Achilles Tendinopathy Toolkit: Appendix D

Achilles Tendinopathy: Medical and Surgical Interventions

The purpose of this document is to summarize common medical and surgical interventions which may be considered for the management of Achilles
tendinopathy – particularly if it is not responding adequately to more strongly supported conservative management strategies (see “ Achilles
Tendinopathy: Summary of the Evidence for Physical Therapy Interventions ”).

Pharmacological Approaches

NSAIDS [1][2]

Method Short term benefit in the acute stage of tendinopathy to minimise inflammatory process.

Proposed Mechanism Interrupts the chemical pathway of inflammation.

Benefit: Pros/Cons Pros:  Inexpensive, easily accessible.

Cons:  Precautions and contraindications that accompany specific medications.

 Inhibition of inflammation may delay repair of muscle tissue or tendon insertion.

Evidence Limited evidence for a modest effect of topical or oral NSAIDs in acute stage in Achilles tendinopathy.
 Take Home Message PTs are involved in the treatment of tendon pain at all stages
'Implications for Physiotherapy recovery. General knowledge of commonly used NSAIDS is important for treatment planning.

Corticosteroid (injection) [3][4][5][6]

Method Short‐term benefit in acute stage. In chronic tendinopathy, the rationale for the use of anti-inflammatory injections is controversial.

Proposed Mechanism Injection into the paratendon to interrupt the inflammatory process.

Benefit: Pros: Easily accessible.

Pros/Cons  Careful administration outside the structure of the tendon is considered ‘safe’ i.e., in the paratendon sheath.

Cons Risk of infection (1%) ‘universal precautions’ required.

:  Destructive; risk of tendon rupture; impairs tendon tissue repair mechanism.

Evidence There is a lack of high quality evidence to support the use of local corticosteroid injections in chronic Achilles tendon lesions.
Generally, lack of well‐designed clinical trials.

Take Home Message PTs are involved in the treatment of tendon pain at all stages of recovery. There are animal studies that suggest risk of tendon
'Implications for rupture after corticosteroid injection. Caution is recommended in progressing the loading of the tendon within two weeks of a
Physiotherapy
 corticosteroid injection (exercise precautions).

Glycerol Trinitrate (GTN) [7][8][9][10][11]

Method Nitro‐glycerine patches applied over tendon to enhance healing.

Proposed Mechanism Nitric oxide may increase blood flow to the tendon and stimulate repair by enhancing fibroblast proliferation.

Benefit: Pros/Cons Pros:  GTN may improve outcomes compared to exercise alone.
 Increased compliance because of ease of application. Selfapplied.
 Non‐invasive.

Cons:  Labour‐ intensive; requires repeated applications over 12 weeks.

 Potential headache as a side-effect of nitro patch.

Evidence Conflicting evidence limits conclusions and widespread use.

Take Home Message If prescribed by a physician, may be applied by a physiotherapist and used in conjunction with an eccentric exercise program.
'Implications for Physiotherapy

 Click to go back to the  contents page

 Click to go back to the  Treatment Algorithm
 Click to go back to the  Summary of Interventions
 Click to go back to  Appendix A: Exercise Programs
 Click to go back to  Appendix B: Low Level Laser Therapy Dosage Calculation
 Click to go back to:  Appendix C: Details of Articles on Interventions

Injection Therapies

Chronic Achilles tendinopathy is associated with abnormal proliferation of neovessels in the ventral portion of the tendon, and along with
accompanying neural tissue, is associated with pain in tendinopathy. The presence of neovessels can be visualized by use of ultrasound (US)
(sonography). Grey ‐scale US is a reliable method to assess tendon structure. Color Doppler or power Doppler has also been used to visualize blood
flow.

Conservative treatment for Achilles tendinopathy is unsuccessful in 24 ‐45% of cases. US ‐guided injections are becoming increasingly considered as
part of ‘best practice’ for treatment of tendinopathies that have failed to respond to other conservative treatment.

Polidocanol [12][13][14][15][16][17]

Method Originally developed as an anaesthetic, and widely used as a sclerosing agent in the treatment of varicose veins.

Proposed Mechanism There is a body of literature that supports the use of US-guided injections of polidocanol to disrupt neovessels and
accompanying nerve structures associated with chronic tendinopathy.

Benefit: Pros: Increasingly used, registered drug with few side‐effects.

 No need to use additional anaesthetic, as it has its own aesthetic properties.
 Pros/Cons Cons Expensive sonography equipment, requiring an experienced operator.
:

Evidence Conflicting evidence limits conclusions and widespread use.

Take Home Message PTs should have knowledge of more invasive techniques to help to facilitate referral of patients to other procedures when
'Implications for conventional treatment fails to result in a sufficient positive response.
Physiotherapy

Prolotherapy [18][19][20]

Method Injecting a small volume of an irritant solution at multiple sites around a tendon insertion to induce a ‘pro-inflammatory’ proliferat
response. One study used hyperosmolar dextrose while another used hypertonic glucose, both with a small amount of anaesthetic.

