46370.
RompeJD,NafeB,FuriaJP&MaffulliN.(2007).Eccentricloading,shockwavetreatment,orawaitandseepolicyfortendinopathyofthemainbodyoftendoAchilles:arandomizedcontrolledtrial.AmericanJournalofSportsMedicine,March,35(3):37483.
SilbernagelK,ThomeeP&KarlsonJ.(2001).Eccentricoverloadtrainingforpatientswithchronicachillestendinopathyarandomizedcontrolledstudywithreliabilitytestingoftheevaluatingmethods.ScandanavianJournalofMedicineandScienceinSports,11:197206.
SilbernagelKG,ThomeeR,ErikssonBI&KarlssonJ.(2007).Continuedsportsactivity,usingapainmonitoringmodelduringrehabilitationinpatientswithAchillestendinopathy:arandomizedcontrolledstudy.AmericanJournalofSportsMedicine,June,35(6):897906.
SystematicReviews
KingmaJJ,deKnikkerR,WittinkHM,&TakkenT.(2007).EccentricOverloadTraininginPatientswithChronicAT:Asystematicreview.BritishJournalofSportsMedicine.June,41(6):e3.
KraemerR,LorenzenJ,VogtPM&KnoblochK.(2010).Systematicreviewabouteccentrictraininginchronicachillestendinopathy.SportverletzSportschaden.December,24(4):20411.[ArticleinGerman,Abstracttranslated]
MagnussenRA,DunnWR&ThomsonAB.(2009).NonoperativetreatmentofmidportionAchilletendinopathy:asystematicreview.ClinicalJournalofSportMedicine.January,19(1):5464.
MeyerA,TumilityS&BaxterGD.(2009).EccentricexerciseprotocolsforchronicnoninsertionalAchillestendinopathy:howmuchisenough?ScandanavianJournalofMedicineandScienceinSports.October,19(5),60915.
WasielewskiNJ&KotskoKM.(2007).Doeseccentricexercisereducepainandimprovestrengthinphysicallyactiveadultswithsymptomaticlowerextremitytendinosis?Asystematicreview.JournalofAthleticTraining.JulSep,42(3):40921.
WoodleyBL,NewshamWestRJ&BaxterGD.(2007).Chronictendinopathy:effectivenessofeccentricexercise.BritishJournalofSportsMedicine.April,41(4):18898;discussion199.
ExpertOpinion
MagnussonSP,LangbergH&KjaerM.(2010).Thepathogenesisoftendinopathy:balancingtheresponsetoloading.NatureReviewsRheumatology.May,6(5):2628.
LASER
RCTs
Bjordal,JM.(2006).Arandomised,placebocontrolledtrialoflowlevellasertherapyforactivatedAchillestendinitiswithmicrodialysismeasurementofperitendinousprostaglandinE2concentrations.BritishJournalofSportsMedicine,40(1):7680.
DarreE,KlokkerM&LundP.(1994).Laserbehandlingafakillessenetendinit.UgeskrLaeger.Nov7;156(45):66803.Danish.
StergioulaA,StergioulaM,AarskogR,LopesMartinsRAB&BjordalJM(2008).Effectsoflowlevellasertherapyandeccentricexercisesinthetreatmentofrecreationalathleteswithchronicachillestendinopathy.TheAmericanJournalofSportsMedicine,36(5):881887.
TumiltyS,MunnJ,AbbottJH,McDonoughS,HurleyDA&BaxterGD.(2008).LasertherapyinthetreatmentofAchillestendinopathy:apilotstudy.PhotomedicineandLaserSurgery,26(1):2530.
TumiltyS,MunnJ,AbbottJH,McDonoughS,HurleyDA,BasfordJR&BaxterG.D.(2010).LaserTherapyintheTreatmentofAchillesTendinopathy:ARandomisedControlledTrial.AIPConf.Proc.May31.Volume1226,pp.163169.
SystematicReviews
BjordalJ&CouppeC.(2001).LowLevelLaserTherapyforTendinopathy.EvidenceofADoseResponsePattern.PhysicalTherapyReviews,6:9199.
BjordalJM,LopesMartinsRAB,JoensenJ&IversenVV.(2010).Theantiinflammatorymechanismoflowlevellasertherapyanditsrelevanceforclinicaluseinphysiotherapy.PhysicalTherapyReviews,15(4):286293.
PeplowPV,ChungTY&BaxterGD.(2010).Applicationoflowlevellasertechnologiesforpainreliefandwoundhealing:overviewofscientificbases.PhysicalTherapyReviews,15(4):253285.
Metaanalysis
TumiltyS,MunnJ,McDonoughS,HurleyDA,BasfordJR&BaxterGD.(2010).Lowlevellasertreatmentoftendinopathy:asystematicreviewwithmetaanalysisPhotomedicineandLaserSurgery,28(1):316.
