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ACHILLES TENDINOPATHY (mid-substance): Summary of the Evidence for Physical Therapy Interventions

PURPOSE,SCOPE&DISCLAIMER:ThepurposeofthisdocumentistoprovidephysicaltherapistswithasummaryoftheevidenceforinterventionscommonlyusedtomanagemidsubstanceAchillestendinopathy.Thisdecisionmakingtoolisevidenceinformedandwherethereisinsufficientevidence,expertinformed.Itisnotintendedtoreplacethecliniciansclinicalreasoningskillsandinterprofessionalcollaboration.Acuterefersprimarilytothestagewiththecardinalsignsofheat,redness,pain,swellingandlossoffunctionandaveryrecentonsetofsymptoms.

INTERVENTIONSTAGEOF

PATHOLOGY

CLINICALRESEARCHEVIDENCE

PUBLISHEDEXPERTOPINION TAKEHOMEMESSAGE

CLINICALIMPLICATION*Seefinalpagefordescriptionofcategories

ManualTherapy

Acute Mayconsider usingmanualtherapyintheacutestageafterundertakingacomprehensivebiomechanicalevaluationofthehip,knee,footandankle.

Jointmobs

No

Yes

Thereisnoclinicalevidencebutthereisexpertlevelconsensustosupporttheuseofjointmobilizationsintheacutestageifassessmentrevealsjointrestriction.

Softtissuetechniques

No

No The clinicalevidenceneithersupportsnorrefutestheuseoffrictionsintheacutestage.

Chronic

Jointmobs Yes

1CS

Yes

Thereisasmallamountof clinicalevidenceandmoresubstantialexpertlevelconsensustosupporttheuseofjointmobilizationsinthechronicstageifassessmentrevealsjointrestriction.

Mayconsider usingmanualtherapyinthechronicstageafterundertakingacomprehensivebiomechanicalevaluationofthehip,knee,footandankle.

Softtissuetechniques

Yes

1SR2CS

Yes

Thereisasmallamountofclinicalevidencetosupporttheuseofsofttissuetechniques,suchasfrictions,inthechronicstage.

Mayconsider atrialofsofttissuetechniques,suchasfrictions,inthechronicstage.

Exercise Acute No

Yes

Thereisasmallamountofexpertopiniontosupporttheuseofstretchesintheacutestage.

Mayconsider usingstretchingexercisesinacutestage.Noprescriptionparametersareprovided.ACSMrecommends1030sechold,24repetitions.

Chronic Yes

14OS

6SR

5RCT

Yes

Thereisalargeamountofclinicalevidencetosupporttheuseofexerciseinthechronicstagebutthepreciseparameterstoensureeffectivenessarenotclear.Eccentricexerciseinparticularissupportedalthoughsomeprotocolsusebothconcentricandeccentricexercise.Malesappeartobenefitslightlymorethanfemalesfromeccentricexercise.

Stronglyconsider usingeccentricexerciseinthechronicstageusingthefollowinggeneralparametersofagradualprogressionto3setsof15repetitions,twiceperdaywiththekneeextendedandwiththekneeflexed.

*SeeAppendixAforfurtherdetailsonexerciseprescription.

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INTERVENTION

STAGEOF

HEALING

CLINICALRESEARCHEVIDENCE

PUBLISHEDEXPERTOPINION TAKEHOMEMESSAGE

CLINICALIMPLICATION*Seefinalpagefordescriptionofcategories

Lowlevellasertherapy(LLLT)

Acute Yes

2SR

Yes Thereisnoclinicalevidence,butthereisaphysiologicalrationale,tosupporttheuseofLLLTintheacutestage.

Mayconsider atrialofLLLTintheacutestage atthedosesrecommendedbytheWorldAssociationforLaserTherapy(www.walt.nu)i.e.,24J/point(notpercm2)*,minimum23points.

*SeeAppendixBforfurtherdetailsoncalculationofdosage.

