Conservative management of mid-portion Achilles tendinopathy

118 Pages·2013·3.71 MB·English

by  Peter Malliaras

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Conservative management of mid-portion Achilles
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7 tendinopathy: a mixed methods study, integrating
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9 systematic review and clinical reasoning
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13 Victoria Rowe1, Stephanie Hemmings1, Christian Barton1, Peter Malliaras1,
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Nicola Maffulli1 and Dylan Morrissey1
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1 Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, The
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Royal London Hospital (Mile End), Bancroft Road, London. E1 4DG
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21 All correspondence to: Dr Dylan Morrissey, Senior Clinical Lecturer and Consultant Physiotherapist, Centre
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for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, The Royal
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24 London Hospital (Mile End), Bancroft Road, London. E1 4DG
25 Email: [email protected]
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Telephone: [phone]
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28 Fax number: [phone]
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31 Acknowledgements
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33 We thank all the physiotherapists that took the time to be interviewed for this
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35 project, especially those who took part in the respondent validation sessions. We
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thank The Nuffield Foundation for funding early work on this project, and in
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particular Cabella Lowe and Mr Charles Percy for their collaborative efforts.
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Word count 4003
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45 Running title: Managing Achilles tendinopathy conservatively
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4 Table of contents
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Conservative management of Achilles tendinopathy: a mixed methods study,
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7 integrating clinical evidence and clinical reasoning ............................................... 2
8 ABSTRACT (267 words) ................................................................................. 4
9 INTRODUCTION ............................................................................................... 6
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METHODOLOGY .............................................................................................. 8
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Step 1: Literature Review ............................................................................ 8
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13 Step 2: Semi-structured Interviews ............................................................ 9
14 Analysis ....................................................................................................... 10
15 FINDINGS ....................................................................................................... 11
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Literature Review ....................................................................................... 11
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Qualitative Analysis ................................................................................... 11
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19 DISCUSSION .................................................................................................. 12
20 Outcome Measures .................................................................................... 12
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Eccentric Exercises ................................................................................... 12
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Extracorporeal Shockwave Therapy (ESWT) .......................................... 13
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24 Orthoses ..................................................................................................... 14
25 Low-Level Laser Therapy (LLLT) .............................................................. 14
26 Topical Glyceryl Trinitrate (TGTN) ........................................................... 15
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Concentric Exercises ................................................................................ 15
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Splinting/Bracing ....................................................................................... 16
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30 Continued Tendon Loading or Physical Activity .................................... 16
31 Therapeutic Ultrasound............................................................................. 17
32 Taping ......................................................................................................... 17
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Specific Soft-tissue Mobilization .............................................................. 18
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35 Calf Stretches ............................................................................................. 19
36 SUMMARY ...................................................................................................... 19
37 LIMITATIONS ............................................................................................. 20
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CONCLUSION ................................................................................................ 21
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References ..................................................................................................... 23
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42 Figure caption:
43 Figure 1. Conservative management pathway for Achilles tendinopathy with
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components identified from the literature review and qualitative data.
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ESWT = extracorporeal shockwave therapy; TGTN = topical glyceryl trinitrate; LLLT =
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low level laser therapy.
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ABSTRACT
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7 Clinicians manage mid-portion Achilles tendinopathy (AT) using complex clinical
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9 reasoning underpinned by a rapidly developing evidence base. The objectives of
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11 the study were to develop an inclusive, accessible review of the literature in
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combination  with  an  account  of  expert  therapists’  related clinical reasoning to
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guide clinical practice and future research. Searches of the electronic databases,
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PubMed, ISI Web of Science, PEDro, CINAHL, Embase, and Google Scholar
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18 were conducted for all papers published from inception to November
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20 2011.Reference lists and citing articles were searched for further relevant
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22 articles. Inclusion required studies to evaluate the effectiveness of any
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conservative intervention for mid-portion AT. Exclusion criteria included in vitro,
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animal and cadaver studies and tendinopathies in other locations (e.g. patella,
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supraspinatus). From a total of 3497 identified in the initial search, 47 studies
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29 fulfilled the inclusion criteria. Studies were scored according to the PEDro scale,
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31 with a score of >8/10 considered of excellent quality, 5-7/10 good, and <4/10
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33 poor. The strength of evidence supporting each treatment modality was then
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rated  as  ‘strong,’  ‘moderate,’  ‘limited,’  ‘conflicting,  or  ‘no  evidence’  according  to  
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the number and quality of articles supporting that modality. Additionally, semi-
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structured interviews were conducted with physiotherapists to explore clinical
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40 reasoning related to the use of various interventions with and without an
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42 evidence base, and their perceptions of available evidence. Evidence was strong
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44 for eccentric loading exercises and extracorporeal shockwave therapy; moderate
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for, splinting/bracing, active rest, low-level laser therapy and concentric exercises
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(i.e. inferior to eccentric exercise). In-shoe foot orthoses and therapeutic
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49 ultrasound had limited evidence. There was conflicting evidence for topical
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51 glycerin tri-nitrate. Taping techniques and soft tissue mobilization were not yet
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53 examined but featured in case studies and in the interview data. Framework
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55 analysis of interview transcripts yielded multiple themes relating to
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physiotherapists’  clinical  reasoning  and  perceptions  of  the  evidence,  including  
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the difficulty in causing pain while treating the condition and the need to vary
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4 research protocols for specific client groups – such as those with metabolic
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6 syndrome as a likely etiological factor. Physiotherapists were commonly
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8 applying the modality with the strongest evidence base, eccentric loading
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exercises. Barriers to research being translated into practice identified included
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the lack of consistency of outcome measures, excessive stringency of some
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authoritative reviews and difficulty in accessing primary research reports. The
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15 broad inclusion criteria meant some lower quality studies were included in this
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17 review. However, this was deliberate to ensure that all available research
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19 evidence for the management of mid-portion AT, and all studies were evaluated
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using the PEDro scale to compensate for the lack of stringent inclusion criteria.
