1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE CANDIDATE AND ADDRESS

PAVAN VIVEK RAJ #9/2, P.V.CRIB 2ND CROSS, TAVAREKEREBTM 1ST STAGEBANGALORE.560029.

2. NAME OF THE INSTITUTION

KEMPEGOWDA INSTITUTE OF PHYSIOTHERAPY,K.R.ROAD,V.V.PURAM, BANGALORE-560 004

3. COURSE OF THE STUDY M.P.T.(MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY)

4. DATE OF ADMISSION 10th MAY 2012

5. TITLE OF THE TOPIC: “A STUDY TO COMPARE THE EFFICACY OF ULTRASOUND WITH ECCENTRIC EXERCISES AND ULTRASOUND WITH CONCENTRIC EXERCISES ON TENDO ACHILLES TENDINITIS IN ATHELETES.’’

6. Brief resume of the intended work :

6.1 Need for the study:

Achilles tendon pain is manifested as a localized painful thickening of the tendon, it is relatively common among middle aged active and recreational athletes1,2. Injury to the Achilles tendon or its surrounding sheath and paratendon, can be due to overuse, improper training, gait abnormalities, age-related degenerative changes, and improper footwear. Overuse injury of the Achilles tendon commonly occurs in active individuals and those who subject the tendon to repetitive forces beyond its ability to heal. This injury has been noted in all types of athletes, not just runners. Individuals who regularly engage in jumping activities and whom they subject the tendon to forces that may be of normal magnitude or the forces that are more frequently applied may increase the grades of the injury. Disorders of the Achilles tendon rank among the most frequently reported overuse injuries in the literature. 9,10,11,12 The majority of those suffering from Achillestendinopathy are individuals engaged in activity, most often at a recreational or competitive level.14 The annual incidence of Achilles tendinopathy in runners has been reported to be between 7% and 9%.15,14 further the Achilles disorders have been reported in a wide variety of sports.16,1714,2 there is an increased prevalence of Achilles tendon injury as age increases,32 the mean age of those affected by Achilles disorders has been reported to be between 30 and 50 years.,17,18,19,20 further data from multiple literatures suggested that the males are affected to a greater extent than females.[2,17,20] . In this study the researcher had considered the active athletes between the age group of 20 to 30 years because of non availability of samples between 30 to 50 years at sports authority of India and sports authority of Karnataka, Bangalore.

In Achilles tendon injury approximately half of the tendon is comprised of fibres from the gastrocnemius and half from the soleus along its course, the tendon changes its shape and orientation proximally and it is broad and flat. As the tendon descends it takes on more of a rounded stature. With further descent, just proximal to its insertion, the Achilles tendon once again becomes flattened and it broadly inserts into the posterior surface of the calcaneum. The Achilles tendon is the largest and strongest6,7 tendon in the body. The Achilles tendon serves as the conjoined tendon for the gastrocnemius and soleus muscles. On an average, the tendon has been reported to be 15 cm in length from the muscle tendon junction to its insertion 3. Blood supply to the Achilles tendon is evident at 3 locations: the muscle-tendon junction, along the course of the tendon, and at the tendon-bone insertion3. Vascular density is greatest at the proximal portion of the tendon and least at the midportion of the tendon4,5. The nerve supply to the Achilles tendon is primarily from branches of the sural nerve [2].

Runners who prematurely increase the intensity, duration, and or frequency of their training sessions are prone to develop Achilles tendon injuries, because the Achilles tendon does not have the time to adapt to the increased demand of the event. Improper training may lead to micro tears and degenerative changes to the Achilles tendon or the surrounding paratendon, which weakens the tendon and predisposing it to further injury. The actin and myosin are present in the tenocytes[21]

which make the tendon to become stiff and resilient with high tensile strength [22,23]. In the male Achilles tendon has a larger cross sectional area than in the female. In younger individuals the tendon has a significantly higher tensile stress before its rupture [24]. The rupture can occur in various activities like running, walking and cycling. During running the loading can reach up to 9 kN, which is corresponding to 12.5 times the body-weight, during slow walking the loading can reach upto 2.6 kN, and less than 1 kN during cycling [25,26 27,28]. The Achilles tendon injury usually occurs due to increase in severity without proper treatment and rehabilitation.

The tendon loses its wavy configuration when it is stretched by more than 2%. As the collagen fibres deform, they respond linearly to increasing loading. At the levels of strain greater than 8%, induces macroscopic rupture.[22] Although there may be an acute inflammation. For functional perspective these disorders are classified into two groups, those that occur at the insertion of the tendon are called as insertional tendinitis and those that occur more proximally are called as noninsertional tendinitis.

