Patients with Achilles pain, stiffness, and muscle power deficits with suspected or confirmed Achilles tendinitis
Interventions and Practices Considered
Note: The use of night splints was considered, but not recommended.
Major Outcomes Considered
Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources) Hand-searches of Published Literature (Secondary Sources) Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
The authors of this guideline independently performed a systematic search of the MEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews (1967 through February 2009) for any relevant articles related to classification, examination, and intervention for musculoskeletal conditions related to the Achilles tendon. Additionally, when relevant articles were identified, their reference lists were hand-searched in an attempt to identify additional articles that might contribute to the outcome of this guideline. Articles from the searches were compiled and reviewed for accuracy by the authors. Articles with the highest levels of evidence that were most relevant to classification, examination, and intervention for patients’ musculoskeletal conditions related to the Achilles tendon were included in this guideline.
It was acknowledged by the Orthopaedic Section of the American Physical Therapy Association (APTA) content experts that only performing a systematic search and review of the evidence related to diagnostic categories based on International Statistical Classification of Diseases and Health Related Problems (ICD) terminology would not be sufficient for these International Classification of Functioning, Disability, and Health (ICF)-based clinical practice guidelines as most of the evidence associated with changes in levels of impairment or function in homogeneous populations is not readily searchable using the ICD terminology.
Weighting According to a Rating Scheme
Levels of Evidence
Individual clinical research articles were graded according to criteria described by the Centre for Evidence-Based Medicine, Oxford, United Kingdom.
Methods Used to Analyze the Evidence
Description of Methods Used to Formulate the Recommendations
Content experts were given the task to identify impairments of body function and structure, activity limitations, and participation restrictions, described using International Classification of Functioning, Disability, and Health (ICF) terminology, that could (1) categorize patients into mutually exclusive impairment patterns upon which to base intervention strategies, and (2) serve as measures of changes in function over the course of an episode of care. The second task given to the content experts was to describe the supporting evidence for the identified impairment pattern classification as well as interventions for patients with activity limitations and impairments of body function and structure consistent with the identified impairment pattern classification.
Rating Scheme for the Strength of the Recommendations
Grades of Recommendation
The overall strength of the evidence supporting recommendations made in this guideline was graded according to guidelines described by Guyatt et al as modified by MacDermid and adopted by the coordinator and reviewers of this project. In this modified system, the typical A, B, C, and D grades of evidence have been modified to include the role of consensus expert opinion and basic science research to demonstrate biological or biomechanical plausibility.
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review Internal Peer Review
Description of Method of Guideline Validation
The Orthopaedic Section, American Physical Therapy Association (APTA) selected consultants from the following areas to serve as reviewers of the early drafts of this clinical practice guideline:
Comments from these reviewers were utilized by the authors to edit this clinical practice guideline prior to submitting it for publication to the Journal of Orthopaedic & Sports Physical Therapy. In addition, several physical therapists practicing in orthopaedic and sports physical therapy settings were sent initial drafts of this clinical practice guideline, along with feedback forms to assess its usefulness, validity, and impact.
Levels of evidence (I–V) and grades of recommendation (A–F) are defined at the end of the “Major Recommendations” field.
For specific groups of individuals, clinicians should consider abnormal ankle dorsiflexion range of motion, abnormal subtalar joint range of motion, decreased ankle plantar flexion strength, increased foot pronation, and abnormal tendon structure as intrinsic risk factors associated with Achilles tendinopathy. Obesity, hypertension, hyperlipidemia, and diabetes are medical conditions associated with Achilles tendinopathy. Clinicians should also consider training errors, environmental factors, and faulty equipment as extrinsic risk factors associated with Achilles tendinopathy. (Grade of Recommendation B)
Self-reported localized pain and perceived stiffness in the Achilles tendon following a period of inactivity (i.e., sleep, prolonged sitting), lessens with an acute bout of activity and may increase after the activity. Symptoms are frequently accompanied with Achilles tendon tenderness, a positive arc sign, and positive findings on the Royal London Hospital test. These signs and symptoms are useful clinical findings for classifying a patient with ankle pain into the International Statistical Classification of Diseases and Health Related Problems (ICD) category of Achilles bursitis or tendinitis and the associated International Classification of Functioning, Disability, and Health (ICF) impairment based category of Achilles pain (b28015 Pain in lower limb), stiffness (b7800 Sensation of muscle stiffness), and muscle power deficits (b7301 Power of muscles of lower limb). (Grade of Recommendation C)
Clinicians should consider diagnostic classifications other than Achilles tendinopathy when the patient’s reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/classification section of this guideline, or when the patient’s symptoms are not resolving with interventions aimed at normalization of the patient’s impairments of body function. (Grade of Recommendation F)
Clinicians should incorporate validated functional outcome measures, such as the Victorian Institute of Sport Assessment and the Foot and Ankle Ability Measure. These should be utilized before and after interventions intended to alleviate the impairments of body function and structure, activity limitations, and participation restrictions associated with Achilles tendinopathy. (Grade of Recommendation A)
Activity Limitation and Participation Restriction Measures
When evaluating functional limitations over an episode of care for those with Achilles tendinopathy, measures of activity limitation and participation restriction can include objective and reproducible assessment of the ability to walk, descend stairs, perform unilateral heel raises, single-limb hop, and participate in recreational activity. (Grade of Recommendation B)
Physical Impairment Measures
When evaluating physical impairment over an episode of care for those with Achilles tendinopathy, one should consider measuring dorsiflexion range of motion, subtalar joint range of motion, plantar flexion strength and endurance, static arch height, forefoot alignment, and pain with palpation. (Grade of Recommendation B)
Clinicians should consider implementing an eccentric loading program to decrease pain and improve function in patients with midportion Achilles tendinopathy. (Grade of Recommendation A)
Low-Level Laser Therapy
Clinicians should consider the use of low-level laser therapy to decrease pain and stiffness in patients with Achilles tendinopathy. (Grade of Recommendation B)
Clinicians should consider the use of iontophoresis with dexamethasone to decrease pain and improve function in patients with Achilles tendinopathy. (Grade of Recommendation B)
Stretching exercises can be used to reduce pain and improve function in patients who exhibit limited dorsiflexion range of motion with Achilles tendinopathy. (Grade of Recommendation C)
A foot orthosis can be used to reduce pain and alter ankle and foot kinematics while running in patients with Achilles tendinopathy. (Grade of Recommendation C)
Soft tissue mobilization can be used to reduce pain and improve mobility and function in patients with Achilles tendinopathy. (Grade of Recommendation F)
Taping may be used in an attempt to decrease strain on the Achilles tendon in patients with Achilles tendinopathy. (Grade of Recommendation F)
Contradictory evidence exists for the use of heel lifts in patients with Achilles tendinopathy. (Grade of Recommendation D)
Night splints are not beneficial in reducing pain when compared to eccentric exercise for patients with Achilles tendinopathy. (Grade of Recommendation C)