Chronic Yes

1MA

5RCT

Yes Thereisconflicting clinicalevidenceandconflictingexpertopiniontosupporttheuseofLLLTinthechronicstage.

Consider atrialofLLLTinthechronicstage atthefollowingparameters:0.9J/point(notpercm2)*;6pointsontendon.

*SeeAppendixBforfurtherdetailsoncalculationofdosage.

Ultrasound(US) Acute No No Thereisnoclinicalevidence,butthereisphysiologicalrationale,tosupporttheuseofUSintheacutestage.

Mayconsider atrialofUSintheacutestage atalowtomoderatedose(0.51.0W/cm2,pulsed1:41:1,3MHz,5minsforeachtreatmentareaequivalentinsizetotransducerhead).

Chronic No No ThereisnoclinicalevidenceandnophysiologicalrationaletosupporttheuseofUSinthechronicstage.

ConsiderNOT usingUS inthechronicstage.

Extracorporealshockwavetherapy(SWT)

FocusedorradialSWT(lowenergy)

Acute No Yes ThereisexpertopinionwhichsuggeststhatSWTbereservedforchronicstage.

ConsiderNOT usingExtracorporealShockWavefortheacutestage.

Chronic Yes

4RCT

1Cohort

Yes Thereisconflicting evidencetosupporttheuseofSWTinthechronicstage.Thereisevidencesuggestingthattheoutcomesaredependentuponthedosageoftheshockwaveenergy(EFDenergyfluxdensity=mJ/mm),ratherthanthetypeofshockwavegeneration(focusedvs.radialSWT).ThereisalsoevidencethattheuseofanestheticrequiredinhighenergyprotocolsdecreasestheeffectivenessofSWT.Therefore,usinglowenergySWTprotocolswithouttheneedforanestheticarerecommendedasmorepractical,moretolerable,andlessexpensivewithequivalentresults.LowenergySWTprotocolscanapplytobothfocusedandradialSWT.

Consider atrialofSWTinthechronicstage,especiallyifotherinterventionshavefailed,atthefollowingparameters:

LowenergySWT:EFD=0.180.3mJ/mm(24Bars)20003000shocks1530Hz35sessions,weeklyintervals.Advisepatientsthatthisisanexperimentaltechnique.SWTenhancestheoutcomescomparedtoeccentricexercisealone,thereforepatientsshouldbeinstructedtocontinuewithawelldesignedexerciseprogram.

April20,2012 Page3

INTERVENTION

STAGEOF

HEALING

CLINICALRESEARCHEVIDENCE

PUBLISHEDEXPERTOPINION TAKEHOMEMESSAGE

CLINICALIMPLICATION*Seefinalpagefordescriptionofcategories

Iontophoresisusingdexamethasone

Acute Yes

1RCT

1review

No Thereisasmallamountofevidencetosupport theapplicationofiontophoresisusingdexamethasoneintheacutestage.Theroleofiontophoresisisstillinvestigational.

Mayconsider,intheacutestage,atrialofiontophoresis,0.4%dexamethasone(aqueous),80mAmin;6sessionsover3weeks.

Aprogramofconcentriceccentricexercisesshouldbecontinuedincombinationwithiontophoresis,ifexerciseloadingistolerated.

Chronic No No Thereisnoevidencethatantiinflammatoryinterventionwithiontophoresisusingdexamethasonehasausefulroleinthechronicstage.

ConsiderNOT usingiontophoresisusingdexamethasoneinthechronicstage.

Taping Acute No Yes Thereisexpertopiniontosupport theuseofantipronationtapingintheacutestage.

Mayconsider using antipronationtaping intheacutestage.

Chronic Yes

1CS

Yes Thereisexpertopiniontosupport theuseofcontrolledpronationtapinginthechronicstage.

Mayconsider using antipronationtaping inthechronicstage.

Orthotics Acute Yes

2CS

Yes Thereisasmallamountofclinicalevidencetosupporttheuseoforthoticsintheacutestage.