Insertional Achilles tendinitis is quite specific and are related to pain at the bone-tendon junction that frequently worsen after exercise but may ultimately become constant. Insertional Achilles tendinitis can be aggravated by running uphill or by activities performed on a hard surface. Frequently, the patient reports a history of poor stretching, running on the heels or over an excessive distance or a sudden increase in training intensity. The tenderness is specifically located either directly posterior or posterolateral to the insertion of the Achilles tendon. As degeneration of the tendon increases, a palpable defect may be detected in the substances of the tendon. Dorsiflexion is limited compared with that of the uninvolved ankle because of the relative tightness of the triceps surae. Pain in the heel is the cardinal symptom, and it is increased by prolonged standing, walking, running uphill, or running on a hard surface. The pain generally emanates from the posterior aspect of the heel and is aggravated by active or passive motion. Radiographs often demonstrate ossification in the most proximal extent of the insertion of the tendon or as a spur of the superior portion of the calcaneum.

Noninsertional Achilles tendinitis generally occurs in the hypo vascular zone, four centimeters proximal to the calcaneum, and the pathological changes are the result of repetitive micro tears that produce degeneration of the collagen, fibrosis, or even heterotrophic ossification within the tendon. The prevalence of noninsertional Achilles tendinitis in runners is high: approximately 10 percent of 109 active runners. Noninsertional tendinitis occurs in more active athletes probably as a result of the repetitive stress of activities involving jumping, pushing off, and cutting. In this study the researcher will be taking non insertional tendinitis samples of Grade 2 and Grade 3.

GRADES OF TENDON INJURIES

There are five grades of tendon injuries:

Grade 1 Pain does not occur during normal activity, but generalized pain is felt in the Achilles tendon about 1 to 3 hours after sport-specific training has ended.

Tenderness in the Achilles tendon usually resolves within 24 hours without intervention.

Grade 2 Minimal pain is present in the Achilles tendon towards the end of the sport-specific training session, but performance is not affected.

Appropriate treatment may be necessary to prevent a Grade 3 injury.

Grade 3 Pain is present in the Achilles tendon at the onset of training, and interferes with the speed and duration of a training session.

Treatment and training modification are necessary to prevent a grade 3 injury from progressing to a grade 4 injury.

Grade 4 Pain in the Achilles tendon restricts training and is also noticeable during activities of daily living; the athlete can no longer continue sport-specific training.

Grade 5 Pain in the Achilles tendon interferes with training as well as activities of daily living.

The Achilles tendon becomes deformed and there is a loss of function of the triceps surae. [29]

Aggressive therapy is required and surgery may be necessary. Conservative therapy is usually successful.

There are so many electrotherapy and exercise therapy modalities were used by researchers for treating tendo Achilles tendinitis were as in this study the researcher have intended to find out the efficacy of ultrasound with eccentric exercises and ultrasound with concentric exercises on tendo achilles tendinitis in athletes.

Treatment models

There are two different types of non surgical treatment models were available for treating Achilles tendintis they are eccentric calf muscle training and concentric calf muscle training. Till date there have been no studies conducted to compare the effectiveness of two different non surgical treatment models in a randomized manner on patients with a strictly defined acute painful condition in the Achilles tendinitis.

Eccentric exercises:

Eccentric training is given by the same physiotherapist. Samples were advised to wear stable shoe while performing the exercises. Samples were instructed to do their eccentric exercises twice daily (3sets X

15 repetition), 7 days/week for 12 weeks.[30]

Three types of exercises are used.

The calf muscle was eccentrically loaded with the knee straight. The calf muscle was eccentrically loaded with the knee bent to maximise

the activation of the soleus muscle Increasing the load by the way of adding weights in a back pack. During the

12 weeks training regimen walking and bicycling was allowed to the sample only with mild discomfort or pain. Light jogging on flat ground with slow pace was allowed after 4-6 weeks of training, were sample could perform without pain.[30]

Concentric exercises:

Concentric training is given by the same physiotherapist. Samples were advised to wear stable shoe while performing the exercises. Samples were instructed to do their concentric exercises two times daily

(3sets X 15 repetition), 7 days/week for 12 weeks.[30]

The exercises used are

Concentric loading of the calf muscle with the knee straight in long sitting position.

Concentric loading of the calf muscle with the knee bent in high sitting position to maximise the activation of the soleus muscle.

Heel raises from upright body position with the knee straight and standing with all body weight on injured side.

Step ups on a bench, with knee bent and with all body weight on injured side.