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Graded evidence combined with qualitative analysis of clinical reasoning
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produced a novel and clinically applicable guide to conservative management of
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26 mid-portion AT. This guide will be useful to novice clinicians learning how to
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28 manage this treatment-resistant condition and to expert clinicians reviewing their
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30 evidence based practice and developing their clinical reasoning. Important areas
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requiring future research were identified including the effectiveness of orthoses,
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the effectiveness of manual therapy, etiological factors, optimal application of
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35 loading related to stage of presentation and how to optimize protocols for
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37 different types of patients such as the older patient with metabolic syndrome as
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39 opposed to the athletically active.
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Key Words: Achilles tendinopathy; qualitative research; systematic review;
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44 physiotherapy
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4 INTRODUCTION
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7 Mid-portion Achilles tendinopathy (AT) is a chronic condition characterized by
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9 localized Achilles tendon pain and swelling, often leading to loss of occupational
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11 capacity and reduced athletic performance.[1] It affects both recreational and
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professional sports participants, with up to 9% of elite athletes in sports involving
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running or jumping suffering from AT.[2] AT is commonly associated with elite
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athletic activity, but affects a varied population with 33% of AT patients being
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18 sedentary individuals, particularly men aged between 35-45 years. [1, 2] The
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20 cause of AT is multi-factorial, and proposed etiological factors include overuse,
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22 adverse lower limb biomechanics (e.g. excessive foot pronation [3]), and
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inappropriate footwear. Patients with diabetes, inflammatory and autoimmune
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conditions are affected by AT, [4] and an emerging development is the
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connection of metabolic factors, such as dyslipidemia, to the risk of developing
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33 Conservative treatment is commonly the first line of management for Achilles
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tendinopathy, usually applied for 3 to 6 months before alternative options such as
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sclerosing injections, [6] high volume image guided injections [7] or minimally
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invasive surgery are considered. The outcome of surgical treatment after failed
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40 conservative management is at times unpredictable, and involves extensive post-
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42 surgical rehabilitation. [8] A retrospective study of athletes surgically treated for
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44 AT found that it took an average of 11.1 months to return to competitive sport. [9]
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Considering the invasiveness and pitfalls of surgical interventions, it is important
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to identify conservative modalities that yield the best clinical outcomes.
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51 There have been previous systematic reviews evaluating conservative treatment
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53 of Achilles tendinopathy.[2, 3, 10] A previous systematic review of non-operative
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55 treatment for mid-portion Achilles tendinopathy included five conservative
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modalities and three injection therapies, concluding that eccentric exercises have
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the strongest supporting evidence and shockwave therapy would benefit from
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4 further research. [10] Recent work has expanded the available evidence base.
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6 Further, the highly stringent approach taken, i.e. including only high quality RCTs
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8 with criteria mainly developed for drug trials, means that some conservative
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interventions with supporting evidence from medium quality studies were not
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included. It is possible that practitioners using these systematic reviews as their
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only guide for clinical reasoning may therefore omit the use of potentially
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Clinical reasoning requires a therapist to draw on knowledge of evidence,
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underlying theoretical constructs and past experience to deliver optimal clinical
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26 care.[11] Informal evidence derived from clinical practice also has a role in
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28 developing clinical reasoning and guiding future research.[12] Therefore,
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30 describing therapist clinical reasoning alongside a graded review of the literature
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has the potential to enhance evidence translation by illustrating the review
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findings  with  experts’  clinical  decision  making  paradigms  and  perceptions  of  the  
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35 published evidence. We anticipated that this combined approach would make the
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37 evidence  ‘come  alive’,  and  therefore  enhance  both accessibility and applicability.