Consider usingorthotics perhapsusingtapingfirst,intheacutestage.

Chronic Yes

2CS

1RCT

Yes Thereisamoderateamountofclinicalevidencetosupporttheuseoforthoticsinthechronicstage.

Consider usingorthotics inthechronicstage.

Nightsplintsandbraces

Acute No Yes Thereisexpertopiniontosupport theuseofnightsplintsandbracesintheacutestage.

Consider atrialofnightsplintsandbraces intheacutestage.

Chronic Yes

3RCT

Yes Thereisamoderateamountofevidenceagainsttheuseofnightsplintsandbracesinthechronicstage.

ConsiderNOT usingnightsplintsandbraces inthechronicstage.

Heelraiseinserts

Acute No Yes Thereissomeexpertopiniontosupporttheuseofheelraiseinsertsintheacutestage.

Mayconsider atrialofinserts intheacutestage.

Chronic Yes

2RCT

Yes Thereisconflicting evidenceforandagainsttheuseofheelinsertsinthechronicstage.

Consider atrialofinserts inthechronicstage.

April20,2012 Page4

INTERVENTION

STAGEOF

HEALING

CLINICALRESEARCHEVIDENCE

PUBLISHEDEXPERTOPINION TAKEHOMEMESSAGE

CLINICALIMPLICATION*Seefinalpagefordescriptionofcategories

Needlingtechniques

Acupuncture(TraditionalChinesemedicine,anatomical,electrical)andIntramuscularstimulation

Acute Yes

1CS

No

Thereisasmallamountofevidencetosupport theuseofTraditionalChineseMedicineelectroacupunctureintheacutestage.Thereisexpertopiniontosupporttheuseofotherneedlingtechniquesintheacutestage.

Consider atrialofelectroacupuncture intheacutestage.

Mayconsideratrialofotheracupuncturerelatedneedlingtechniquesintheacutestage.

Chronic Yes

1CS

No

Thereisasmallamountofevidencetosupport useofTraditionalChineseAcupunctureinthechronicstage.Thereisexpertopinionontheuseofotherneedlingtechniquesinthechronicstage.

Consider atrialofTraditionalChineseAcupunctureinthechronicstage.

Mayconsideratrialofotheracupuncturerelatedneedlingtechniquesinthechronicstage.

CSCasestudies;MAMetaanalyses;OSObservationalstudies;RCTRandomizedcontrolledtrials;SRSystematicreviews

Foranyinterventionselectedbytheclinician,itisstronglyrecommendedthattheclinicianuseoneormoreofthefollowingoutcomemeasures:A. Patientreportedoutcomemeasuresuchas:

Aglobalmeasureoflowerextremityfunction:e.g.,TheLowerExtremityFunctionalScale(LEFS)notspecifictoAchillestendinopathy http://www.physther.net/content/79/4/371/F1.large.jpg

Detailedquestionnaire,specifictoAchillestendinopathye.g.theVISAAquestionnaire http://bjsm.bmj.com/content/suppl/2001/11/09/35.5.335.DC1/01055_Fig_1_data_supplement.pdf

(clickonviewquestionnaire)B. Patientspecificfunctionaloutcomemeasuresuchas:

Howmuchweightcanbeappliedtotheplantarflexedfootonaweighingscalebeforethe onsetofpain Thenumberofheelraisesbeforetheonsetofpain Thenumberofheeldropsbeforetheonsetofpain Thenumberofheeldropswithaspecificweightinabackpackbefore

theonsetofpain

Howfarcantheclientwalkorrunbeforetheonsetofpain

ExplanationofClinicalImplications

Stronglyconsider:Highlevel/highqualityevidencethatthisshouldbeincludedintreatment.

Consider:Consistentlowerlevel/lowerqualityorinconsistentevidencethatthisshouldbeincludedintreatment.