Rope skipping with the knees bent, Side jumps with knees bent.[30]

Therapeutic ultrasound

Therapeutic ultrasound reduces the swelling in the acute inflammatory phase and improves healing of the tendon. It also stimulates the synthesis of collagen in tendon fibroblasts and cell division during periods of rapid cell proliferation. Therapeutic ultrasound is hence a desirable treatment option in the treatment of acute Achilles tendinopathy. Further there are so many researchers used ultrasound as the ideal modality for treating Achilles tendinopathy.[22]

VISUAL ANALOGUE SCALE (V.A.S):

A Visual Analogue Scale of pain is an instrument used to measure the amount of pain a patient feels, according to Journal of Clinical Nursing. The visual analogue scale of pain is usually a 100 mm-long horizontal line, which may contain word descriptors at each end like mild pain and the worst pain. The patient represents their perception of the amount of pain by marking a point on the horizontal line between two points [31,32]. The visual analogue scale score is measured in millimeters from the left hand end of the line to the point indicated by the patient. VAS is measured at the end of 1st month, 2nd month and 3rd month respectively

FOOT AND ANKLE ABILITY MEASURE (FAAM)

Foot and Ankle Ability Measure (FAAM) is a self reported tool of physical function for individuals with leg, ankle, and foot musculoskeletal disorders. The tool consists of the 21-item activities of daily living (ADL) and 8-item Sports subscales, which together produced information about the sample. The Test- retest reliability of FAAM was 0.89 and 0.87 for the ADL and Sports subscales respectively. [33,34]

Range of Motion [ROM]

The Range of Motion is measured at the end of 1st month, 2nd month and 3rd month respectively in patients having acute Achilles tendinopathy, the goniometer is the valid tool to assess the range of motion of ankle joint.

PURPOSE OF THE STUDY:

To compare the effect of ultrasound with eccentric exercises and ultrasound with concentric exercises of tendo Achilles tendinitis on active athletes to reduce the pain and to improve the range of motion of the ankle joint.

HYPOTHESIS:

Null Hypothesis:

There will not be a significant difference between the subjects treated with eccentric exercises with ultrasound versus concentric exercises with ultrasound in grade 2 and grade 3 tendo Achilles tendonitis in active athletes. Alternate Hypothesis:

There will be a significant difference between the subjects treated with eccentric exercises with ultrasound versus concentric exercises with ultrasound in grade 2 and grade 3 tendo Achilles tendonitis in active athletes.

6.2 REVIEW OF LITERATURE:

Khan K.M, Bonar .F, Desmond P.M et al (1991) stated that tendinosis is a painful condition in the middle portion of the tendon and this can be seen in radiographic images or ultrasonography.[35]

Movin T (1998) stated that the characteristic morphological features of tendinosis is due to increased amount of interfibrillar glycosaminoglycans and changes in the collagen fiber.[36]

Rolf C, Movin T (1997) stated that the incidence of overuse injuries were due to greater participation in recreational and competitive sporting activities and also excessive repetitive overload of tendo achilles leads to tendinitis.[37]

Sorosky B, Press J, Plastaras C, Rittenberg J (1996) stated that Acute irritation of a healthy Achilles tendon has been associated with inflammation of the paratendon where the localized swelling between the paratendon and Achilles tendon can be visualized and palpated.[38]

Saltzman CL, Tearse DS, O’Brien (1998) stated that the Achilles tendon is the largest and strongest tendon in the body. The Achilles serves as the conjoined tendon for the gastrocnemius and soleus muscles. On an average, the tendon has been reported to be 15 cm in length from the muscle tendon junction to its insertion on the posterior aspect of the calcaneus.[39]

Fredberg et al found that out of 96 asymptomatic professional soccer players (18-35 years old) 11% of players showed abnormal ultrasonography signal prior to the start of the season. At the end of the season, 45% of the players had developed a painful Achilles tendinosis with abnormal ultrasound signal.[40]

J´ozsa LG, Kannus P., Ippolito E, Natali PG, Postacchini F, Accinni L, DeMartino C., Ker RF Thermann H, Frerichs O, Biewener A, Krettek C, Schandelmaier P.stated that Actin and myosin are present in the tenocytes. Tendons are stiff and resilient, with high tensile strength. In the male, tendo Achillis has a larger cross sectional area than in the female, with greater stiffness and ruptures at a higher maximum force.[41]

Curwin and Stanish,Fyfe and Stanish, and Stanish et al published a report documenting their use of progressive eccentric exercise as a part of a program to reduce the symptoms associated with achilles tendinosis.[42]

Kingma JJ, Silbernagel KG, Thomee R, Thomee P, et al concluded that the role of eccentric loading on achilles tendinosis showed that eccentric exercises are more likely to generate a better outcome [43]