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EXTRA-CORPOREAL SHOCK WAVE THERAPY LOW ENERGY (FOCUSED AND RADIAL)
Cohort
LakshmananP,ODohertyD.(2004).ChronicAchillestendinopathy:treatmentwithextracorporealshockwavetherapy.FootandAnkleSurgery.10:125130.
RCTs
CostaML,ShepstoneL,DonellST,ThomasTL.(2005).ShockWaveTherapyforchronicAchillestendonpain:arandomizedplacebocontrolledtrial.ClinicalOrthopedicsandRelatedResearch.440:199204.
RompeJ,NafeB,FuriaJ.(2007).Eccentricloading,shockwavetherapyorwaitandseepolicyfortendinopathyofthemainbodyoftendoachillis:arandomizedcontrolledtrial.AmericanJournalofSportsMedicine.35(3):374383.
RompeJ,FuriaJ,MaffulliN.(2009).EccentricloadingvseccentricloadingplusshockwavetreatmentformidportionAchillestendinopathy.Arandomizedcontrolledtrial.AmericanJournalofSportsMedicine.37(3):463470.
RasmussenS,ChristensenM,MathiesenI,SimonsonO.(2008).ShockwavetherapyforchronicAchillestendinopathy:adoubleblind,randomizedclinicaltrialofefficacy.ActaOrthopaedica.79(2):249256.
IONTOPHORESIS WITH DEXAMETHASONE
RCTs
NeeterC,ThomeeR,SilbernagelK,ThomeeP,KarlsonJ.(2003).IontophoresiswithandwithoutdexamethasoneinthetreatmentofacuteAchillestendonpain.ScandinavianJournalofMedicineandScienceinSports.13(6):376382.
Review
BrownCD,LauberCA.(2011).Evidencebasedguidelinesforutilizationofdexamethasoneiontophoresis.InternationalJournalofAthleticTherapyandTraining.16(4):3336.
TAPING
RiddleDL&FreemanDB.(1988).ManagementofapatientwithadiagnosisofbilateralplantarfasciitisandAchillestendinitis.Acasereport.PhysTher.Dec;68(12):19136.
SmithM,BrookerS,VicenzinoB&McPoilT.(2004).Useofantipronationtapingtoassesssuitabilityoforthoticprescription:casereport.AustJPhysiother.;50(2):1113.
ORTHOTICS
MayerF,HirschmullerA,MullerS,SchuberthM&BaurH.(2007).Effectsofshorttermtreatmentstrategiesover4weeksinAchillestendinopathy.BrJSportsMed,41(7):e6.
GrossML,DavlinL&EvanskiPM(1991).Effectivenessoforthoticshoeinsertsinthelongdistancerunner.AmJSportsMed19:409412.
DonoghueOA,HarrisonAJ,LaxtonP&JonesRK.(2008).OrthoticcontrolofrearfootandlowerlimbmotionduringrunninginparticipantswithchronicAchillestendoninjury.SportsBiomech.May;7(2):194205.
GreeneBL.(2002).PhysicaltherapistmanagementoffluoroquinoloneinducedAchillestendinopathy.PhysTher.Dec;82(12):122431.
RiddleDL&FreemanDB.(1988).ManagementofapatientwithadiagnosisofbilateralplantarfasciitisandAchillestendinitis.Acasereport.PhysTher.Dec;68(12):19136.
BRACES AND NIGHT SPLINTS
KnoblochK,SchreibmuellerL,LongoUGetal.(2008).EccentricexercisesforthemanagementoftendinopathyofthemainbodyoftheAchillestendonwithorwithouttheAirHeelBrace.Arandomizedcontrolledtrial.A:effectsonpainandmicrocirculation.DisabilRehabil30:168591.
PetersenW,WelpR&RosenbaumD.(2007).ChronicAchillestendinopathy:aprospectiverandomizedstudycomparingthetherapeuticeffectofeccentrictraining,theAirHeelbrace,andacombinationofboth.AmJSportsMed;35:165967.
deVosRJ,WeirA,VisserRJetal.(2007).TheadditionalvalueofanightsplinttoeccentricexercisesinchronicmidportionAchillestendinopathy:arandomisedcontrolledtrial.BrJSportsMed;41:e5.
HEEL RAISE INSERTS
MacLellanGE&VyvyanB.(1981).ManagementofpainbeneaththeheelandAchillestendonitiswithviscoelasticheelinserts.BrJSportsMed.Jun;15(2):11721.
LowdonA,BaderDL&MowatAG(1984).TheeffectofheelpadsonthetreatmentofAchillestendinitis:adoubleblindtrial.AmJSportsMed.NovDec;12(6):4315.
NEEDLING TECHNIQUES/ACUPUNCTURE
JensFoellS(2010).IselectroacupunctureasafeandcosteffectivetreatmentforAchillestendonopathyinaprimarycaresetting?InternationalMusculoskeletalMedicine.32(2)5154.
FaganN&StatenP.(2003).Anauditofselfacupunctureinprimarycare.AcupunctMed;21:2831.