Mayconsider:Noclinicalevidencebutexpertopinionand/orplausiblephysiologicalrationalethatthisshouldbeincludedintreatment.

ConsiderNOT:Highlevel/highqualityevidencethatthisshouldnotbeincludedintreatment.

DevelopedbytheBCPhysicalTherapyTendinopathyTaskForce:Dr.JosephAnthony,AllisonEzzat,DianaHughes,JRJustesen,Dr.AlexScott,MichaelYates,AlisonHoens.APhysicalTherapyKnowledgeBrokerprojectsupportedby:UBCDepartmentofPhysicalTherapy,PhysiotherapyAssociationofBC,VancouverCoastalResearchInstituteandProvidenceHealthcareResearchInstitute.

April20,2012 Page5

REFERENCES PleaseseeAppendixCAchillesTendinopathy:DetailsofIndividualArticlesforthespecificdetailsoneachofthearticlesreferencedinthisdocument. MANUAL THERAPY

Casestudies

Voorn,R.(1998).Casereport:cansacroiliacjointdysfunctioncausechronicAchillestendonitis?JOSPT.27(6);436443.

WoodmanRM,PareL.(1982).EvaluationandtreatmentofsofttissuelesionsoftheankleandforefootusingaCyriaxapproach.PhysicalTherapy.62(8);114447.

ChristensonRE.(2007).EffectivenessofspecificsofttissuemobilizationsforthemanagementofAchillestendinosis:SinglecasestudyExperimentaldesign.ManualTherapy,12;6371.

ExpertOpinion

CarciaCR,MartinRL,HouckJ,WukichDK.(2010).Achillespain,stiffness,andmusclepowerdeficits:achillestendinitis.JOrthopSportsPhysTherapy:40(9)A1A26.

SystematicReviews

BrosseauL,CasimiroL,MilneS.etal.(2002).Deeptransversefrictionmassagefortreatingtendinitis.CochraneDatabaseSystematicReviews.4.

EXERCISE

ObservationalStudies

AlfredsonH,PietilaT,JonssonP&LorentzonR.(1998).HeavyloadeccentriccalfmuscletrainingforthetreatmentofchronicAchillestendinosis.AmericanJournalofSportsMedicine.26(3),36066.

GaerdinA,MovinT,SvenssonL&ShalabiA.(2010).ThelongtermclinicalandMRIresultsfollowingeccentriccalfmuscletraininginchronicAchillestendinosis.SkeletalRadiology.May,39(5),43542.

KnoblochK,SchreibmuellerL,KraemerR,JogodzinskiM,Vogt,PM&RedekerJ.(2010).GenderandeccentrictraininginAchillesmidportiontendinopathy.KneeSurgery,SportsTraumatology,Arthroscopy.May,18(5),64855.

OhbergL,LorentzonR&AlfredsonH.(2004).EccentrictraininginpatientswithchronicAchillestendinosis:normalisedtendonstructureanddecreasedthicknessatfollowup.BritishJournalofSportsMedicine.February,38(1),811;discussion11.

PetersenW,WelpR&RosenbaumD.(2007).ChronicAT:aprospectiverandomizedtrialcomparingthetherapeuticeffectofeccentrictraining,theAirHeelbrace,andacombinationofboth.AmericanJournalofSportsMedicine.October,35(10),165967.

RichardsPJ,McCallIW,DayC,BelcherJ&MaffulliN.(2010).LongitiudinalmicrovascularityinAchillestendinopathy.SkeletalRadiology.June,39(6),50921.

RoosEM,EngstromM,LagerquistA&SoderbergB.(2004).Clinicalimprovementafter6weeksofeccentricexerciseinpatientswithmidportionAchillestendinopathy:arandomizedtrialwithoneyearfollowup.ScandanavianJournalofMedicineandScienceinSports.October,14(5),28695.

ShalabiA,KristoffersenWibergM,AspelinP&MovinT.(2004).ImmediateAchillestendonresponseafterstrengthtrainingevaluatedbyMRI.MedicineandScienceinSportsandExercise.November,36(11),18416.