Proposed Mechanism Fibroblast proliferation, collagen maturation and resolution of neovessels are observed, with near normal appearance of tendon tissue s
observed with US.

New viable tissue hypothesised to result from local release of cell growth factors.

Medical dextrose also has a weak sclerosing effect on vessels.

Benefit: Pros:  Can be performed with or without US‐guided localisation. 

 Pros/Cons Cons: Not covered by medical plans (BC); usually requires a private fee that reflects the expertise of the practitioner.
 Requires three or more repeated treatments.

Evidence Limited evidence suggests that prolotherapy combined with eccentric exercise for Achilles tendon loading may provide more rapid impro
in symptoms than eccentrics alone, although long‐term VISA‐A scores are similar.

Take Home Message Prolotherapy may enhance outcomes compared to using eccentric exercise, alone.
'Implications for
Physiotherapy

Platelet Rich Plasma (PRP) and Autologous whole blood [19][21][22][23][24]

Method Autologous blood injections involve the reinjection of a patient’s own whole
In PRP the autologous blood is centrifuged to collect a concentrate of the platelets and plasma. This is then injected back into the p
tendon.

Proposed Mechanism Cellular and humoral (blood) mediators promote healing in areas of tendon degeneration.

Benefit: Pros/Cons Pros:  Non-surgical option

 Can be performed with or without US-guided localization

Cons:  RCT-level evidence of lack of effectiveness

 Requires expensive blood processing equipment and centrifuge. Also, it is a US-guided technique requiring sonography
 experienced operator.

Evidence Two high-quality RCTs have shown both PRP and autologous whole blood injection to be ineffective.

Take Home Message PTs are part of a treatment team when treating tendon injury. General knowledge of PRP and relevant high quality RCTs is impo
'Implications for assist patients in decision-making.
Physiotherapy

High volume injection (HVI) or Hydrostatic dissection [25][26][27]

Method Small volume of anaesthetic/steroid and high volume of saline, delivered by US‐guided imaging.

Proposed Mechanism The pressure created by the volume of substance into the tendon sheath is proposed to disrupt the neovessel ingrowth in A
tendinopathy.

Benefit: Pros/Cons Pros:  Non‐surgical option.

Cons:  Requires sonography equipment.

Evidence Limited evidence of effectiveness.

Take Home Message Potential treatment option for Achilles tendinopathy that has failed to respond to a more conservative approach.
 'Implications for
Physiotherapy

 Click to go back to the  contents page

 Click to go back to the  Treatment Algorithm
 Click to go back to the  Summary of Interventions
 Click to go back to  Appendix A: Exercise Programs
 Click to go back to  Appendix B: Low Level Laser Therapy Dosage Calculation
 Click to go back to:  Appendix C: Details of Articles on Interventions

Dry Needling

The term ‘dry needling’ has been used to describe several techniques that involve insertion of a needle without injection of a substance. Needling of the
tendon has been described by a number of practitioners using a hypodermic needle. Similar results using acupuncture needles have become more
common. The technique is described below.

Dry Needline using a Hypordermic Needle ("tendon fenestration") [28]

Method Tissue trauma from the cutting edge of the needle/lumen.

Proposed Mechanism Repeated lancing of abnormal tendon tissue creates haemorrhage followed by an inflammatory response, granulation and healing
needling techniques employ US to guide the needle (percutaneous needle tenotomy).

Benefit: Pros:  Invasive treatment that avoids full surgical exposure and risks.
 Pros/Cons

Cons: Requires sonography equipment.

 Potential to permanently injure the tendon

Evidence Limited evience of effectiveness.

Take Home Message An invasive treatment with limited evidence.

'Implications for
Physiotherapy

 Click to go back to the  contents page

 Click to go back to the  Treatment Algorithm
 Click to go back to the  Summary of Interventions
 Click to go back to  Appendix A: Exercise Programs
 Click to go back to  Appendix B: Low Level Laser Therapy Dosage Calculation
 Click to go back to:  Appendix C: Details of Articles on Interventions