Rees JD, Lichtwark GA, Wolman RL, et al. concluded that during eccentric loading there was a greater degree of force of oscillations within the tendons to induce maximal efficiency. [44]

Ohberg L, Alfredson H, Alfredson H reported that the eccentric loading profile has been shown to reduce vascularity and possibly decrease vascular infiltration into the tendon and alter the nociceptive inputs. This in turn may have secondary effects on the pain and loading of the tendon. [45]

Silbernagel et al. have described good results with eccentric overload training on patients with Achilles tendon pain; where the tendon pain was not specified.[46]

Vertommen et al 1992 compared concentric and eccentric exercise for the treatment of Achilles tendinosis symptoms. Eccentric ankle drop and standard isometric plantar-flexion exercises were used for each of the treatment groups. [47]

Jin WJ,Yu TY 2003 conducted a prospective observational study on VAS in acute pain measurement, this study shows that VAS is sufficiently reliable to be used to assess acute pain. [48]

Downie WW, Leatham PA et al 1978 concluded that 10 point (0-10) numerical rating scale performs better than both a 4 point simple descriptive scale and continuous VAS. [49]

Ngoc Quan Phan(2012) conducted a study on Prospective Study on Validity and Reliability of the Visual Analogue Scale The study concluded that high reliability and concurrent validity was found for VAS.[50]

Williamson A., Hoggart B et al 2005 Concluded that visual analogue scale, verbal rating scale and numeric rating scale are valid, reliable and appropriate for using clinical practice [51]

Gajdosik RL, et al 1987 concluded that clinicians should interpret and report goniometric results as ROM measurements only. But not as measurements of factors that may affect ROM.[52]

Youdas JW, Bogard CL et al 1993 examined intratester and intertester reliability for goniometric measurements for active ankle dorsiflexion and ankle plantar flexion.[53]

Rob Roy L. Martin, James J. Irrgang,Ray G. Burdett, Stephen F. Conti, Jessie M. Van Swearingen(2005) stated that The FAAM was developed to meet the need for a self-reported evaluative instrument that comprehensively assesses physical function of individuals with musculoskeletal disorders of the leg, foot, and ankle. These results indicate that the FAAM is a reliable, valid, and responsive measure of self-reported physical function for individuals participating in physical therapy, with or without operative intervention, for a broad range of musculoskeletal disorders of the leg, foot, and ankle. [54]

Julie Powers stated that ultrasound therapy is an approved physical therapy treatment used by doctors and physical therapists to reduce or eliminate pain. There are many benefits of ultrasound which enhances healing process, increase in the blood circulation and reduction in pain. [55]

Clayton’s electrotherapy and practice by Angela Forfter and Nigel Palastanga- 9th edition (2002); states that the unit of intensity when using ultrasound is watt, so an average intensity is watts per square centimeter. [56]

Clayton’s electrotherapy and practice by Angela Forfter and Nigel Palastanga- 9th edition (2002);states that the ultrasound waves are not transmitted by air, thus some couplet which does transmit them must be interposed between the transducer and the skin of the patient. Treatment usually lasts for 5 to 10 minutes each day.[57]

Warren CG, Koblanski JN, Sigelmann RA;concluded that during ultrasound any coupling media should be used to transmit the ultrasound energy sufficiently.[58]

John Low and Ann Reed, foreword by Mary Dyson Phd, electrotherapy explained principles and practice; Direct contact method is commonly used for treating tendon injury. The method of application is as follows: The treatment head is moved continuously over the surface while even pressure is maintained in order to iron out the irregularities in the sonic field.[59]

Gann N,1991; Ziskin M, Mc Diarmid T, Michlovitz S-1990; concluded that the therapeutic ultrasound at a frequency of 1MHz is absorbed at a depth of 3-5cms and is therefore recommended for deeper injuries. A frequency of 3MHz is recommended for more superficial lesions at a depth of 1-2 cms.[60]

Ebenbichler G R ,Erdogmus CB , Resch K L.,et al;concluded that 24 days of application of ultrasound therapy at 0.8 -1 W/cm2 (5 times per week for 3 weeks) reduced the painful symptoms in patients.[61]

Robertson VJ, Baker KG:2001;concluded that active ultrasound was more effective than placebo ultrasound in diseases of the musculoskeletal system and soft tissues and it had a greater effect on improving range of motion.[62]

6.3 Objective of the Study:

1. To assess the effectiveness of ultrasound with concentric exercises to reduce pain and improve the physical performance of athletes who have grade 2 and grade 3 tendo achilles tendinitis.