SilbernagelKG,BrorssonA&LundbergM.(2011).ThemajorityofpatientswithAchillestendinopathyrecoverfullywhentreatedwithexercisealone:a5yearfollowup.AmericanJournalofSportsMedicine.March,39(3),60713.

SilbernagelKG,ThomeeR,ErikssonBI&Karlsson,J.(2007).FullsymptomaticrecoverydoesnotensurefullrecoveryofmuscletendonfunctioninpatientswithAchillestendinopathy.BritishJournalofSportsMedicine.April,41(4),27680;discussion280.

VerrallG,Scholfield,S&BrustadT.(2011).ChronicAchillestendinopathytreatedwitheccentricstretchingprogram.FootAnkleInternational.September,32(9),8439.

WesthE,KongsgaardM,BojsenMollerJ,AagaardP,HansenM,KjaerM&Magnuson,S.P.(2008).Effectofhabitualexerciseonthestructuralandmechanicalpropertiesofhumantendon,invivo,inmenandwomen.ScandinavianJournalofMedicineandScienceinSports.Feb;18(1):2330.

RCTs

BackmanLJ,AnderssonG,WennstigG,ForsgrenS&DanielsonP.(2011).EndogenoussubstancePproductionintheAchillestendonincreaseswithloadinginaninvivomodeloftendinopathypeptidergicelevationprecedingtendinosisliketissuechanges.JournalofMusculoskeletalandNeuronalInteractions,June,11(2),13340.

RompeJD,FuriaJ&MaffulliN.(2009).EccentricloadingversuseccentricloadingplusshockwavetreatmentformidportionAchillestendinopathy:arandomizedcontrolledtrial.AmericanJournalofSportsMedicine,March,37(3),46370.

RompeJD,NafeB,FuriaJP&MaffulliN.(2007).Eccentricloading,shockwavetreatment,orawaitandseepolicyfortendinopathyofthemainbodyoftendoAchilles:arandomizedcontrolledtrial.AmericanJournalofSportsMedicine,March,35(3):37483.

SilbernagelK,ThomeeP&KarlsonJ.(2001).Eccentricoverloadtrainingforpatientswithchronicachillestendinopathyarandomizedcontrolledstudywithreliabilitytestingoftheevaluatingmethods.ScandanavianJournalofMedicineandScienceinSports,11:197206.

SilbernagelKG,ThomeeR,ErikssonBI&KarlssonJ.(2007).Continuedsportsactivity,usingapainmonitoringmodelduringrehabilitationinpatientswithAchillestendinopathy:arandomizedcontrolledstudy.AmericanJournalofSportsMedicine,June,35(6):897906.

SystematicReviews

KingmaJJ,deKnikkerR,WittinkHM,&TakkenT.(2007).EccentricOverloadTraininginPatientswithChronicAT:Asystematicreview.BritishJournalofSportsMedicine.June,41(6):e3.

KraemerR,LorenzenJ,VogtPM&KnoblochK.(2010).Systematicreviewabouteccentrictraininginchronicachillestendinopathy.SportverletzSportschaden.December,24(4):20411.[ArticleinGerman,Abstracttranslated]

MagnussenRA,DunnWR&ThomsonAB.(2009).NonoperativetreatmentofmidportionAchilletendinopathy:asystematicreview.ClinicalJournalofSportMedicine.January,19(1):5464.

MeyerA,TumilityS&BaxterGD.(2009).EccentricexerciseprotocolsforchronicnoninsertionalAchillestendinopathy:howmuchisenough?ScandanavianJournalofMedicineandScienceinSports.October,19(5),60915.

WasielewskiNJ&KotskoKM.(2007).Doeseccentricexercisereducepainandimprovestrengthinphysicallyactiveadultswithsymptomaticlowerextremitytendinosis?Asystematicreview.JournalofAthleticTraining.JulSep,42(3):40921.