Related articles
Achilles Tendinopathy Toolkit: Appendix A - PhysiopediaAchilles Tendinopathy: Exercise Programs 1. Phased Achilles Tendon Loading Program (As
per Silbernagel et al.[1]) Phase 1: Weeks 1-2 Patient status: Pain and difficulty with all activities, difficulty performing ten 1 ‐legged heel raises Goal:
Start to exercise, gain understanding of their injury and of pain ‐monitoring model Treatment program: Perform exercises every day Pain ‐monitoring
model information and advice on exercise activity Circulation exercises (moving foot up/down) Two ‐legged heel raises standing on the floor (3 sets of
10‐15 repetitions/set) One ‐legged heel raises standing on the floor (3 sets of 10) Sitting heel raises (3 sets of 10) Eccentric heel raises standing on the
floor (3 sets of 10) Phase 2: Weeks 2-5 Patient status: Pain with exercise, morning stiffness, pain when performing heel raises Goal: Start strengthening
Treatment program: Perform exercises every day Two ‐legged heel raises standing on edge of stair (3 sets of 15) One ‐legged heel raises standing on
edge of stair (3 sets of 15) Sitting heel raises (3 sets of 15) Eccentric heel raises standing on edge of stair (3 sets of 15) Quick ‐rebounding heel raises (3
sets of 20) Phase 3: Weeks 3–12 (longer if needed) Patient status: Handled the phase 2 exercise program, no pain distally in tendon insertion, possibly
decreased or increased morning stiffness Goal: Heavier strength training, increase or start running and/or jumping activity Treatment program: Perform
exercises every day and with heavier load 2 ‐3 times/week One ‐legged heel raises standing on edge of stair with added weight (3 sets of 15) Sitting heel
raises (3 sets of 15) Eccentric heel raises standing on edge of stair with added weight (3 sets of 15) Quick ‐rebounding heel raises (3 sets of 20)
Plyometric training Phase 4: Week 12–6 months (longer if needed) Patient status: Minimal symptoms, morning stiffness not every day, can participate
in sports without difficulty Goal: Maintenance exercise, no symptoms Treatment program: Perform exercises 2 ‐3 times/week One ‐legged heel raises
standing on edge of stair with added weight (3 sets of 15) Eccentric heel raises standing on edge of stair with added weight (3 sets of 15) Quick ‐
rebounding heel raises (3 sets of 20) 2. 12-Week Eccentric Loading Program (As per Alfredson et al.[2]) 3 x 15 repetitions twice per day with extended
knee, and another 3 x 15 repetitions twice per day with a flexed knee. All exercises were 7 days per week. Patients were told to continue to exercise
with pain unless it became disabling. Patients were allowed to jog during their 12 ‐week rehabilitation so long as it caused only mild discomfort. A B C
Figure 1. From an upright body position and standing with all body weight on the forefoot and the ankle joint in plantar flexion lifted by the non ‐injured
leg (A), the calf muscle was loaded eccentrically by having the patient lower the heel with the knee straight (B) and with the knee bent (C). Figure 2.
Once the eccentric loads were performed at body weight without any discomfort, subjects were given a  backpack that was successively loaded with
weight. In this way their eccentric loading was gradually increased. If very  high weights ended up becoming needed then the subject used a weight
machine. Click to go back to the contents page Click to go back to the  Treatment Algorithm Click to go back to the Summary of Interventions Click to
continue to Appendix B: Low Level Laser Therapy Dosage Calculation Click to continue to: Appendix C: Details of Articles on Interventions Click to
continue to: Appendix D: Medical and Surgical Interventions Download  Achilles Tendinopathy Toolkit: Appendix A File:Download Appendix A -
Exercise Programs.pdfLateral Epicondyle Tendinopathy Toolkit: Appendix G - Medical and Surgical Interventions - Physiopedia Pharmacological
Approaches NSAIDs[1] Method Oral or topical application. Proposed Mechanism Interrupts the main pathway of inflammation by inhibiting the action
of cyclooxygenases. Benefit: Pros/Cons Pros: Inexpensive, easily accessible. Cons: Precautions and contra-indications that accompany specific
medications. Increased risk of gastrointestinal complications. Evidence Weak evidence for temporary pain relief in lateral elbow tendinopathy.
Insufficient evidence to make a recommendation. Relative effectiveness of oral vs. topical application has not been examined. Take Home Message
Implications for Physiotherapy General knowledge of commonly used NSAIDS is important for treatment planning. NSAIDs are not curative for this
condition and there is no evidence of sustained benefit in the long term. Corticosteroid (Injection)[2][3][4][5] Method Peritendinous injections.
Proposed Mechanism Applied locally to interrupt the inflammatory process. Reduces tendon blood flow and tissue thickening. Benefit: Pros/Cons Pros:
Easily accessible. Careful administration outside the structure of the tendon is considered ‘safe’( i.e. in the paratendon sheath). Cons: Worse long-term
outcomes. Risk of infection (1%) ‘Universal precautions’ required. Destructive; impairs tissue repair mechanism. Intra-tendon injection may weaken
tissue structure, with risk of tendon rupture. Skin depigmentation. Sub-cutaneous atrophy. Post injection pain. Evidence There is high quality evidence
that local corticosteroid injections are effective for short term pain relief, but are inferior to multimodal physiotherapy in the long term (6 and 12
months). Repeated injections (3-6 times in 18 months) has poorer outcome than a single injection on pain reduction. The benefit of early pain reduction
to assist in return to activity may be counter-productive due to increased risk of recurrence. Take Home Message Implications for Physiotherapy
