Jayaseelan, D. J., Kecman, M., Alcorn, D., & Sault, J. D. Journal of Manual & Manipulative Therapy, 2017; 25(2), 106-114.
Abstracted by Victoria White SPT, Missouri State University, Springfield, MO
Achilles tendinopathy (AT) can be a chronic condition that many runners struggle with, causing limited function, stiffness, pain, and tenderness 2 – 7 cm proximal to the insertion site. Eccentric exercises are supported strongly by evidence for conservative management of AT, but up to 29% of patients end up having surgical intervention, showing that some patients have needs that eccentric exercises are not meeting. Limited ankle dorsiflexion can contribute to the development of AT and dorsiflexion mobility has improved in other populations after joint mobilizations, so using joint mobilizations may help prevent overuse of the Achilles tendon.
The aim of this report is to investigate how patients respond to adding manual therapy to an eccentric exercise program for AT.
Three runners were seen for MRI confirmed chronic AT at an outpatient PT clinic. None of the patients had prior treatment for their AT. Each of them had a goal to return to running without symptoms. Objective testing was done which included: symptom provoking motions, regional screening, balance, range of motion, force generation capacity, joint physiologic and accessory mobility, self-report outcome measures, and quantitative sensory testing. The mechanism of injury for all 3 runners was listed as overuse with dysfunction of the plantar flexor mechanism including restricted gastrocnemius length and hypomobility of the talocrural and subtalar joints. Running gait was assessed and Patients 1 and 3 were noted to have increased pronation through mid/terminal stance on their affected side. Patient 2 was noted to have early heel rise on his affected side. All patients reported their pain at best 0/10 and at worst their pain ranged 5-8/10.
All patients were prescribed an eccentric loading program (eccentric heel drop) and gastrocnemius stretching, in addition to joint thrust and non-thrust manipulations, at the discretion of the PT. Some of the manual therapy techniques used include: talocrural distraction thrust manipulation, AP glide of talus, standing belt mobilization for ankle dorsiflexion, and lateral glide of subtalar joint.
By week 3, patients were reporting slight improvement in their symptoms. At week 12, walking and running gait were re-evaluated and no remarkable impairments were noted. Patients were symptom free and had normal mobility in the talocrural and subtalar joints. They were discharged from therapy at this point with instructions to continue stretching and eccentric exercises as a home exercise program. In addition to eccentric exercises and stretching, manual therapy appears to be a safe and effective intervention for chronic AT. The researchers noted that there were limitations of this report including the small sample size and non-experimental study design.
This article was of particular interest to me as a runner because I have recently dealt with AT. I used eccentric exercises for my treatment and this pain has since subsided, but I was curious what other treatment options would be good for me if this problem arises again in the future.
The term tendinopathy is used to refer to tendon pathology, which has several categories within it, including tendinosis and tendinitis (Kisner & Colby, 2013).
In school, I have learned that often what someone describes as a tendinitis is more likely a tendinosis, depending on the chronicity of the problem and the age of the patient. Some characteristics of tendonitis include a younger patient and presence of inflammation, while a tendinosis is characterized by an older patient, increased ground substance and cross-sectional area, and absence of inflammation.
This article looked beyond the common exercise intervention for AT which is cited to be eccentric exercises (Kaux, Forthomme, Le Goff, Crielaard, & Croisier, 2011). Looking at eccentric exercises more specifically, several articles I looked at discussed Alfredson’s model of eccentric training, using a heel drop exercise program for 6-12 weeks with avoidance of concentric contraction (Alfredson & Cook, 2007).
As the writers shared, this was a report, so it did not have an experimental design which makes it harder to draw conclusions from. Due to this, some limitations include it not having a control group and a small sample size. Even so, I think this is something that would be worthwhile for future studies to look into further. The clinical practice guidelines include manual therapy in the interventions for AT (Martin, Chimenti, Cuddeford, Houck, Matheson, McDonough, & Carcia, 2018). It makes sense that if there is a limitation in joint motion, contributing to the Achilles tendinopathy, that restoring proper motion to the joint would be good for decreasing the stress on the joint to help healing and to prevent the problem from recurring in the future. This is something that should be evaluated on each patient individually because each patient will not experience a limitation of motion in the same place and will need various manual therapy techniques as appropriate.
Alfredson, H., & Cook, J. (2007). A treatment algorithm for managing Achilles tendinopathy: new treatment options. British journal of sports medicine, 41(4), 211-216.
Kaux, J. F., Forthomme, B., Le Goff, C., Crielaard, J. M., & Croisier, J. L. (2011). Current opinions on tendinopathy. Journal of Sports Science & Medicine, 10(2), 238-253.
Kisner, C., & Colby, L. A. (2013). Therapeutic exercise: foundations and techniques. Philadelphia: F.A. Davis.
Martin, R. L., Chimenti, R., Cuddeford, T., Houck, J., Matheson, J. W., McDonough, C. M., & Carcia, C. R. (2018). Achilles pain, stiffness, and muscle power deficits: Midportion achilles tendinopathy revision 2018: Clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the american physical therapy association. Journal of Orthopaedic & Sports Physical Therapy, 48(5), A1-A38.