Clinical Kit 26-2-2014 - Achilles Tendinopathy

Past readers of my blog 'Creating Clinical Success' will know about my past incursions into the realm of achilles tendinopathy. If you missed out here are the blog links;

Researchers MARC STEVENS and CHEE-WEE TAN have just published a paper in Journal of Orthopaedic & Sports Physical Therapy titled "Effectiveness of the Alfredson Protocol Compared With a Lower Repetition-Volume Protocol for Midportion Achilles Tendinopathy: A Randomized Controlled Trial".

The research comparison taken in this paper looked at the standard protocol of 180 eccentric heel drops cf. a Do-As-Tolerated protocol for 6 weeks. The short time frame is a bit of a weakness, as 12 weeks is standard. They used the The Victorian Institute of Sport Assessment-Achilles (VISA-A) as the primary outcome measure, along with VAS pain scale and a Satisfaction of Treatment score. The Alfredson group n=15 and Do-As-Tolerate group n=13, had dropouts of n=4 and n=2 respectively. At three weeks the Alfredson group had a poorer VISA-A and VAS and by 6 weeks (end of study) both groups had significant within group improvements in VISA-A, VAS and Treatment Satisfaction scores. You can check out the abstract here.

You can learn the skill and importance of using Musculoskeletal US to assist in grading, imaging (client feedback) and progressing treatment at Peter Esselbach's Rehabilitative Ultrasound Imaging - Level 1 and Rehabilitative Ultrasound Imaging - Level 2. Peter will also be presenting his Level 3 course in Perth for those with previous experience and wishing to enhance both their musculoskeletal and real time US skills.

This approach has been something that I have been developing clinically for several years and to me is a good example of evidence best practice; where you combine research, personal experience and client expectations/goals to develop the best individualised treatment program.

The etiology of tendinopathy is still unclear; however, histological evidence consistently demonstrates an absence of prostaglandin-mediated inflammation so standard RICE and NSAIDs approaches are largely inappropriate. Research for mid substance tendinopathy has shown promising results under the standardised Alfredson Protocol of 180 eccentric heel drops per day. Having had mid substance achilles tendinopathy myself and been aware of this protocol and the approximate 80% success rate, I was pretty happy to commence my rehab and get back to my land based exercises. Not so easy.

Mentally I thought a session AM/PM would be easy - like brushing my teeth, but it just didn't seem to happen everyday. Then after 3 weeks and still hobbling to the bathroom in the morning, I wasn't so sure about the; Ignore Pain tenement, nor the other of Increase the Load regularly! I looked for other options as you will know from my previous blogs.

That personal experience led me to re evaluate the 'guidelines' of the Alfredson Protocol and make some subtle changes which mirror the findings of Stevens and Tan. The first was to find the persons baseline. This may have meant an obese client, with no past history in regular exercise for 5+ years, may have started eccentric exercises in sitting, while an athlete that over did a couple of back to back sand hill sessions, starting on the full 180/day with an extra 5kg. The other was to build up the numbers slowly, with the guideline that 15 - 20 minutes sore/stiff after exercising was okay (necessary), but not 1-2 hours.

There is no doubt that increasing client's eccentric and concentric strength is the only way to go for long term success, so developing a program that is effective (research driven), clinically relevant (clinician's experience) and personally achievable (client's expectations) is paramount for success. The other tip I find useful as a past runner, is to teach clients to become familiar with the normal sensation of palpating their achilles first thing in the morning. You pick up over training and irritation much sooner with self palpation (local mechanical stress) than you do when running or at rest. Then you can instigate appropriate training changes sooner rather than later, proactive cf. reactive.

All the best,

Doug Cary FACP
Specialist Musculoskeletal Physiotherapist (awarded by Australian College of Physiotherapy, 2009)
PhD Candidate Curtin University
Clinical Director AAP Education

email: doug@aapeducation.com.au

ph/fx: 08 90715055

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