November 2009

Achilles tendinopathy: A four-part approach

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This clinical strategy for Achilles tendinopathy includes massage techniques that apply pressure along injured soft tissues to promote healing, as well as Mulligan taping for the control of pronation and management of symptoms.

by Russell Woodman, FSOM,OCS,MCTA, DPT, and Juan C. Garbalosa, PhD, PT

Achilles tendinopathies (AT) encompass inflammation (tendinitis) or microtears (tendinosis) of the Achilles tendon.1 A typical cause of AT is the application of repetitive and or excessive loads to the Achilles tendon. An increase in the prevalence of AT has been reported in the last 10 years.2 Achilles tendinopathies reportedly comprise 6.5% of all running injuries.3

In order to determine the appropriate method of treatment for AT, a systematic evaluative process should be employed. This process should include a detailed history, selective tissue tension tests, and appropriate specialty (adjunct) tests. The history should ascertain the pattern of symptom(s) the patient is experiencing, including symptom onset, duration and cessation. Particular attention should be paid as to what brings on and alleviates the patient’s symptom(s). The presence of risk factors that predispose an individual for the development of AT should also be determined.

Achilles tendinopathies most frequently occur in individuals between 30 to 50 years of age, with more males sustaining AT’s than females.4 Other factors associated with AT are altered biomechanics of the lower extremity (e.g., excessive pronation of the rearfoot during stance), decreased flexibility of the gastroc-soleus complex, impaired circulation, improper footwear, improper training, and being involved in a competitive sport.4 A common denominator in the majority of these factors is an excessive load that is repeatedly placed upon the Achilles tendon.

Examination

Upon obtaining the patient’s history, a physical examination should be performed. The examination should begin with a visual inspection. The examiner should pay particular attention to the patient’s foot posture. Specifically, the presence of an everted calcaneus with a collapsed arch while weight bearing should be ascertained. Such a finding may be indicative of a flexible flat foot, which potentially may cause abnormal foot mechanics.5 A selective tissue tension test should then ensue, consisting of active, passive and resistive movement tests.6 During the selective tissue tension test, it is imperative that the patient understands that the examiner needs clear answers as to which movements alter the patient’s symptom(s). In most instances, the movements that provoke pain are of most importance. However, identifying movements or activities that diminish or relieve the symptom(s) can also be helpful in reaching a diagnosis and thus developing an effective treatment plan.

achilles-table1Active movement of the foot and ankle are first performed as a functional test for mobility and symptom reproduction (Table 1). These are followed by passive range of motion tests (Table 1) to assess the status of the non contractile tissues. During the passive tests, the examiner seeks to answer three questions:

1. Does the passive test reproduce the patient’s symptoms?

2. Is the range of motion normal, excessive, or limited?

3. Does the examiner perceive the end feel ( the feel of the joint at the end of its range of motion) to be normal?7

In AT, the examiner should expect to find pain on standing plantar flexion, with the remaining active motions being of full range and asymptomatic. The anterior fibers of the Achilles tendon can be pinched between the calcaneus and tibia at the extremes of passive plantar flexion, thus a patient with a AT located in the deep anterior fibers of the Achilles tendon will have pain on passive plantar flexion. All other passive movements will be of full range and painless with a normal end feel.7

At the completion of the passive tests, resistive tests are performed with the foot and ankle joint in a neutral joint position, with the exception of the plantar flexors (Table 1). The plantar flexors are tested by having the patient perform standing active plantar flexion. All patients with AT will have an increase of pain on standing active plantar flexion. If the lesion is severe, this muscle test will also elicit weakness as the pain inhibits the muscle contraction. All other resistive movements will be strong and painless.7 Once selective tissue tension testing is complete, the examiner performs palpation to confirm the exact location of the lesion. The examiner should expect to find tenderness upon palpation. The location of the tenderness is dependent upon the site of the lesion. For example, if the lesion is located in the medial fibers of the Achilles tendon, then palpation in this area should elicit tenderness. If the lesion is located in the deep anterior distal fibers, however, the examiner may not be able to elicit positive findings during palpation as this site is not palpable.7

A biomechanical foot evaluation should be performed if, based upon the visual inspection performed earlier, the patient is suspected of having a flexible flat foot. The aim of the evaluation should be to ascertain if the patient’s rearfoot is pronating excessively and, if possible, the cause of the pronation. The evaluation should incorporate an assessment of foot motion during barefoot walking and/or barefoot and shod running, measurement of navicular drop, and assessment of the frontal plane relationship of the forefoot to the rearfoot while non weight bearing, as a minimum.5,8 While the subject is walking over land or on a treadmill, the extent and duration of calcaneal eversion should be noted. The use of a video camera can aid in assessing the calcaneal motion.

The rearfoot should evert from initial contact through midstance and then invert. If the calcaneus remains everted after heel off, the rearfoot is considered to be pronating excessively. An everted calcaneus will increase the stress to the medial aspect of the Achilles tendon.9 Two potential causes of excessive rearfoot pronation are a flexible flat foot and a forefoot varus deformity. A navicular drop greater than or equal to 15 mm is indicative of a flexible foot.10 A forefoot varus greater than 11º should be considered abnormal and a potential cause of excessive rearfoot pronation.11 A direct correlation between navicular drop and forefoot varus and AT has been noted in the literature.12,13

In addition to the above tests, we advise the administration of a questionnaire such as the VISA-A (Victorian Institute of Sports Assessment-Achilles) to measure the functional severity of the tendinopathy. The questionnaire is also very useful to measure progress and final outcome of the rehabilitation process. This questionnaire has been found to be both valid and reliable in evaluating AT.14

Treatment

Once the diagnosis of AT has been reached, a myriad of treatments may be employed for the management of AT. These include ice, immobilization, foot orthotics, heel lifts, deep friction massage, Achilles tendon stretching exercises, eccentric gastrocnemius training, corticosteroids and taping.2,3,4,15,16,17 These treatments are designed to either decrease pain, increase the efficiency of the gastrocnemius in stance, or stabilize the tendon in a more appropriate position. Ice, immobilization, corticosteroids, and deep friction massage are aimed at reducing pain and promoting proper healing. Foot orthotics,stretching and eccentric exrecise, and taping are aimed at increasing the efficiency of the gastrocnemius in stance and stabilizing the tendon. Most studies indicate that these treatments show positive results initially. 2,3,4,15,16,17

Clinically, we have found that a four pronged approach is most efficacious for the treatment of AT. Using this approach we have encountered success rates of up to 80%.

First, the patient must be educated to refrain from any repetitious activities such as long distance running that places repeated stress on the Achilles tendon. In those patients who are unwilling to reduce their activity levels, the likelihood of treatment success is drastically decreased. Once the patient is pain free and any biomechanical issues have been resolved, the patient in most cases should be able to resume their normal routine.

Figure 1

Figure 1

Second, the application of deep friction massage three times per week to the exact location of the lesion (Figure 1) should be administered. This treatment modality still lacks conclusive evidence of its efficacy, but recent research has indicated that massage like pressure applied along the soft tissue lesion enhances the healing process by recruitment and activation of fibroblasts.18,19 The patient will most likely require three to nine, 15 minute sessions of deep friction massage, before they are symptom free. Typically, according to our clinical experience and those of Cyriax and Russell, the massage is administered three times per week for two to three weeks.6 No further massage is indicated when isometric resistive muscle testing and prolonged repetitive use of the muscle during functional activities is no longer painful to the patient.6

Third, employ an eccentric exercise program, such as the program proposed by Stanish, to help relieve the patient’s symptoms and allow for a more successful return to rigorous physical activity.20 Stanish’s program consists of gentle stretching, eccentric exercises and ice to the gastrocnemius.20 Care must be given to make sure that this regimen does not exacerbate the patient’s pain. In some cases the exercises can be implemented concurrently with deep friction massage, in other cases the clinician must wait until isometric muscle testing and repetitive movements of the involved muscle are pain free. Eccentric exercise programs have been shown to be effective in the treatment of tendinopathies.21 If the patient exhibits excessive rear foot pronation, we recommend that the patient’s pronation be controlled, either by Mulligan taping or an orthotic (see below), prior to eccentric exercise.

For those patients who present with abnormal pronation of the foot, the last prong of our treatment program is to develop a strategy to control this abnormal movement. The first step in this strategy is the application of Mulligan taping. In our clinical experience, if the abnormal movement is a contributing factor in the patient’s symptoms then the taping should provide an immediate decrease in their pain. Although the clinical effectiveness of Mulligan taping for AT has not been established, it has been shown to reduce calcaneal eversion both statically and during gait in asymptomatic patients.22

Figure 2a

Figure 2a

Mulligan taping of the Achilles tendon attempts to reposition the tendon to prevent the medial convexity of the tendon that causes an excessive stretch on the medial fibers during rearfoot pronation. The taping creates a laterally directed force on the Achilles tendon, creating a concavity of the medial fibers and a diminished pronation of the rearfoot. This concavity slackens the medial fibers, preventing excessive tension on these fibers during daily activity and allowing healing to occur. Compared to other antipronation taping techniques (such as that proposed by Smith), this technique only requires two as opposed to numerous pieces of tape to control rearfoot pronation.23 The Mulligan taping should be used daily to control calcaneal motion. If the taping is successful in improving the patient’s symptom(s), this could justify the need for an orthotic as a more permanent method to control pronation.