2. To assess the effectiveness of ultrasound with eccentric exercises to reduce pain and improve the physical performance of athletes who have grade 2 and grade 3 tendo achilles tendinitis.

3. To compare the effect of eccentric exercises with ultrasound versus concentric exercises with ultrasound to reduce pain and improve the physical performance of athletes who have had grade 2 and grade 3 tendo achilles tendonitis.

7. Materials and Methods

7.1 SOURCES OF DATA: Sports authority of India Sports authority of Karnataka

7.2 METHODS OF DATA COLLECTION:

(a) Study Design: Randomized study design.

Sample size: 60 (Group A-30 Subjects and Group B- 30 Subjects)

Sample Design : Random Sampling

Materials Used:

Ultrasound Equipment Ultrasound Gel Data collection/Record sheets Consent form Cotton FAAM VAS scale Goniometer

(b) Inclusion Criteria: Athletes with Grade 2, grade 3 tendo achilles tendinitis Athletes with the age group between 20-30years Male and female active athletes

(c) Exclusion Criteria: Athletes with post surgical tendo achilles tendon. Athletes with calcaneal fracture induced tendo achilles tendinitis Any sprain of ankle with tendo achilles tendinitis Any pathology induced tendo achilles tendinitis Any vascular disease induced tendo achilles tendinitis Tendo achilles tendinitis with nerve injury. Foot drop with tendo achilles tendinitis

7.3 Does the study require any Investigations or Interventions to be conducted on Patients or other Humans or Animals? If so , Please describe briefly:

Yes, a Non invasive intervention on patients is required. .

Methodology:

A] Patients who fulfill inclusion and exclusion criteria are taken for the

study.B] Intervention is explained to the patients in a language understood by them.

C] Informed written consent is taken from the patient or from family members

Subjects will be divided in two groups by simple random sampling method. 30 subjects in each group will be allocated for the study The patients in Group A will be given ultrasound with concentric exercises The patients in Group B will be given ultrasound with eccentric exercises

Group A patients were given ultrasound with concentric exercises. Weeks 1–2

Concentric loading of the calf muscle with the knee straight Two types of exercises were used.

The calf muscle was concentrically loaded both with the knee straight, and to maximize the activation of the soleus muscle,Also with the knee bent the patients were told to continue doing the exercise despite experiencing pain during the exercise. Each of the two exercises included 20 repetitions carried out in 2 or 3 sets However, no training through disabling pain was encouraged. The patients were told that muscle soreness during the first 1–2 weeks of training might be expected.30

Weeks 3-5 Heel raises from an upright body position, with the knee straight and standing with all body weight on the injured sideTwo types of exercises were used.

The calf muscle was concentrically loaded with the knee straight with 3 x 15 repetitions. The patients stood with all their bodyweight on their injured leg, and the heel was lifted from the ground by concentric contraction of the calf muscle. They loaded the calf muscle only concentrically; no eccentric loading followed. Instead, the non injured leg was used to return to the starting position.To maximize the activation of the soleus muscle, step-ups were used, with the knee bent.

Weeks 6-12Elevating the load by adding weight in a back –pack Four types of exercises were used. The calf muscle was concentrically loaded both with the knee straight and to maximize the activation of the soleus muscle with the knee bent .Two exercises like rope skipping and side jumps were used with the purpose of placing heavy loads on the calf muscle.

Group B will be given ultrasound with eccentric exercises.

Eccentric calf muscle with the knee straight from an upright body position and

standing with all the weight on the ventral half of the foot with ankle joint in plantar flexion lifted by the non injured leg. The calf muscle was loaded eccentrically by having the patient to lower the heel beneath the lever.

The calf muscle is eccentrically loaded both with the knees straight and to maximize the activation of the soleus muscle it can also be done with the knees bent.

In the beginning the loading consists of the bodyweight, and the patients are made to stand with all their body weight on their injured leg (lifted to that position by the uninjured leg). From an upright body position and standing with all body weight on the forefoot, with the ankle joint in plantar flexion, the calf muscle was loaded by having the patient to lower the heel beneath the lever.

They loaded the calf muscle only eccentrically; no concentric loading followed. Instead, the non injured leg was used to return to the starting position. The patients were told to continue doing the exercise despite experiencing pain during the exercise. However, no training through disabling pain was encouraged. When they were able to perform the eccentric loading without experiencing any minor pain or discomfort, they were instructed to increase the load by adding weight.

This could be done easily using a backpack that was successively loaded with weight). This gradually increases the eccentric calf muscle loading.

