Instrument Assisted Soft Tissue Mobilization in the Treatment of Achilles Tendinopathy

94 Pages·2017·1.3 MB·English

University of New Mexico
UNM Digital Repository
Doctor of Physical Therapy Capstones Health Sciences Center Student Scholarship
Winter 5-14-2018
Instrument Assisted Soft Tissue Mobilization in the
Treatment of Achilles Tendinopathy
Asael Boone Checketts
University of New Mexico, [email protected]
Follow this and additional works at:https://digitalrepository.unm.edu/dpt
Recommended Citation
Checketts, Asael Boone. "Instrument Assisted Soft Tissue Mobilization in the Treatment of Achilles Tendinopathy." (2018).
https://digitalrepository.unm.edu/dpt/142
This Capstone is brought to you for free and open access by the Health Sciences Center Student Scholarship at UNM Digital Repository. It has been
accepted for inclusion in Doctor of Physical Therapy Capstones by an authorized administrator of UNM Digital Repository. For more information,
please [email protected].
Instrument Assisted Soft Tissue Mobilization in

the Treatment of Achilles Tendinopathy

By:
Asael B. Checketts
Doctoral Candidate
University of New Mexico School of Medicine
Division of Physical Therapy
Class of 2018

Advisor:
Ron Andrews, PT, PhD, OCS, Associate Professor

Approved by the Division of Physical Therapy, School of Medicine,
University of New Mexico in partial fulfillment of the requirements for
the degree of Doctor of Physical Therapy.
Abstract
Background/Purpose: Achilles tendinopathy (AT) is a common injury in runners and is not
uncommon in sedentary individuals. This condition is often treated with eccentric loading,
although many conservative treatments have been tried. One alternative treatment for Achilles
tendinopathy is instrument assisted soft tissue mobilization (IASTM). The purpose of this study
is to find out if IASTM is as effective at treating Achilles tendinopathy as eccentric exercise. Is
IASTM as effective as eccentric loading in the treatment of AT in middle aged runners?
Case Description: A man reported to an outpatient clinic with an acutely strained calf. The
patient had a quick initial recovery but returned to the clinic after reinjuring his calf. Further
history and examination revealed an underlying Achilles tendinopathy. The physical therapist
immediately began treatment with an eccentric loading program. As treatment progressed the
patient expressed a desire for quicker results. The physical therapist suggested the use of IASTM
as another treatment option.
Outcomes: The literature is mixed on the efficacy of IASTM, and some does not support
eccentric exercises in the treatment of Achilles tendinopathy. However, the latest research shows
clinical evidence supporting eccentric exercise and IASTM as effective treatments, with the most
effective results being with the two as complimentary treatments. With the addition of IASTM to
his treatment the patient began to improve in his recovery including a decrease in pain and an
increase in activity measured by miles run.
Discussion: Data continues to be gathered on IASTM and its effect on tendinopathy. More
research is needed to confirm the results of the few positive studies available in the literature.
While data on effectiveness is gathered, there is little risk of adverse effects from the use of
IASTM to treat AT.
1
Table of Contents
Abstract ........................................................................................................................................... 1
Table of Contents ............................................................................................................................ 2
Background ..................................................................................................................................... 3
Case Description ............................................................................................................................. 6
Methods........................................................................................................................................... 8
Summary of Articles ..................................................................................................................... 10
Discussion ..................................................................................................................................... 22
Conclusion .................................................................................................................................... 24
Reference list ................................................................................................................................ 26
Appendix A ................................................................................................................................... 28
Appendix B ................................................................................................................................... 31