Corticosteroid injections provide short-term relief but are associated with worse long-term outcomes with a high rate of recurrence. Glycerol Trinitrate
(GTN)[6][7] Method Nitro-glycerine patches (1.25mg/24 hrs) applied over tendon to enhance healing. Proposed Mechanism Nitric oxide may stimulate
repair by enhancing collagen synthesis in tenocytes. Benefit: Pros/Cons Pros: GTN + exercise improve outcomes compared to exercise alone. Increased
compliance because of ease of application. Self-applied. Non-invasive. Cons: Requires repeated applications over 12 weeks. Potential headache as a
side-effect of nitro patch. Evidence A small amount of RCT level evidence suggests that GTN patches combined with exercise achieve clinically
significant benefits compared to exercise alone. Take Home Message Implications for Physiotherapy Use of GTN may enhance exercise outcomes. If
prescribed by a physician, it may be applied by a physiotherapist and used in conjunction with a multimodal exercise program. Injection Therapies
Polidocanol[8][9] Method Originally developed as an anaesthetic and widely used as a sclerosing agent in the treatment of varicose veins. Proposed
Mechanism Ablation of neurovascular proliferation in painful tendon. Benefit: Pros/Cons Pros: May be less damaging than corticosteroid injections.
Cons: Evidence suggests lack of efficacy. Evidence 1 RCT: demonstrated no superiority to placebo (anaesthetic only). Take Home Message
Implications for Physiotherapy PTs should have knowledge of various injection techniques to help to facilitate referral of patients to other procedures
when conventional treatment fails to result in a sufficient positive response. Prolotherapy[10][9] Method Most common injectant is hyperosmolar
dextrose with small amount of anaesthetic to induce a ‘proinflammatory’ proliferative cell response to assist in tissue repair. Proposed Mechanism New
viable tissue is hypothesized to result from the local release of cell growth factors. Medical dextrose also has a weak sclerosing effect on vessels.
Benefit: Pros/Cons Pros: Non-surgical option. Can be performed with or without USguided localization. US-guided technique permits localization to a
specific target site. However, injections without US imaging may also be effective, even in a sub-cutaneous approach superficial to the target tissue.
Cons: Not covered by medical plans (British Columbia); usually requires a private fee that reflects the expertise of the practitioner. Requires three or
more repeated treatments, similar to other injection therapies. Expensive sonography equipment requiring an experienced operator. Evidence A small
amount of evidence demonstrates superiority to placebo injections. Take Home Message Implications for Physiotherapy Prolotherapy may enhance
outcomes compared to using exercise alone. Platelet Rich Plasma (PRP)[9][11][12][5] Method Centrifuge of autologous blood to collect a concentrate
of the platelets and plasma. This is then injected back into the patient’s tendon. Proposed Mechanism Cellular and humoral (blood) mediators promote
healing in areas of tendon degeneration. Benefit: Pros/Cons Pros: Non-surgical option. Cons: Requires expensive blood processing equipment and
centrifuge. Also, it is a US-guided technique requiring sonography and an experienced operator. Evidence A small amount of evidence suggests that
PRP injection is no more effective than placebo. Studies also suggest that PRP injections for lateral elbow tendinopathy are superior to corticosteroid
outcomes at 1 year follow-up, due to the fact that corticosteroid injection leads to worse long-term outcomes. Take Home Message Implications for
Physiotherapy General knowledge of PRP is important to assist patients in decision-making. Botox (Botulinum Toxin A)[13][14] Method Injection of
botox into the wrist extensors. Proposed Mechanism Paralysis of the extensor muscles causes a period of unloading, reducing the irritation of injured
tendon tissue and allowing healing to proceed. Benefit: Pros/Cons Pros: Non-surgical option. Cons: Can cause paralysis with loss of finger extension.
Evidence A small amount of evidence suggests that Botox injection is superior to placebo. Take Home Message Implications for Physiotherapy
Provides another treatment option when conservative treatment has been unsatisfactory. Surgical Approaches Denervation[15] Method Open incision
and resection of posterior cutaneous nerve of the forearm. Proposed Mechanism Interrupts pain transmission and potential influence of nerves on failed
healing response in the tendon (neurogenic inflammation). Benefit: Pros/Cons Pros: Short recovery compared to more invasive surgery. Faster return to
work. Improved pain relief compared to surgical debridement. Cons: Risk of infection. Evidence Small amount of evidence (retrospective case series)
indicates superiority to standard technique. Take Home Message Implications for Physiotherapy PT may be involved in the post-op rehabilitation
following surgery. Surgical Debridement[16] Method Incision to expose the tendon, with excision of disorganized and fibrotic tendon tissue and
adhesions. Proposed Mechanism Surgery creates granulation and repair, and removes fibrotic tissue. Benefit: Pros/Cons Pros: High success rates
reported by some centres. Cons: Risk of infection. Long post-op recovery of 3-6 months. Limited data on outcomes with this procedure. Evidence Open
surgery may be a successful option for patients that have failed to respond to conservative treatment. Take Home Message Implications for
Physiotherapy PT may be involved in the post-op rehabilitation following surgery. Download Lateral Epicondyle Tendinopathy Toolkit: Appendix G -