Both the groups are administered ultrasound in the direct contact technique with: 1mhz ultrasound modality 0.8-1.0watts/ cm2 intensity for 6 minutes. Ultrasonic gel is used as a coupling media. 2cms Diameter transducer.

. The subjects are assessed with VAS, FAAM and Ankle range of motion with

goniometer at the end of 1st, 2nd and 3rd month respectively.

Visual Analogue Scale (V.A.S):

A Visual Analogue Scale of pain is an instrument used to measure the amount of pain a patient feels, according to Journal of Clinical Nursing. The visual analogue scale of pain is usually a 100 mm-long horizontal line, which may contain word descriptors at each end. The patient represents their perception of the amount of pain she feels by marking a horizontal line between two points. The visual analogue scale score is measured in millimeters from the left hand end of the line to the point indicated by the patient.31,32

Foot and Ankle Ability Measure (FAAM)

Foot and Ankle Ability Measure (FAAM) is a self reported tool for

individuals with leg, ankle, and foot musculoskeletal disorders. It consists of the 21-item activities of daily living (ADL) and 8-item Sports subscales. The test retest reliability of FAAM is 0.89 and 0.87 for the ADL and Sports subscales, respectively. Along with this the range of motion of the ankle joint will be measured.33,34

Range of Motion [ROM]

The Range of Motion is measured in patients having acute Achilles tendinopathy, the goniometer is the valid tool to assess the range of motion of ankle joint. The purpose of goniometry is to measure the angle of joint position or range of joint motion. Therefore, a valid goniometric measurement is one that truly represents the actual joint angle or the total Range of Motion. The ankle range of motion can be measured by the way of keeping fulcrum at the lateral malleoli, the mobile arm should be fixed at the lateral border of the foot and the stable arm should be placed parallel to the fibula for recording the ankle Range of Motion

Frequency of the exercises can be given 3 sets x15 repetitions, twice daily 7 days a week for 12 weeks :

Frequency of ultrasound can be given thrice a week for 6 weeks. The outcome measurement of VAS, FAAM and ankle Range of motion can

be measured at the end of 1st month, 2nd month and 3rd month respectively. Duration of the study : 1 year

Statistical Analysis:

Paired T Test can be used for statistical analysis

7.4 Has Ethical Clearance been obtained from your Institution in case of 7.3? Yes.

8. LIST OF REFERENCES:

1. Kvist M Achilles tendon injuries in athletes. Sports med 1994;18:173-201.

2. Jozsa L, Kannus p. human tendons. Anatomy, physiology,and pathology.

3. O’Brien M. The anatomy of the Achilles tendon. Foot Ankle Clin. 2005;10:225-238. http://dx.doi.org/10.1016/j.fcl.2005.01.

4. Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br. 1989;71:100-101.

5. Leadbetter WB, Mooar PA, Lane GJ, Lee SJ. The surgical treatment of tendinitis. Clinical rationale and biologic basis. Clin Sports Med.1992;11:679-712.

6. Saltzman CL, Tearse DS. Achilles tendon injuries. J Am Acad Orthop Surg. 1998;6:316-325.

7. Bjur D, Alfredson H, Forsgren S. The innervation pattern of the human Achilles tendon: studies of the normal and tendinosis tendon with markers for general and sensory innervation. Cell Tissue Res. 2005;320:201-206.http://dx.doi.org/10.1007/s00441-004-1014-3.

8. Alfredson H, Thorsen K, Lorentzon R. In situ microdialysis in tendon tissue: high levels of glutamate, but not prostaglandin E2 in chronic Achilles tendon pain. Knee Surg Sports Traumatol Arthrosc.1999;7:378-381.

9. Ames PR, Longo UG, Denaro V, Maffulli N. Achilles tendon problems: not just an orthopaedic issue. Disabil Rehabil. 2008;30:1646-1650. http://dx.doi.org/10.1080/09638280701785882.

10. Clement DB, Taunton JE, Smart GW. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med. 1984;12:179-184.

11. Kvist M. Achilles tendon injuries in athletes. Ann Chir Gynaecol.1991;80:188-201.

12. Maffulli N, Wong J, Almekinders LC. Types and epidemiology of tendinopathy. Clin Sports Med. 2003;22:675-692.

13. Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med.2009;19:54-64. http://dx.doi.org/10.1097/JSM.0b013e31818ef090

14. Kujala UM, Sarna S, Kaprio J. Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med. 2005;15:133-135.

15. Johansson C. Injuries in elite orienteers. Am J Sports Med. 1986;14:410-415.

16. Fahlstrom M, Lorentzon R, Alfredson H. Painful conditions in the Achilles

tendon region in elite badminton players. Am J Sports Med. 2002;30:51-54.