2
Background
Achilles Tendinopathy
Achilles tendinopathy (AT) is a medical diagnosis characterized by pain and stiffness in
the area of the Achilles tendon usually diagnosed symptomatically. Formerly referred to as
tendonitis or tendinosis, the term tendinopathy is a generic descriptor of the clinical conditions in
and around tendons arising from overuse.1 Achilles tendinopathy has become the overarching
phrase to refer to the chronic condition in which the Achilles tendon is injured and fails to heal.
Achilles tendinopathy is commonly observed in athletes, especially those in endurance sports
such as running, but has been observed in significant numbers of sedentary individuals as well.2
A normal Achilles tendon is composed primarily of type I collagen well organized and
aligned longitudinally. The tendon appears shiny and white. In persons with AT the tendon is
characterized by being thicker, uneven and brownish with no inflammatory markers present.
Type III collagen is found in higher than normal proportions contributing to the irregularity of
tendon tissue.3
Treatment Options
Treatment of AT is generally conservative with mixed reports on the efficacy of
treatment. Eccentric loading of the tendon has become the gold standard for conservative
management of the condition4, 5. However research shows that up to 45% of patients treated with
eccentric exercise fail to respond to treatment.4 Extracorporeal shockwave therapy, deep friction
massage, therapeutic ultrasound, low level laser, concentric loading, stretching and many other
modalities have also been used to treat AT. When conservative treatment fails surgery is an
option for some individuals that has shown positive outcomes in many patients.6 Due to the
3
inconsistency of conservative treatments available, additional treatments are being sought to
more effectively meet the challenges of treating AT.
IASTM
Instrument Assisted Soft Tissue Mobilization (IASTM) is a quickly growing treatment
field that is seen as another conservative treatment for AT. It is said to have roots in ancient
Greece and Rome with the use of a “strigil” a small metallic object used for medical purposes as
well as a traditional Chinese therapy “gua sha.”7,8 While understanding of the mechanisms of
IASTM differs among clinicians, the overarching theory is that using “tools” primarily of
stainless steel, clinicians can pinpoint tissues below the skin of patients such as adhesions and
target them more effectively promoting normal functional movement. Secondarily, IASTM
applied at a proper threshold is believed to cause capillary hemorrhage inducing a healing
response as well as a loading mechanism sufficient to induce collagen synthesis.7, 10 Studies have
found IASTM more effective than using hands for soft tissue mobilization by reducing fatigue in
practitioners and increasing therapeutic effect in patients.7, 9 Several specific treatment programs
have evolved in recent years in IASTM including Graston, ASTYM, and HawkGrips. Each
technique differs slightly in application but are based on similar biomechanical principles. In this
paper they are referred to generally as instrument assisted soft tissue mobilization unless
otherwise indicated.
PICO Question
PICO, or Problem/Patient, Intervention, Comparison, Outcome is a method for deriving
quality research questions. The goal is to identify a specific problem in a given population,
acknowledge an intervention and what it will be compared to, and finally identify the outcome
being measured. Achilles Tendinopathy is a commonly seen diagnosis in physical therapy and
4
conservative treatments options are many and varied with eccentric loading being the
predominant treatment of choice. The purpose of this review is to answer this question: Is
IASTM as effective as eccentric loading in the treatment of AT in middle aged runners? This
review seeks to find the current best evidence on AT treatment, combined with a better
understanding of the best evidence regarding the mechanisms, protocols, and effectiveness of
IASTM to address this question.

5
Case Description
History
The patient referenced in this analysis is a 67 year old male referred to outpatient
physical therapy for an acute R calf strain. The patient was recently retired and had started a
regular exercise routine including more running. He “pulled” his calf while running up a hill. He
attempted to treat it himself but after a few weeks with limited improvement he saw his primary
care physician and was referred to physical therapy. The patient’s primary goal for therapy was
to return to running and to be able to go on a canoe trip he had planned in three weeks.
Evaluation
The patient’s evaluation indicated a grade one calf strain, particularly affecting the
fibularis muscles as well as tibialis posterior. Walking gait appeared normal. No other
impairments were readily visible.
Treatment and Follow Up
Using a treatment consisting of therapeutic exercise, soft tissue mobilization and ice, the
patient’s pain subsided and function improved. The patient was able to go on his river trip but on
the last day of the trip reinjured his calf. Upon re-evaluation, the patient mentioned that he had a
history of soreness on and off at the back of his heel that had been present for the last few years.
Further testing revealed signs and symptoms consistent with Achilles tendinopathy.
With the additional information regarding the chronicity of the underlying injury, the
therapist educated the patient regarding prognosis and possible treatments, including IASTM.
The patient was interested in this proposed technique so it was added to his treatment. The
patient showed rapid improvement using IASTM along with similar treatments used previously.
6
Within three weeks he had met his goals regarding pain reduction and return to activity. The
patient was discharged and lost to follow-up.

7
Methods
For this analysis, a search was conducted on in PubMed and CINAHL databases looking
for research papers pertaining to current best practice to see if IASTM is as effective as eccentric
exercise for conservative treatment of Achilles tendinopathy. Due to the lack of evidence in this
area, the search was expanded to include the efficacy of IASTM in the treatment of AT or other
tendinopathies, and current best practice for the conservative treatment of AT or other
tendinopathies. Search terms included tendinopathy, physical therapy, chiropractic, Graston,
ASTYM, instrument assisted soft tissue mobilization, soft tissue, and rehabilitation to glean the
most relevant literature. All searches were limited to ten years. The combination of searches
yielded 67 results.
These research papers were reviewed based on title and abstract relevance to the PICO
question as well as Oxford level of evidence. This left ten remaining papers, of which two were
duplicates. The eight papers gathered were then further examined and fell into two main groups;
three papers examined the conservative treatment of tendinopathy (not limited to Achilles
tendon) and five papers looked specifically at the effectiveness of IASTM as a modality.
Research papers kept included four systematic reviews and four RCTs. A visual of this process is
shown in Figure 1. These papers were then analyzed using a standardized procedure and can be
referenced in appendix B. Brief summaries of findings in each paper are included in appendix A.
Additional research papers were gleaned from the reference lists of the eight papers analyzed to
provide background information.
8