In the second installment of this series we want to review the most common courses of treatment for Achilles tendinopathy and discuss their current efficacy. There are a number of different approaches that one may encounter in the medical community. So, let’s review the effectiveness of those approaches.
What doesn’t work
NSAIDs: There is little scientific basis for the use of non-steroidal anti-inflammatory (NSAIDs) medications. As we know from part 1 of this blog post, Achilles tendinopathy is NOT an inflammatory process. So, medications that work to reduce inflammation would add no value to your ability to heal. Unless you like unnecessary side effects from medication, stay away from the NSAIDs.
Corticosteriod Injections: Just like NSAIDs cortisone is an anti-inflammatory and has no medical rationale for it’s use on this condition. If that’s not enough, adverse effects were reported in 82% of corticosteroid trials that included further tendon atrophy, tendon rupture, and decreased tendon strength. This is a no brainer, cortisone has no business being in your Achilles tendon.
What might work
The jury, aka the scientific community, is still out on these interventions. Some studies have shown some success but there is still more research that needs to be done before the scientific community puts their seal of approval on these treatments.
Extracoporeal shockwave therapy: This is a treatment technique that uses high energy acoustic waves to deliver a mechanical force to the body’s tissues. The workings of this treatment are poorly understood but there have been recent clinical trials that show good results for those with chronic Achilles tendinopathy. Unfortunately, there needs to be more high-level evidence and specific treatment parameters identified before this treatment moves up the list.
PRP: PRP is the injection of platelet-rich plasma (PRP) into a site of tendon injury. PRP stimulates healing through a number of growth factors in the plasma. There is a lot of good evidence out there that PRP can help tendon healing elsewhere in the body. Unfortunately, there is not a lot of evidence specific to the Achilles tendon.
Prolotherapy: Prolotherapy is the injection of hyperosmolar dextrose into the tendon. Clinical trials have demonstrated a reduction in pain, improvement in tendon strength and reduction in the size of intratendinous tears associated with the disorder. Although early research shows benefits with this procedure there still needs to be more high-level studies performed before this treatment is deemed truly effective.
Low level laser therapy: There is conflicting evidence to suggest low level laser therapy is beneficial to Achilles tendinopathy. There are randomized control trials that demonstrate improvement in tendon healing and elasticity. However other trials showed no effect on pain compared to controls. There is high level evidence to suggest that low level laser therapy may be an effective treatment but more studies are needed to confirm this.
Ultrasound: In animal studies ulatrsound has been shown to stimulate tissue growth and tendon healing. In the acute phases of tendon injury, it has been shown to reduce pain, swelling, and improve patient function. However there has not been a lot of new evidence to continue to demonstrate its efficacy and for this reason it stays in the “what might work” section of this post.
What does work
Eccentric Exercise: Eccentric exercise remains the gold standard for treating Achilles tendinopathy. There is good high-level evidence for the benefits of eccentric exercise in the management of Achilles tendinopathy. The mechanism behind the benefits of eccentric exercise are not well understood. Theoretically eccentric exercise produces rapid strengthening of the calf muscle, stiffening of the tendon, and lengthening of the tendon. Studies have shown some adverse effects if proper form or insufficient rest between bouts of exercise occur so it is important that a physical therapist prescribe the correct dosage of exercise. Most research recommends a course of 6 to 12 weeks of eccentric exercise.
Deep friction massage and tendon mobilization: Studies have demonstrated that deep friction massage combined with stretching can increase tendon healing, improve elasticity of the tendon, and reduce strain through the muscle-tendon unit.
There you have it, a quick review of the current treatment approaches to managing this frustrating condition. Physical therapy can play an important role in the rehabilitative process of Achilles tendinopathy. We can have a very quick and positive affect on a number of biomechanical risk factors associated with the condition. Likewise we are the exercise experts and should be used to manage your exercise prescription as it relates to eccentric exercises.
Li H & Hua Y. Achilles tendinopathy: current concepts about the basic science and clinical treatments. BioMed Research International. 2016(6). https://dx.doi.org/10.1155/2016/6492597.
Chaudhry, F. Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review. Eur J Orthop Surg Traumatol. 2017(27). 441-448.