WoodleyBL,NewshamWestRJ&BaxterGD.(2007).Chronictendinopathy:effectivenessofeccentricexercise.BritishJournalofSportsMedicine.April,41(4):18898;discussion199.

ExpertOpinion

MagnussonSP,LangbergH&KjaerM.(2010).Thepathogenesisoftendinopathy:balancingtheresponsetoloading.NatureReviewsRheumatology.May,6(5):2628.

LASER

RCTs

Bjordal,JM.(2006).Arandomised,placebocontrolledtrialoflowlevellasertherapyforactivatedAchillestendinitiswithmicrodialysismeasurementofperitendinousprostaglandinE2concentrations.BritishJournalofSportsMedicine,40(1):7680.

DarreE,KlokkerM&LundP.(1994).Laserbehandlingafakillessenetendinit.UgeskrLaeger.Nov7;156(45):66803.Danish.

StergioulaA,StergioulaM,AarskogR,LopesMartinsRAB&BjordalJM(2008).Effectsoflowlevellasertherapyandeccentricexercisesinthetreatmentofrecreationalathleteswithchronicachillestendinopathy.TheAmericanJournalofSportsMedicine,36(5):881887.

TumiltyS,MunnJ,AbbottJH,McDonoughS,HurleyDA&BaxterGD.(2008).LasertherapyinthetreatmentofAchillestendinopathy:apilotstudy.PhotomedicineandLaserSurgery,26(1):2530.

TumiltyS,MunnJ,AbbottJH,McDonoughS,HurleyDA,BasfordJR&BaxterG.D.(2010).LaserTherapyintheTreatmentofAchillesTendinopathy:ARandomisedControlledTrial.AIPConf.Proc.May31.Volume1226,pp.163169.

SystematicReviews

BjordalJ&CouppeC.(2001).LowLevelLaserTherapyforTendinopathy.EvidenceofADoseResponsePattern.PhysicalTherapyReviews,6:9199.

BjordalJM,LopesMartinsRAB,JoensenJ&IversenVV.(2010).Theantiinflammatorymechanismoflowlevellasertherapyanditsrelevanceforclinicaluseinphysiotherapy.PhysicalTherapyReviews,15(4):286293.

PeplowPV,ChungTY&BaxterGD.(2010).Applicationoflowlevellasertechnologiesforpainreliefandwoundhealing:overviewofscientificbases.PhysicalTherapyReviews,15(4):253285.

Metaanalysis

TumiltyS,MunnJ,McDonoughS,HurleyDA,BasfordJR&BaxterGD.(2010).Lowlevellasertreatmentoftendinopathy:asystematicreviewwithmetaanalysisPhotomedicineandLaserSurgery,28(1):316.

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EXTRA-CORPOREAL SHOCK WAVE THERAPY LOW ENERGY (FOCUSED AND RADIAL)

Cohort

LakshmananP,ODohertyD.(2004).ChronicAchillestendinopathy:treatmentwithextracorporealshockwavetherapy.FootandAnkleSurgery.10:125130.

RCTs

CostaML,ShepstoneL,DonellST,ThomasTL.(2005).ShockWaveTherapyforchronicAchillestendonpain:arandomizedplacebocontrolledtrial.ClinicalOrthopedicsandRelatedResearch.440:199204.

RompeJ,NafeB,FuriaJ.(2007).Eccentricloading,shockwavetherapyorwaitandseepolicyfortendinopathyofthemainbodyoftendoachillis:arandomizedcontrolledtrial.AmericanJournalofSportsMedicine.35(3):374383.

RompeJ,FuriaJ,MaffulliN.(2009).EccentricloadingvseccentricloadingplusshockwavetreatmentformidportionAchillestendinopathy.Arandomizedcontrolledtrial.AmericanJournalofSportsMedicine.37(3):463470.