17. Fordham S, Garbutt G, Lopes P. Epidemiology of injuries in adventure racing athletes. Br J Sports Med. 2004;38:300-303.

18. Krolo I, Viskovic K, Ikic D, Klaric-Custovic R, Marotti M, Cicvara T. The risk of sports activities--the injuries of the Achilles tendon in sportsmen. Coll Antropol. 2007;31:275-278.

19. Petersen W, Welp R, Rosenbaum D. Chronic Achilles tendinopathy: a prospective randomized study comparing the therapeutic effect of eccentric training, the AirHeel brace, and a combination of both. Am J Sports Med. 2007;35:1659-1667. http://dx.doi.org/10.1177/0363546507303558.

20. Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med. 2007;35:374-383. http://dx.doi.org/10.1177/0363546506295940.

21. Ippolito E, Natali PG, Postacchini F, Accinni L, DeMartino C. Morphological, immunochemical, and biochemical study of Achilles tendon at various ages. J Bone Joint Surg [Am] 1980;62-A:583-98.

22. D Kader, A Saxena, T Movin, N Maffulli Achilles tendinopathy: some aspects of basic science and clinical management Br J Sports Med 2002;36:239–249

23. Ker RF. Dynamic tensile properties of the plantaris tendon. J Exp Biol 1981;93:283-302.

24. Thermann H, Frerichs O, Biewener A, Krettek C, Schandelmaier P. Biomechanical studies of human Achilles tendon rupture. Unfallchirurg 1995;98:570-5.

25. Gregor RJ, Komi PV, Jarvinen M. Achilles tendon forces during cycling. Int J Sports Med 1987;8 Suppl 1:9-14.

26. Komi PV. Relevance of in vivo force measurements to human biomechanics. J Biomech 1990;23 Suppl 1:23-34.

27. Komi PV, Fukashiro S, Jarvinen M. Biomechanical loading of Achilles tendon during normal locomotion. Clin Sports Med 1992;11:521-31.

28. Movin T. Aspects of aetiology, pathoanatomy and diagnostic methods in chronic mid-portion achillodynia. Thesis, Karolinska Institute 1998.

29. Sundqvist H, Forsskahl B, Kvist M. A promising novel therapy for Achilles peritendinitis. International Journal of Sports Medicine. 1987; (8): 298-303.

30. N.Mafi, R. Lorentzo, Alfredson Knee Surg, Sports Traumatol, Arthrosc(2001) 9 :42–47.

31. D. Gould et al. Information Point, Visual Analog Scale: Jounal of Clinical Nursing. 2001; 10:706.

32. American college of rheumatology WOMAC index available from: http://www.rheumatology.org/practice/clinical/clinicianresearchers/outcomes-instrumentation/WOMAC.asp.

33. Martin RL, Irrgang JJ. A survey of self-reported outcome instruments for the foot and ankle. J Orthop Sports Phys Ther. 2007;37:72-84.

34. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot Ankle Int. 2005;26:968-983.

35. Khan KM, Bonar F, Desmond PM et al. (1996) Patellar tendinosis (jumper’s knee): findings at histopathologic examination, US, and MR imaging. Victorian Institute of Sport tendon Study Group. Radiology 200:821–827

36. Movin T (1998) Aspects of aetiology, pathoanatomy and diagnostic methods in chronic mid-portion Achillodynia. Thesis, Karolinska Institute Stockholm

37. Rolf C, Movin T. Etiology, histopathology and outcome of surgery in achillodynia. Foot Ankle Int 1997;18:565-9.

38. Sorosky B, Press J, Plastaras C, Rittenberg J (1996) (Clin J Sport Med 2004;14:40–44)

39. Saltzman CL, Tearse DS. Achilles tendon injuries. J Am Acad Orthop Surg. 1998;6:316-325.

40. J´ozsa LG, Kannus P., Ippolito E, Natali PG, Postacchini F, Accinni L, DeMartino C., et al from keele university;stoke on tent,England and the university of Aberdeen Scotland

41. Richard sadovsky, m.d.deyle gd, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med February 1, 2000; 132:173-81.

42. Curwin and Stanish,Fyfe and Stanish, and Stanish et alDoes Eccentric Exercise Reduce Pain and Improve Strength in Physically Active Adults With Symptomatic Lower Extremity Tendinosis? A Systematic ReviewJ Athl

Train. 2007 Jul-Sep; 42(3): 409–421.

43. Kingma JJ, Silbernagel KG, Thomee R, Thomee P, et al Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review Br J Sports Med. 2007 June; 41(6): e1–e5. Published online 2006 October 11. doi:  10.1136/bjsm.2006.030916.

