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Achilles Tendinitis Clinical Guidelines CHRISTOPHER R. CARCIA, PT, PhDHE8HEOB$C7HJ?D"PT, PhD@;<<>EK9A"PT, PhD:7D;A$MKA?9>" MD Achilles Pain, Sti!ness, and Muscle Power Deficits: Achilles Tendinitis Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther. 2010:40(9):A1-A26. doi:10.2519/jospt.2010.0305 RECOMMENDATIONS$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ A2 INTRODUCTION$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$A3 METHODS$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$A3 CLINICAL GUIDELINES: Impairment-Function-Based Diagnosis $$$$$$$$$$$$$$$$$$ A7 CLINICAL GUIDELINES: Examinations$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ A11 CLINICAL GUIDELINES: Interventions$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$A16 SUMMARY OF RECOMMENDATIONS$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ A21 AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS$$$$$$A22 REFERENCES$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ A23 H;L?;M;HI0Heo7bjcWd"C:IWdZhW9khm_d"8IYF^oi_e"F^:7dj^edo:[b_jje"FJ"F^:@e^d:[M_jj":FJ7cWdZW<[hbWdZ":FJ >[b[d[<[Whed"FJ@eoCWY:[hc_Z"FJ"F^:@Wc[iM$CWj^[ied":FJJ^ecWi=$CYFe_bFJ"F^:F^_b_fCY9bkh["FJ"F^: Ij[f^[dH[_iY^b":FJFWkbI^[a[bb["C:"F^:7$Hkii[bbIc_j^"@h"FJ";Z:B[ib_[JehXkhd":FJ@Wc[iPWY^Wp[mia_":FJ <ehWkj^eh"YeehZ_dWjeh"WdZh[l_[m[hWøb_Wj_edii[[[dZe\j[nj$(&'&Ehj^efW[Z_YI[Yj_ed7c[h_YWdF^oi_YWbJ^[hWfo7iieY_Wj_ed7FJ7"?dY"WdZj^[Journal of Orthopaedic & Sports Physical Therapy$J^[Ehj^efW[Z_YI[Yj_ed"7FJ7"?dY"WdZj^[Journal of Orthopaedic & Sports Physical TherapyYedi[djjej^[h[fheZkY_d]WdZ Z_ijh_Xkj_d]j^_i]k_Z[b_d[\eh[ZkYWj_edWbfkhfei[i$7ZZh[iiYehh[ifedZ[dY[je@ei[f^@$=eZ][i":FJ"?9<FhWYj_Y[=k_Z[b_d[i9eehZ_dWjeh"Ehj^efW[Z_YI[Yj_ed"7FJ7 ?dY"(/(&;Wij7l[dk[Iekj^"Ik_j[(&&"BW9heii["M?+*,&'$;#cW_b0_Y\6ehj^efj$eh] 40-09 Guidelines-Achilles Tendinopathy.indd 1 8/18/10 11:22 AM Achilles Tendinopathy: Clinical Practice Guidelines Recommendations* H?IA<79JEHI0 For specific groups of individuals, clinicians ;N7C?D7J?EDÅF>OI?97B?CF7?HC;DJC;7IKH;I0 When evaluat- should consider abnormal ankle dorsiflexion range of mo- ing physical impairment over an episode of care for those with tion, abnormal subtalar joint range of motion, decreased ankle Achilles tendinopathy, one should consider measuring dorsi- plantar flexion strength, increased foot pronation, and abnor- flexion range of motion, subtalar joint range of motion, plantar mal tendon structure as intrinsic risk factors associated with flexion strength and endurance, static arch height, forefoot Achilles tendinopathy. Obesity, hypertension, hyperlipidemia, alignment, and pain with palpation. (Recommendations based and diabetes are medical conditions associated with Achilles on moderate evidence.) tendinopathy. Clinicians should also consider training errors, environmental factors, and faulty equipment as extrinsic risk ?DJ;HL;DJ?EDIÅ;99;DJH?9BE7:?D=0 Clinicians should consider factors associated with Achilles tendinopathy. (Recommenda- implementing an eccentric loading program to decrease pain tion based on moderate evidence.) and improve function in patients with midportion Achilles ten- dinopathy. (Recommendation based on strong evidence.) :?7=DEI?I%9B7II?<?97J?ED0 Self-reported localized pain and perceived sti!ness in the Achilles tendon following a period of ?DJ;HL;DJ?EDIÅBEM#B;L;BB7I;HJ>;H7FO0 Clinicians should inactivity (ie, sleep, prolonged sitting), lessens with an acute consider the use of low-level laser therapy to decrease pain and bout of activity and may increase after the activity. Symptoms sti!ness in patients with Achilles tendinopathy. (Recommenda- are frequently accompanied with Achilles tendon tenderness, tion based on moderate evidence.) a positive arc sign, and positive findings on the Royal London Hospital test. These signs and symptoms are useful clinical ?DJ;HL;DJ?EDIÅ?EDJEF>EH;I?I0 Clinicians should consider findings for classifying a patient with ankle pain into the ICD the use of iontophoresis with dexamethasone to decrease pain category of Achilles bursitis or tendinitis and the associated ICF and improve function in patients with Achilles tendinopathy. impairment-based category of Achilles pain (b28015 Pain in (Recommendation based on moderate evidence.) lower limb), sti!ness (b7800 Sensation of muscle sti!ness), and ?DJ;HL;DJ?EDIÅIJH;J9>?D=0 Stretching exercises can be used muscle power deficits (b7301 Power of muscles of lower limb). to reduce pain and improve function in patients who exhibit (Recommendation based on weak evidence.) limited dorsiflexion range of motion with Achilles tendinopathy. (Recommendation based on weak evidence). :?<<;H;DJ?7B:?7=DEI?I0 Clinicians should consider diagnos- tic classifications other than Achilles tendinopathy when the ?DJ;HL;DJ?EDIÅ<EEJEHJ>EI;I0 A foot orthosis can be used to patient’s reported activity limitations or impairments of body reduce pain and alter ankle and foot kinematics while running function and structure are not consistent with those presented in patients with Achilles tendinopathy. (Recommendation based in the diagnosis/classification section of this guideline, or, when on weak evidence.) the patient’s symptoms are not resolving with interventions aimed at normalization of the patient’s impairments of body ?DJ;HL;DJ?EDIÅC7DK7BJ>;H7FO0 Soft tissue mobilization can function. (Recommendation based on expert opinion.) be used to reduce pain and improve mobility and function in patients with Achilles tendinopathy. (Recommendation based ;N7C?D7J?EDÅEKJ9EC;C;7IKH;I0 Clinicians should incor- on expert opinion.) porate validated functional outcome measures, such as the Victorian Institute of Sport Assessment and the Foot and Ankle ?DJ;HL;DJ?EDIÅJ7F?D=0 Taping may be used in an attempt to Ability Measure. These should be utilized before and after inter- decrease strain on the Achilles tendon in patients with Achilles ventions intended to alleviate the impairments of body function tendinopathy. (Recommendation based on expert opinion.) and structure, activity limitations, and participation restrictions associated with Achilles tendinopathy. (Recommendation based ?DJ;HL;DJ?EDIÅ>;;BB?<J0 Contradictory evidence exists for the on strong evidence.) use of heel lifts in patients with Achilles tendinopathy. (Recom- mendation based on conflicting evidence.) ;N7C?D7J?EDÅ79J?L?JOB?C?J7J?ED7D:F7HJ?9?F7J?EDH;IJH?9- J?EDC;7IKH;I0 When evaluating functional limitations over an ?DJ;HL;DJ?EDIÅD?=>JIFB?DJ0 Night splints are not benefi- episode of care for those with Achilles tendinopathy, measures cial in reducing pain when compared to eccentric exercise for of activity limitation and participation restriction can include patients with Achilles tendinopathy. (Recommendation based objective and reproducible assessment of the ability to walk, on weak evidence.) descend stairs, perform unilateral heel raises and single-limb hop, and participate in recreational activity. (Recommendation J^[i[h[Yecc[dZWj_ediWdZYb_d_YWbfhWYj_Y[]k_Z[b_d[iWh[XWi[Zedj^[iY_[dj_ÓY based on moderate evidence.) b_j[hWjkh[fkXb_i^[Zfh_ehje<[XhkWho(&&/$ a2 | september 2010 | number 9 | volume 40 | journal of orthopaedic & sports physical therapy 40-09 Guidelines-Achilles Tendinopathy.indd 2 8/18/10 10:18 AM Achilles Tendinopathy: Clinical Practice Guidelines Introduction 7?CE<J>;=K?:;B?D; accepted terminology, of the practice of orthopaedic physi- The Orthopaedic Section of the American Physical Therapy cal therapists Association (APTA) has an ongoing e"ort to create evidence- Ikhob]^bg_hkfZmbhg_hkiZrhklZg]\eZbflk^ob^p^klk^`Zk]- based practice guidelines for orthopaedic physical therapy ing the practice of orthopaedic physical therapy for common management of patients with musculoskeletal impairments musculoskeletal conditions described in the World Health Organization’s International <k^Zm^ Z k^_^k^g\^ in[eb\Zmbhg _hk hkmahiZ^]b\ iarlb\Ze Classification of Functioning, Disability, and Health (ICF).135 therapy clinicians, academic instructors, clinical instructors, students, interns, residents, and fellows regarding the best The purposes of these clinical guidelines are to: current practice of orthopaedic physical therapy IJ7J;C;DJE<?DJ;DJ =^l\kb[^^ob]^g\^&[Zl^]iarlb\Zema^kZirikZ\mb\^bg\en]bg` This guideline is not intended to be construed or to serve as a diagnosis, prognosis, intervention, and assessment of out- standard of clinical care. Standards of care are determined on come for musculoskeletal disorders commonly managed by the basis of all clinical data available for an individual patient orthopaedic physical therapists and are subject to change as scientific knowledge and technol- <eZllb_rZg]]^Ög^\hffhgfnl\nehld^e^mZe\hg]bmbhglnl- ogy advance and patterns of care evolve. These parameters of ing the World Health Organization’s terminology related to practice should be considered guidelines only. Adherence to impairments of body function and body structure, activity them will not ensure a successful outcome in every patient, limitations, and participation restrictions nor should they be construed as including all proper methods B]^gmb_rbgm^ko^gmbhgllniihkm^][r\nkk^gm[^lm^ob]^g\^mh of care or excluding other acceptable methods of care aimed address impairments of body function and structure, activ- at the same results. The ultimate judgment regarding a par- ity limitations, and participation restrictions associated with ticular clinical procedure or treatment plan must be made in common
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