Medical and Surgical Interventions http://physicaltherapy.med.ubc.ca/files/2013/07/Appendix-G.-Lateral-Epicondyle-Tendinopathy-Medical-and-
Surgical-Interventions-June-2013.pdf Acknowledgements Developed by M. Yates & A Scott. BC Physiotherapy Tendinopathy Task Force. June
2013Achilles Tendinopathy Toolkit: Appendix B - PhysiopediaAchilles Tendinopathy: Low Level Laser Therapy Dosage Calculation Current
recommendations specify that LLLT dosage be provided in Joules (J, total energy), rather than the previous recommended Joules/cm2 (J/cm2, energy
density). Use Joules rather than Joules/cm2 to specify how much energy is delivered in a treatment. In Laser devices that do not calculate Joules
automatically, dose can be determined in seconds of exposure required to give the desired Joules by using the following calculation: Joules =
watts.seconds hence, Seconds = Joules/watts For example: For a 50 mW Laser (= 0.050 Watts), with a required dose = 2 J per point… Seconds
exposure = 2 / 0.05 = 40 secs This change is very important clinically as the use of the previously recommended Joules/cm2 resulted in confusion when
comparing dosages between protocols. The resultant dose in Joules/cm2 could be the consequence of a number of different treatment options. For
example, 4 J/cm2 can be delivered by: Option #1 a 20 mW Laser with a beam cross section of 0.5 cm2 in 100 seconds i.e., 4 = (0.02/0.5 x 100) Option
#2 a 10 mW laser with a beam cross ‐section of 0.25 cm2 in 100 seconds i.e., 4 = (0.01/0.25 x 100) In Option #1, the total energy delivered would be 2 J
In Option #2 the total energy would be 1 J This example illustrates that using Joules/cm2 resulted in one patient receiving twice the total amount of
energy that is received by the other patient! Therefore, all physical therapists using LLLT should be delivering dosages based on Joules rather than
Joules/cm2. Using Joules rather than Joules/cm2 will enable better standardization of dosage and permit comparison across different treatment regimes.
The World Association of Laser Therapy (WALT) provides dosage guidelines using Joules for various conditions. These dosage guidelines are based
upon the best evidence from the literature in conjunction with expert opinion. Physical Therapists are encouraged to set LLLT dose according to the
WALT guidelines found via this link. (Note that the WALT guidelines are given for surface exposure.) Click to go back to the contents page Click to go
back to the Treatment Algorithm Click to go back to the Summary of Interventions Click to go back to Appendix A: Exercise Programs Click to
continue to: Appendix C: Details of Articles on Interventions Click to continue to:  Appendix D: Medical and Surgical Interventions Download Achilles
Tendinopathy Toolkit: Appendix B File:Download Appendix B - Low Level Laser Therapy Dosage Calculation.pdf Retrieved from
"https://www.physio-pedia.com/index.php?title=Achilles_Tendinopathy_Toolkit:_Appendix_B&oldid=197305" Categories: Sports Medicine
TendinopathyAchilles Tendinopathy Toolkit: Summary of Interventions - Physiopedia 6 Acknowledgements Achilles Tendinopathy (mid-substance): 
Summary of the Evidence for Physical Therapy Interventions Click to go back to the contents page Click to go back to the  Treatment Algorithm Click
to continue to Appendix A: Exercise Programs Click to continue to Appendix B: Low Level Laser Therapy Dosage Calculation Click to continue
to: Appendix C: Details of Articles on Interventions Click to continue to:  Appendix D: Medical and Surgical Interventions Manual Therapy Joint mobs
Stage of pathology Acute Chronic Clinical research evidence No Yes 1CS[1] Published expert opinion Yes[2] Yes[2] Take home message There is no
clinical evidence but there is expert level consensus to support the use of joint mobilizations in the acute stage if assessment  reveals joint restriction.
There is a small amount of clinical evidence and more substantial expert level consensus to support the use of joint mobilizations in the chronic stage
if assessment reveals joint restriction. Clinical implication May consider using manual therapy in the acute stage after undertaking a comprehensive
biomechanical evaluation of the ‐ Joint mobs hip, knee, foot and ankle. May consider using manual therapy in the chronic stage after undertaking a
comprehensive biomechanical evaluation of the hip, knee, foot and ankle. Soft-tissue techniques Stage of pathology Acute Chronic Clinical research
evidence No Yes 1 SR[3] 2 CS[4][5] Published expert opinion No Yes[2] Take home message The clinical evidence neither supports nor refutes  the use
of frictions in the acute stage. There is a small amount of clinical evidence to support the use of soft tissue techniques, such as  frictions, in the chronic
stage. Clinical implication May consider using manual therapy in the acute stage after undertaking a comprehensive biomechanical  evaluation of the ‐
Joint mobs hip, knee, foot and ankle. May consider a trial of soft tissue techniques, such as frictions, in the chronic stage.  Combining with an eccentric
exercise regime may produce superior results. CS ‐ Case studies; SR ‐ Systematic reviews. Exercise Stage of pathology Acute Chronic Clinical research
evidence No Yes 14 OS[6][7][8][9][10][11][12][13][14][15][16][17] 7 SR[18][19][20][21][22][23][24] 8 RCT[25][26][27][28][29][30][31][32]
Published expert opinion Yes[33] Yes[33] Take home message There is a small amount of expert opinion to  support the use of stretches in the acute
stage. There is a large amount of clinical evidence to support the use of exercise in the chronic stage but  the precise parameters to ensure effectiveness
are not clear. Eccentric exercise in particular is supported although some protocols use both concentric and eccentric exercise. One RCT showed heavy
