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
Achilles Tendinopathy
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
Review of Literature
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
Anatomy of the Achilles Tendon
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
Achilles Tendinopathy
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
Review of Literature
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
Anatomy of the Achilles Tendon
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
Achilles Tendinopathy
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
Review of Literature
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
Anatomy of the Achilles Tendon
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
Achilles Tendinopathy
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
Review of Literature
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
Anatomy of the Achilles Tendon
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
Review of Literature
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
Anatomy of the Achilles Tendon
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
Review of Literature
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
Anatomy of the Achilles Tendon
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
Review of Literature
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
Anatomy of the Achilles Tendon
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
Review of Literature
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
Anatomy of the Achilles Tendon
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
Anatomy of the Achilles Tendon
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
Anatomy of the Achilles Tendon
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
Anatomy of the Achilles Tendon
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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 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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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)
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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 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)
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
Eccentric Training Model
Eccentric Training Model
Eccentric Training Model
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 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
Eccentric Training Model
Eccentric Training Model
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 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
Eccentric Training Model
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 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
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 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
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
THANK YOU