The taping technique is most easily accomplished when two practitioners work together. To apply the tape, the patient is positioned prone, with the involved ankle over the edge of a treatment table (Figure 2). Once the patient is in this position, the skin over the distal aspect of the lower leg (from the musculotendionous junction to the insertion of the Achilles tendon on the calcaneus) is cleansed with an alcohol impregnated gauze pad. One clinician will then stabilize the lower leg and position the calcaneus in maximal inversion (Figure 2). The second clinician applies a base tape consisting of a two inch wide strip of cross-elastic non-woven based tape (BSN-Jobst, Charlotte, NC). The tape is

Figure 2b

Figure 2b

placed on the medial fibers of the Achilles tendon and is pulled over the posterior aspect of the tendon and around the front of the ankle, just short of touching where the starting edge of the base tape was placed (Figure 2). This procedure is performed again but this time with a two inch wide strip of rayon backed zinc oxide tape (BSN-Jobst, Charlotte, NC). Water proof tape (Covidien, Mansfield, MA) can also be employed with the same success. Other tapes ,such as Kinesio Tex tape (KMS LLC, Albuquerque, NM), should not be utilized as they have too much elasticity and cannot hold the tendon in proper alignment.

Some patients may experience a rash after the application of the tape, which Mulligan believes is frequently due to the acidity of the tape.9 To prevent the rash, aluminum with magnesium hydroxide – oral (Johnson and Johnson, Langhorne, PA) can be applied to the skin prior to the application of the tapes. Once the aluminum with magnesium hydroxide has dried, the excess residue is brushed off and the tape is then applied.

Summary

Figure 2c

Figure 2c

While some evidence indicates that modalities such as orthotics, deep friction massage and therapeutic exercise have a place in the treatment of various soft tissue injuries, carefully controlled experimental research is still lacking. Only recently are we beginning to understand how, at least theoretically, massage techniques that apply pressure along injured soft tissues can promote healing. Research is also needed to determine the long-term effectiveness of Mulligan taping for the control of pronation and in the management of AT. At present we believe that, in conjunction with patient education, deep friction massage, eccentric exercise, and Mulligan taping for AT is an effective treatment program in the management of patients with AT.

Russell Woodman FSOM,OCS,MCTA, DPT is na professor of physical therapy at Quinnipiac University in Hamden, CT. Juan C. Garbalosa, PhD, PT, is a clinical associate professor of physical therapy and the director of the Motion Analysis Laboratory at Quinnipiac University.

Figure Captions:

Figure 1. Deep friction massage of the anterior aspect of the Achilles tendon.

Figure 2. Mulligan taping technique for Achilles tendinopathy. 2a. Application of base tape while maintaining the Achilles tendon in a lateral glided position. 2b. A two inch wide strip of rayon backed zinc oxide tape is next applied in a lateral – anterior direction. 2c. Rayon tape is then pulled in a medial- posterior direction.

REFERENCES

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15. Croisier JL, Forthomme B, Foidart-Dessalle M, et al. Treatment of recurrent tendinitis by isokinetic eccentric exercises. Isokin Exerc Sci 2001;9:133-141.

16. Kernozek TW, Ricard MD. Foot placement angle and arch type: effect on rearfoot motion. Arch Phys Med Rehabil 1990;71(12):988-991.

17. Mulligan BR. Manual therapy: Nags, snags, MWMs, etc. 5th ed. Wellington, NZ: Plane View Services;2004;141-143.

18. Loghmani MT, Warden SJ. Instrument-assisted cross-fiber massage accelerates knee ligament healing. J Orthop Sports Phys Ther 2009;39(7):506-514.

19. Gehlsen GM, Ganion LR, Helfst R. Fibroblast responses to variation in soft tissue mobilization pressure. Med Sci Sports Exerc1999;31(4):531-535.

20. Stanish WD, Curwin S, Rubinovich M. Tendinitis: the analysis and treatment for running. Clin Sports Med;1985:4(4):593-609.

21. Shalabi A, Kristoffersen-Wilberg M, Svensson L, et al. Eccentric training of the gastrocnemius-soleus complex in chronic achilles tendonopathy results in decrease tendon volume and intratendinous signal as evaluated by MRI. Am J Sports Med 2004;32(5):1286-1296.

22. Alexander J, Garbalosa JC, Woodman R, Henley J. The effectiveness of the achilles tendinopathy Mulligan taping technique on rearfoot motion during weight bearing. Submittted for publication, 2009.

23. Smith M, Brooker S, Vicenzino B, McPoil T. Use of anti-pronation taping to assess suitability of an orthotic prescription: case report. Aus J Physiother 2004:50(2):111-113.

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