44. Rees JD, Lichtwark GA, Wolman RL, et al. Eccentric exercises; why do they work, what are the problems and how can we improve them? Br J Sports Med 2009;43:242-246 doi:10.1136/bjsm.2008.052910

45. Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 2004 Feb;38(1):8-11; discussion 11.

46. Silbernagel KG, Thomee R, Thomee P, Karlsson J. Eccentric overload training for patients with chronic Achilles tendon pain: a randomised controlled study with reliability testing of the evaluation methods. Scan J Med Sci Sports. 2001;11:197–206.

47. Niesen-Vertommen SL, Taunton JE, Clement DB, Mosher RE. The effect of eccentric versus concentric exercise in the management of Achillestendonitis. Clin J Sport Med. 1992;2:109–113.

48. Jin WJ, Yu TY, Jin YH, Lee JB. Visual Analogue Scale in Acute Pain measurement: Its Usefulness as a Pain Measurement Tool in an Emergency Setting.   J Korean Soc Emerg Med. 2003 Mar;14(1):61-65

49. Downie WW, Leatham PA, Rhind VM et al. Studies with pain rating scales. Ann Rheum Dis 1978; 37(4): 378-81.

50. Ngoc Quan Phan , Christine Blome, Fleur Fritz, Joachim Gerss, Adam Reich, Toshiya Ebata, Matthias Augustin Assessment of Pruritus Intensity: Prospective Study on Validity and Reliability of the Visual Analogue Scale, Numerical Rating Scale and Verbal Rating Scale in 471 Patients with Chronic Pruritus. cta Derm Venereol. 2011 Dec 15;:     22170091 

51. Williamson A., Hoggart B et al 2005 Pain: a review of three commonly used pain rating scales  Submitted for publication: 20 November 2003Accepted for publication: 25 October 2005

52. Gajdosik RL, et al Clinical Measurement of Range of MotionPhysical Therapy December 1987 vol. 67no. 12 

53. Youdas JW, Bogard CL, Suman VJ- Reliability of goniometric measurements and visual estimates of ankle joint ROM obtained in a clinical setting. Arch phys Med rehabilitation 1993; 74(10); 1113-8.

54. RobRoy L. Martin, P.T., Ph.D., C.S.C.S. James J. Irrgang, Ph.D., P.T., A.T.C.Evidence of Validity for the Foot and Ankle Ability Measure (FAAM) Arch phys Med rehabilitation 2005; 74(10); 1113-8.

55. Julie Powers - Evidence based treatment for plantar fasciitis. March 2007.

56. Clayton’s Electrotherapy theory and practice by Angela Forfter and Nigel palastanga – 9th edition (2002) -Ultrasound-165p-179p.

57. Clayton’s Electrotherapy theory and practice by Angela Forfter and Nigel palastanga – 9th edition (2002) - TENS-103p-107p

58. Warren CG, Koblanski JN, Sigelmann RA. Ultrasound coupling media: their relative transmissivity. Arch Phys Med Rehabil. 1976 May;57(5):218-22

59. John Low and Ann Read, 3rd edition,-Electro therapy Explained principle and practice pg-113 to 129

60. Gann N,1991; Ziskin M, Mc Diarmid T, Michlovitz S-1990; Therapeutic ultrasound in soft tissue lesions Rheumatology (1990) 40 (12): 1331-1336.

61. Ebenbichler GR, Erdogmus CB,Resch KL, et al; Ultrasound therapy for calcific tendinitis of theshoulder. N Engl J Med 1999;340(20):1533-1538.

62. Derya CELIK, Ata Can ATALAR, Sabahattin SAHINKAYA, Mehmet DeMIrhan. The value of intermittent ultrasound in Subacromial impingement syndrome. Acta Orthop Traumatol Turc 2009;43:243-47.

9. SIGNATURE OF THE CANDIDATE:

10. REMARKS OF THE GUIDE:

11. NAMES AND DESIGNATION OF:

11.1 GUIDE: Dr. R.RAJA ASSOCIATE PROFESSOR

11.2 SIGNATURE:

11.3 CO-GUIDE(s): Dr. RAVISH.MBBS,MS(ORTHOPAEDICS)PROFESSOR OF ORTHOPAEDICSDEPARTMENT OF ORTHOPAEDICS

11.4 SIGNATURE(s):

11.5 HEAD OF THE DEPARTMENT:

PROF. R. BALASARVANAN,MPTPRINCIPAL, KIPT.

11.6 SIGNATURE :

12. 12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL:

12.2 Signature: