Master Class

The conservative management of Achilles tendinopathy☆

Heel lifts, placed inside footwear are recommended for the management of numerous musculoskeletal conditions. Despite the potential therapeutic benefit of heel lifts, the mechanism(s) by which they exert their effects is unclear. The aim of this systematic review was to synthesise reported findings and summarise the effects of heel lifts on lower limb biomechanics and muscle function.

Do heel lifts affect lower limb biomechanics and muscle function during walking and running?

Electronic databases (MEDLINE, EMBASE, CINAHL, SPORTDiscus, AMED) were searched from inception to April 2018. Studies were included if they (i) included participants without a limb length discrepancy or neurological condition, (ii) evaluated the effect of bilateral heel lifts that were removable (attached to the participants’ foot (barefoot) or inserted inside footwear) or an existing feature of a shoe, and (iii) assessed lower limb biomechanics or muscle function during walking or running in asymptomatic or symptomatic participants.

A total of 23 studies (377 participants) were included. Study quality, assessed using a Modified Quality Index, ranged from 5 to 13 out of 15. A large number of biomechanical parameters were assessed, but few effects were statistically significant. The differences that were significant and had a large effect size are described below. In asymptomatic participants, heel lifts of 10 mm decreased duration of swing phase (standardised mean difference [SMD] = -1.3) and heel lifts of at least 5 cm decreased velocity (SMD = -0.93) during walking. In asymptomatic participants, heel lifts of 15 mm decreased maximum ankle dorsiflexion angle (SMD = -1.5) and heel lifts of 12 and 18 mm decreased gastrocnemius muscle tendon unit length (SMD = -0.96) during running. In participants with restricted ankle joint dorsiflexion, heel lifts of 6 and 9 mm increased medial gastrocnemius electromyography amplitude (SMD between 0.68 and 0.98) during walking. In participants with haemophilia, heel lifts of 9 mm increased ankle joint maximum range of motion (SMD = 1.6) during walking.

Heel lifts affect specific lower limb biomechanical and muscle function parameters during walking and running. The clinical relevance and potential therapeutic benefits of these effects needs further investigation.

Achilles tendinopathy is a common pathology that is considered difficult to treat. At a time of austerity in the NHS it is essential to have carefully designed pathways that are monitored in terms of cost and effectiveness. However, a paucity of evidence exists for what the “best value” dedicated “joined up” pathway of care is for this difficult condition.

Design, implement and evaluate the impact of a new therapist lead pathway for Tendon- Achilles Pain (TAP). 

Process mapping, driver diagrams, stakeholder analysis and a series of Plan-Do-Study-Act cycles were used to design and implement TAP. To assess the impact of TAP, data was compared on whole system measures for 46 patients treated with referral to the traditional service (without TAP) and 46 patients managed according to the newly designed pathway (with TAP). A cost analysis was also conducted.

A quality improvement approach led to the successful design and implementation of a therapist lead TAP.

The impact of TAP included positive effects on patient satisfaction, a decrease in duplication of treatments, investigations and inappropriate reviews with consultants. No safety concerns were found. TAP was also £44,000 cheaper per annum than the previous service.

Collaboration between orthopaedic and therapy services has resulted in a standardised pathway of care for patients with an Achilles tendinopathy.  It has removed unwanted variation, provided an opportunity to monitor the outcomes of treatments and resulted in decreased cost for the health board.

La tendinopatía patelar crónica afecta principalmente a deportistas con sobrecarga del mecanismo extensor de rodilla. En las últimas décadas el ejercicio excéntrico se ha transformado en una indicación de rutina para el manejo de esta condición clínica. Se realizará una síntesis de la evidencia a través de una revisión sistemática de ensayos clínicos aleatorizados que hayan comparado un programa de ejercicio excéntrico declinado con uno estándar para el manejo de estos pacientes. El objetivo de esta revisión es determinar si existe evidencia científica que avale que el ejercicio excéntrico declinado es más efectivo que el ejercicio excéntrico estándar en el tratamiento de pacientes con tendinopatía patelar crónica. La estrategia de búsqueda incluyó ensayos clínicos aleatorizados (ECA) y ensayos clínicos controlados (ECC); las bases de datos usadas fueron: Medline, Cinahl, Pedro, Central, Lilacs. Los resultados obtenidos fueron de cuatro artículos que cumplían con nuestros criterios de elegibilidad. Se concluye que existe evidencia contradictoria sobre que el ejercicio excéntrico declinado sea más efectivo que el ejercicio excéntrico estándar en el manejo del dolor y la mejora de la funcionalidad, a corto, medio y largo plazo en pacientes con tendinopatía patelar crónica.

Chronic patellar tendinopathy affects mainly overhead athletes with knee extensor mechanism. In recent decades eccentric exercise has become an indication for routine clinical management of this condition. There will be a synthesis of evidence through a systematic review of randomized clinical trials that have compared an eccentric exercise program declined versus a standard for the management of these patients. The aim of this review is to determine whether there is scientific evidence that proves that declined eccentric exercise is more effective than standard eccentric exercise in the treatment of chronic patellar tendinopathy patients. The search strategy included randomized controlled trials (RCTs) and controlled clinical trials (CCTs); the databases used were MEDLINE, CINAHL, PEDro, CENTRAL, LILACS. The results were four articles that met our eligibility criteria. We conclude that there is conflicting evidence that eccentric exercise declined to be more effective than standard eccentric exercise in pain management and improved functionality, the short, medium and long term in patients with chronic patellar tendinopathy.

A single case study ABA design was used to evaluate the effectiveness of a treatment protocol of accessory and combined specific soft tissue mobilizations (SSTMs) in a 39-year-old female with a 5-year history of Achilles tendinosis. The study involved three phases each lasting 6 weeks: a pre-treatment, treatment and post-treatment phase. There was also a 3-month follow-up after the post-treatment phase. The VISA A questionnaire was used as a severity index for Achilles tendinosis to quantify symptoms and dysfunction. A visual analogue scale (VAS) was used to record pain. Dorsiflexion range was measured using a goniometer with the knee extended to reflect gastrocnemius length and a weight-bearing dorsiflexion lunge test was used as a measure for soleus length. Following treatment, considerable improvements were recorded in all outcomes. The subject returned to a full gym programme and recorded no pain on the VAS as well as scoring 100% on the index of severity for Achilles tendinosis during the post-treatment phase and follow-up. The single case study design limits generalization but the results support the use of SSTMs in the treatment of Achilles tendinosis and suggests that further research into this intervention is warranted.