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41 The overall aim of this study was to develop evidence-based, descriptive and
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clinically applicable guidance to conservative management of mid-portion
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Achilles tendinopathy. Our objectives were to (i) grade evidence for conservative
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46 treatments for Achilles tendinopathy via a thorough literature search and critique;
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48 (ii)  qualitatively  analyze  physiotherapists’  clinical  reasoning  related  to  the  use  of  a  
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50 wide range of interventions; (iii)  establish  clinicians’  perceptions  of  the  available  
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evidence; and (iv) identify areas for future research emerging both from the
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evidence base and semi-structured interviews. It is anticipated that this guide will
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not only present a review of the state of the current evidence base but also
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4 METHODOLOGY
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6 Step 1: Literature Review
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8 Searches of the electronic databases, PubMed, ISI Web of Science, PEDro,
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CINAHL, Embase, and Google Scholar were conducted for all papers published
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from inception through to November 2011(see Figure 1). The search strategy
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was designed to be highly sensitive, and included a wide range of terms for
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15 possible conservative treatment modalities for AT and study types (see Table i
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17 for details). Duplicates were removed, and relevant titles selected from the
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19 search results. Full papers were retrieved if the subjects were human adults
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(aged > 18 years) with mid-portion Achilles tendinopathy. Studies with insertional
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tendinopathies were only included if a sub-group of mid-portion AT participants
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could be separated from the main group. Studies were required to recruit
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26 participants with chronic pain or symptoms (i.e. at least 3 months), to ensure a
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28 true tendinopathy was studied. Conservative modalities were considered as any
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30 intervention not involving surgery, injection therapy or orally administered
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pharmacotherapies. Studies were required to make a comparison between two
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groups or compare the before and after effects of an intervention. Exclusion
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35 criteria included in vitro, animal and cadaver studies and tendinopathies in other
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37 locations (e.g. patella, supraspinatus). Reference lists and citing articles were
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Studies were scored according to the PEDro scale [13], with a score of >8/10
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considered of excellent quality, 5-7/10 good, and <4/10 poor. This is a reliable
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46 measure for the quality of evidence.[14] This involved a supplementary search of
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48 the PEDro database for pre-scored articles. If a study had not yet been graded
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50 on the database, two reviewers (VR, SJH) scored the article on two separate
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occasions. A third assessor (DM) was available to resolve any contentious
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issues, of which there were two.
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57 All interventions described in a multi-intervention trial were discussed individually.
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4 and assigned a level of 1 to 5 determined by the number and quality of articles
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Step 2: Semi-structured Interviews
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15 Physiotherapists with extensive experience of managing Achilles tendinopathy
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17 were recruited to take part in the study to optimise the wealth of information able
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frame was developed to purposively recruit [16] therapists with a wide range of
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experience and backgrounds, including physiotherapists working in the public,
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private, research and clinical settings with a range of years of experience (Table
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optimize the external validity to practicing physiotherapists while ensuring a high
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level of expertise to contribute to the interviews. In total, 19 physiotherapists were
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35 recruited and interviewed. Ethics approval for conducting the qualitative part of
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37 the study was granted by the Queen Mary Research and Ethics Committee.
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39 Written informed consent was obtained prior to each interview.
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A topic guide was constructed using results from the literature review and
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discussion within the research team to ensure that key aspects were covered
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48 physiotherapists’   background,   frequency   of   treating   AT,   important   aspects   of  
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affect treatment decisions. Key areas included perceptions of evidence for
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conservative modalities and reasoning for choosing certain treatments and not
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others. Face-to-face, semi-structured interviews [16] lasting an average of 30
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Analysis
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Framework analysis was completed by the primary author (VR) who is a non-
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15 clinician to evaluate the interview transcripts.[17] The researcher familiarized
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17 themselves with the interview data and identified themes and sub-themes
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19 forming a thematic framework. The framework was indexed, and this was applied
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to the transcripts as a labeled code for sections of text. Data for each main theme
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were presented as a chart with sub-themes. One chart was developed for each
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theme. Each chart provided an analytical tool through which allowed for
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analysis. Respondent validation was further conducted by presenting a group of
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the physiotherapists that were interviewed with the final framework charts.[18]
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Four physiotherapists completed feedback forms with agreements,
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sought by three expert physiotherapists (CB, PM and DM) involved in the study.
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4 FINDINGS
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Literature Review
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Forty-two studies and five follow-up studies were reviewed and scored according
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to the PEDro scale [13], yielding 5 studies of excellent quality [19-23], 17 of good
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12 quality [24-40], and 25 of poor quality [41-65]. Eleven treatment modalities were
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The review identified strong evidence (Table ii) for the efficacy of eccentric
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25 active rest. Moderate evidence found concentric exercises to be effective but not
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as effective as eccentric exercises. Foot orthoses and therapeutic ultrasound had
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limited evidence. Only single case studies and a within-subject design study were
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identified for taping and soft-tissue   mobilizations   which   were   classed   as   “No  
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Qualitative Analysis
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Nineteen interview transcripts were analyzed. The topic guide was used to inform
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the themes with 14 themes and 48 subthemes identified. The themes were
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43 charted into 7 groups under two sections: firstly, perceptions of the evidence for
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The findings are both tabulated in tables iv and v and discussed in the results
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section alongside the evidence review findings.
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