slow resistance training is equally as effective as eccentric training. Clinical implication May consider using stretching exercises in acute stage. No
prescription parameters are provided. ACSM recommends 10-30 sec hold, 2 ‐4 repetitions. Strongly consider using eccentric exercise in the chronic
stage. See Appendix A for further details on exercise prescription. OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic
reviews. Low level laser therapy (LLLT) Stage of pathology Acute Chronic Clinical research evidence Yes 2 SR[34][35][36] Yes 1 MA[37] 6 RCT[38]
[39][40][41][42][43] Published expert opinion Yes Yes Take home message There is no clinical evidence, but there is a  physiological rationale, to
support the use of LLLT in the acute stage. There is conflicting clinical evidence and conflicting  expert opinion to support the use of LLLT in
the chronic stage. Clinical implication May consider a trial of LLLT in the acute stage at the doses  recommended by the World Association for Laser
Therapy (www.walt.nu) i.e., 2 ‐4 J/point (not per cm2)*, minimum 2 ‐3 points. *See 'Appendix B  'for further details on calculation of dosage. Consider a
trial of LLLT in the chronic stage at the following parameters: 0.9 J/point (not per cm2)*; 6 points on tendon. *See Appendix B 'for further details on
calculation of dosage. MA ‐ Meta ‐analyses; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews. Ultrasound (US) Stage of pathology Acute
Chronic Clinical research evidence No No Published expert opinion No No Take home message There is no clinical evidence, but there is physiological
rationale, to support the use of US in the acute stage. There is no clinical evidence and no physiological  rationale to support the use of US in the
chronic stage. Clinical implication May consider a trial of US in the acute stage at a low to moderate dose (0.5 ‐ 1.0 W/cm2, pulsed 1:4 ‐1:1, 3 MHz, 5
mins for each treatment area equivalent in size to transducer head). Consider NOT using US in the chronic stage. Extracorporeal shock wave therapy
(ESWT) Stage of pathology Acute Chronic Clinical research evidence No Yes 4 RCT[44][45][46][47] 1 Cohort[48] 1SR  [49] Published expert opinion
Yes Yes Take home message There is expert opinion which suggests that ESWT be  reserved for chronic stage. There is conflicting evidence to support
the use of ESWT in the chronic stage. There is evidence suggesting that the outcomes are dependent upon the dosage of the shock wave energy (EFD ‐
energy flux density = mJ/mm²), rather than the type of shock wave generation (focused vs. radial ESWT). There is also evidence that the use of
anaesthetic required in high energy protocols decreases the  effectiveness of ESWT. Therefore, using low energy ESWT protocols without the need for
anaesthetic are recommended as more practical, more tolerable, and less expensive with equivalent results. Low energy ESWT protocols can apply to
both focused and radial ESWT. Clinical implication Consider NOT using Extracorporeal Shock Wave for the  acute stage. Consider a trial of ESWT in
the chronic stage, especially if other interventions have failed, at the following parameters:  Low energy SWT: EFD = 0.18 – 0.3 mJ/mm² (2 ‐4 Bars)  
2000‐3000 shocks   15‐30 Hz  3‐5 sessions, weekly intervals.   ESWT may enhance outcomes compared to exercise alone, therefore patients should be
instructed to continue with a well ‐designed exercise program. RCT ‐ Randomized controlled trials; SR - Systematic review Iontophoresis using
dexamethasone Stage of pathology Acute Chronic Clinical research evidence Yes 1 RCT  [50] 1 SR [51] No Published expert opinion No No Take home
message There is a small amount of evidence to support the application of iontophoresis using dexamethasone in the acute stage. The role of
iontophoresis is still investigational. There is no evidence that anti ‐inflammatory intervention with iontophoresis using dexamethasone has a useful role
in the chronic stage. Clinical implication May consider, in the acute stage, a trial of iontophoresis, 0.4% dexamethasone (aqueous), 80 mA ‐min; 6
sessions over 3 weeks. A program of concentric ‐eccentric exercises should be continued in combination with iontophoresis, if exercise loading is
tolerated. Consider NOT using iontophoresis using dexamethasone in the chronic stage. RCT ‐ Randomized controlled trial; SR - Systematic Review
Taping Stage of pathology Acute Chronic Clinical research evidence No Yes 3 CS  [52][53][54] 1SR [55] Published expert opinion Yes Yes Take home
message There is expert opinion to support the use of antipronation taping in the acute stage. There is expert opinion and a small amount of clinical
evidence to support the use of controlled pronation taping in the chronic stage. Clinical implication May consider using antipronation taping in the
acute stage. May consider using antipronation taping in the chronic  stage. CS ‐ Case studies; SR - Systematic Review Orthotics Stage of pathology
Acute Chronic Clinical research evidence Yes 2 CS [56][57] Yes 3 CS [58][59][60] 2 RCT[61][62] 1 SR [63] Published expert opinion Yes Yes Take
home message There is a small amount of clinical evidence to  support the use of orthotics in the acute stage. There is a moderate amount of clinical
evidence tosupport the use of orthotics in the chronic stage. Clinical implication Consider using orthotics – perhaps using taping first, in the acute stage.
Consider using orthotics in the chronic stage. CS ‐ Case studies; RCT ‐ Randomized controlled trials; SR - Systematic Review Night splints and braces
Stage of pathology Acute Chronic Clinical research evidence No Yes 3 RCT[64][65][66] 1 SR  [67] Published expert opinion Yes Yes Take home
message There is expert opinion to support the use of night splints and braces in the acute stage. There is a moderate amount of evidence against the use
of night splints and braces in the chronic stage in conjunction with eccentric exercise. Clinical implication Consider a trial of night splints and braces in
the acute stage. Consider NOT using night splints and braces in the chronic stage  in conjunction with exercise.  RCT ‐ Randomized controlled trials; SR
- Systematic Review Heel raise inserts Stage of pathology Acute Chronic Clinical research evidence No Yes 2 RCT[68][69] Published expert opinion
Yes Yes Take home message There is some expert opinion to support the use of  heel raise inserts in the acute stage. There is conflicting evidence for
and against the use of heel inserts in the chronic stage. Clinical implication May consider a trial of inserts in the acute stage. Consider a trial of inserts
in the chronic stage. RCT ‐ Randomized controlled trials. Needling techniques[70][71] Acupuncture (trasitional Chinese medicine, anatomical,
electrical) and intramuscular stimulation. Stage of pathology Acute Chronic Clinical research evidence Yes 1 CS Yes 1 CS Published expert opinion No
No Take home message There is a small amount of evidence to support the use of Traditional Chinese Medicine electroacupuncture in the acute stage.
There is expert opinion to support the use of other needling techniques in the acute stage. There is a small amount of evidence to support use of
Traditional Chinese Acupuncture in the chronic stage. There is expert opinion on the use of other needling techniques in the chronic stage. Clinical
implication Consider a trial of electro ‐acupuncture in the acute stage. May consider a trial of other acupuncture ‐related needling techniques in the acute
stage. Consider a trial of Traditional Chinese Acupuncture in the chronic stage. May consider a trial of other acupuncture ‐related needling techniques in
the chronic stage. CS ‐ Case studies. Click to go back to the contents page Click to go back to the  Treatment Algorithm Click to continue to Appendix
A: Exercise Programs Click to continue to Appendix B: Low Level Laser Therapy Dosage Calculation Click to continue to:  Appendix C: Details of
Articles on Interventions Click to continue to: Appendix D: Medical and Surgical Interventions Outcome measures For any intervention selected by the
clinician, it is strongly recommended that the clinician use one or more of the following outcome measures. A. Patient reported outcome measure Such
as: A global measure of lower extremity function: e.g., The Lower Extremity Functional Scale (LEFS) ‐ not  specific to Achilles tendinopathy Available
here Detailed questionnaire, specific to Achilles tendinopathy e.g. the VISA ‐A questionnaire Available here  (Click on ‘view questionnaire’) B. Patient
specific functional outcome measure Such as: How much weight can be applied to the plantar flexed foot on a weighing scale before the onset of pain
The number of heel raises before the onset of pain The number of heel drops before the onset of pain The number of heel drops with a specific weight in
a backpack before the onset of pain How far can the client walk or run before the onset of pain Click to go back to the contents page Click to go back to
the Treatment Algorithm Click to continue to Appendix A: Exercise Programs Click to continue to Appendix B: Low Level Laser Therapy Dosage
Calculation Click to continue to: Appendix C: Details of Articles on Interventions Click to continue to:  Appendix D: Medical and Surgical Interventions
Explanation of clinical implications Strongly consider: High level/high quality evidence that this should be included in treatment. Consider:  Consistent
lower level/lower quality or inconsistent evidence that this should be included in treatment. May consider:  No clinical evidence but expert opinion
and/or plausible physiological rationale that this should be included in treatment. Consider NOT:  High level/high quality evidence that this should not
be included in treatment. Click to go back to the contents page Click to go back to the  Treatment Algorithm Click to continue to Appendix A: Exercise
Programs Click to continue to Appendix B: Low Level Laser Therapy Dosage Calculation Click to continue to:  Appendix C: Details of Articles on
Interventions Click to continue to: Appendix D: Medical and Surgical Interventions Download Achilles Tendinopathy Toolkit: Summary of
Interventions File:Download Achilles Tendinopathy - Summary of Interventions.pdf Microsoft Word - Appendix D. Achilles Tendinopathy - Medical
and Surgical Interventions FINAL (April 20, 2012).doc: McLauchlan , G, Handoll, H. (2009). Interventions for treating acute and chronic Achilles
tendinitis. Cochrane Collaboration of Systemic Reviews. 2:1 ‐36. Corticosteroid (injection) Short ‐term benefit in acute stage. In chronic tendinopathy,
the role of inflammation is unclear, and the rationale for the use of anti ‐inflammatory injections is controversial. Many studies report an absence of
cellular features of inflammation in chronic tendinopathy. Injection into the paratendon to interrupt the inflammatory process. PROS: � Easily
accessible. � Careful administration outside the structure of the tendon is considered ‘safe’ i.e., in the paratendon sheath. CONS: � Invasive, painful.
� Risk of infection (1%) ‘universal precautions’ required. � Destructive; risk of tendon rupture; impairs tissue repair mechanism. Weak evidence for
a modest effect in acute stage in Achilles tendinopathy. Recommendation for a short course of NSAIDs for acute symptoms within 14 days. No
difference between oral or topical application. There is a lack of high quality evidence to support the use of local corticosteroid injections in chronic
Achilles tendon lesions. Generally, lack of well ‐designed clinical trials.

