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Re: Night splints have no place in tendinopathy - and compliance is of utmost importance

Dear editor

We read with great interest the randomized trial of de Vos and coworkers regarding the additional value of night splinting to eccentric training in Achilles mid-portion tendinopathy. Functional improvement assessed using the VISA-score and patient satisfaction were not different between sole eccentric training and the combination of eccentric training and the night splint.

Roos found in 2004 in a randomized trial with 44 patients no further pain reduction when using a night splint in mid-portion Achilles tendinopathy [3]. Based on this two randomized trial it seems that there is no place for the night splint as a passive and rigid orthesis in the therapy of Achilles tendinopathy. But not only in the Achilles region, also in the plantar region the night splint does not seem to be beneficial above placebo.

A randomized study published in 1999 with 116 patients with plantar fasciitis, where the addition of a night splint to antirheumatic medication, stretching exercise and shoe recommendations was not superior [2]. Therefore, the rigid night splint does not seem to play a role in tendinopathy.

A second important question is raised by the authors: the critical compliance. As with each physiotherapy which is performed without direct supervision it is mandatory to convince the trainees. De Vos reported that more than a quarter of the patients in both groups reported performing less than 50% of the prescribed intensity. We agree with de Vos that the compliance should be point out in detail in all studies in tendinopathy, which is pending in the majority of published studies.

In a randomised trial comparing eccentric training and eccentric training plus a pneumatic Achilles wrap (dj ortho AirHeel™, [1] with 112 randomized patients, 91 patients completed the study over the 12-week period (81% compliance). In case the patients did not fulfill an 80% compliance regarding the daily eccentric training and/or the Achilles wrap, subjects were addressed to the drop out group. The 21 participants not fulfilling the study were 50% male with a mean age of 51 years and a body mass index of 25.2. 32% of the drop out patients were active smokers of 20 cigarettes a day or more at the time of the study. The major drawbacks among these drop patients were overwhelming pain, recommendation to quit the study by orthopaedic surgeons or osteopaths or moving the city. One patient underwent surgery for bilateral mid-portion Achilles tendinopathy in a 61-year-old secretary (BMI 22). No Achilles tendon rupture or partial tear happened among the participants.

Regarding compliance issues all physicians prescribing eccentric training have to further enhance patients’ attitude towards tendinopathy and the possible painful eccentric training regimen. We should try to work out exactly why non-compliance occurs in our studies and report in detail about these drop out patients to learn out more how we might get them in the future, since eccentric training seems to be a reasonable non-invasive treatment option in tendinopathy.

References

[1] Knobloch K, Schreibmueller L, Jagodzinski M, Zeichen J, Vogt PM, Krettek C. Tendon and paratendon Achilles microcirculation in eccentric training and an Achilles wrap in insertional and mid-portion tendinopathy – a randomized trial. Br J Sports Med 2006, Oct 11.

[2] Probe RA, Baca M, Adams R, Preece C. Night split treatment for plantar fasciitis. A prospective randomized study. Clin Orthop Relat Res 1999;358:190-5.