RasmussenS,ChristensenM,MathiesenI,SimonsonO.(2008).ShockwavetherapyforchronicAchillestendinopathy:adoubleblind,randomizedclinicaltrialofefficacy.ActaOrthopaedica.79(2):249256.

IONTOPHORESIS WITH DEXAMETHASONE

RCTs

NeeterC,ThomeeR,SilbernagelK,ThomeeP,KarlsonJ.(2003).IontophoresiswithandwithoutdexamethasoneinthetreatmentofacuteAchillestendonpain.ScandinavianJournalofMedicineandScienceinSports.13(6):376382.

Review

BrownCD,LauberCA.(2011).Evidencebasedguidelinesforutilizationofdexamethasoneiontophoresis.InternationalJournalofAthleticTherapyandTraining.16(4):3336.

TAPING

RiddleDL&FreemanDB.(1988).ManagementofapatientwithadiagnosisofbilateralplantarfasciitisandAchillestendinitis.Acasereport.PhysTher.Dec;68(12):19136.

SmithM,BrookerS,VicenzinoB&McPoilT.(2004).Useofantipronationtapingtoassesssuitabilityoforthoticprescription:casereport.AustJPhysiother.;50(2):1113.

ORTHOTICS

MayerF,HirschmullerA,MullerS,SchuberthM&BaurH.(2007).Effectsofshorttermtreatmentstrategiesover4weeksinAchillestendinopathy.BrJSportsMed,41(7):e6.

GrossML,DavlinL&EvanskiPM(1991).Effectivenessoforthoticshoeinsertsinthelongdistancerunner.AmJSportsMed19:409412.

DonoghueOA,HarrisonAJ,LaxtonP&JonesRK.(2008).OrthoticcontrolofrearfootandlowerlimbmotionduringrunninginparticipantswithchronicAchillestendoninjury.SportsBiomech.May;7(2):194205.

GreeneBL.(2002).PhysicaltherapistmanagementoffluoroquinoloneinducedAchillestendinopathy.PhysTher.Dec;82(12):122431.

RiddleDL&FreemanDB.(1988).ManagementofapatientwithadiagnosisofbilateralplantarfasciitisandAchillestendinitis.Acasereport.PhysTher.Dec;68(12):19136.

BRACES AND NIGHT SPLINTS

KnoblochK,SchreibmuellerL,LongoUGetal.(2008).EccentricexercisesforthemanagementoftendinopathyofthemainbodyoftheAchillestendonwithorwithouttheAirHeelBrace.Arandomizedcontrolledtrial.A:effectsonpainandmicrocirculation.DisabilRehabil30:168591.

PetersenW,WelpR&RosenbaumD.(2007).ChronicAchillestendinopathy:aprospectiverandomizedstudycomparingthetherapeuticeffectofeccentrictraining,theAirHeelbrace,andacombinationofboth.AmJSportsMed;35:165967.

deVosRJ,WeirA,VisserRJetal.(2007).TheadditionalvalueofanightsplinttoeccentricexercisesinchronicmidportionAchillestendinopathy:arandomisedcontrolledtrial.BrJSportsMed;41:e5.

HEEL RAISE INSERTS

MacLellanGE&VyvyanB.(1981).ManagementofpainbeneaththeheelandAchillestendonitiswithviscoelasticheelinserts.BrJSportsMed.Jun;15(2):11721.

LowdonA,BaderDL&MowatAG(1984).TheeffectofheelpadsonthetreatmentofAchillestendinitis:adoubleblindtrial.AmJSportsMed.NovDec;12(6):4315.

NEEDLING TECHNIQUES/ACUPUNCTURE

JensFoellS(2010).IselectroacupunctureasafeandcosteffectivetreatmentforAchillestendonopathyinaprimarycaresetting?InternationalMusculoskeletalMedicine.32(2)5154.

FaganN&StatenP.(2003).Anauditofselfacupunctureinprimarycare.AcupunctMed;21:2831.