Surgical Approaches

Surgical success rates are reported at 85% for Achilles tendinopathy that have failed to respond to conservative measures.

Percutaneous tenetomy [29][30]

Method Techniques include closed dissection of the tendon sheath by US‐guided percutaneous longitudinal internal tenotomy; or open surgical e
of the tendon.

Proposed Mechanism Surgical trauma creates granulation and repair, and interrupts fibrous adhesions.

Benefit: Pros:  Simple procedure that can be done as an outpatient.

Pros/Cons

Cons: Risk of infection.

Evidence Satisfactory outcomes for selected patients that do not have complicated Achilles pathology, and have failed to respond to a cons
treatment approach. Treatment seems to be effective in the long-term with regard to returning to pre-injury level of functioning. Paratendi
is a negative prognostic factor.

Take Home Message PT may be involved in the post‐op rehabilitation following surgery.
'Implications for
 Physiotherapy

Surgical debridement [31][32]

Method Central longitudinal incision to expose the tendon,

excision of disorganised and fibrotic tendon tissue and adhesions. Additional diathermy to destroy neovessels.

Proposed Mechanism Surgery creates granulation and repair, and removes fibrotic tissue.

Benefit: Pros/Cons Pros:  High success rates reported by some centres in terms of reducing pain and improving functionality

Cons:  Risk of infection.

 Long post‐op recovery of 3‐6 months.

Evidence Surgery may be a successful option for patients that have failed to respond to conservative treatment, or have complicated Achilles
pathology.

Take Home Message PT may be involved in the post‐op rehabilitation following surgery.
'Implications for
Physiotherapy
Minimally invasive stripping [33]

Method Small incision in made allowing a probe or scapel to be inserted ventral to the tendon. The area of neovascularisation is stripped

Proposed Mechanism Disrupts abnormal blood/nerve supply, releases adhesions.

Benefit: Pros/Cons Pros:  High success rate reported.

 Minimal trauma to tendon
 Quick return to sport
 Reduced risk of infection comparing to open surgery

Cons:  Risk of infection.

 Potential loss of gliding function due to long term increased

Evidence Retrospective, short-term studies only

Take Home Message PT may be involved in the post‐op rehabilitation following surgery.
'Implications for Physiotherapy

Download Achilles Tendinopathy Toolkit: Appendix D

File:Download Appendix D - Medical and Surgical Interventions.pdf

 References

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Acknowledgements

Developed by Michael Yates, PT. BC Physiotherapy Tendinopathy Task Force. April 2012.

Updated by Alexandra Kobza, Dr. Alex Scott. June 2015.