Achilles pain, stiffness, and muscle power deficits: achilles tendinitis

Carcia CR, Martin RL, Houck J, Wukich DK [Orthopaedic Section of the American Physical Therapy Association]
The Journal of Orthopaedic and Sports Physical Therapy 2010 Sep;40(9):A1-A26
practice guideline
RECOMMENDATIONS:
RISK FACTORS: 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. (Recommendation based on moderate evidence).
DIAGNOSIS/CLASSIFICATION: Self-reported localized pain and perceived stiffness in the Achilles tendon following a period of inactivity (ie, 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 ICD category of Achilles bursitis or tendinitis and the associated 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). (Recommendation based on weak evidence).
DIFFERENTIAL DIAGNOSIS: 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. (Recommendation based on expert opinion).
EXAMINATION -- OUTCOME MEASURES: 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. (Recommendation based on strong evidence).
EXAMINATION -- 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 and single-limb hop, and participate in recreational activity. (Recommendation based on moderate evidence).
EXAMINATION -- 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. (Recommendations based on moderate evidence).
INTERVENTIONS -- ECCENTRIC LOADING: Clinicians should consider implementing an eccentric loading program to decrease pain and improve function in patients with midportion Achilles tendinopathy. (Recommendation based on strong evidence).
INTERVENTIONS -- LOW-LEVEL LASER THERAPY: Clinicians should consider the use of low-level laser therapy to decrease pain and stiffness in patients with Achilles tendinopathy. (Recommendation based on moderate evidence).
INTERVENTIONS -- IONTOPHORESIS: Clinicians should consider the use of iontophoresis with dexamethasone to decrease pain and improve function in patients with Achilles tendinopathy. (Recommendation based on moderate evidence).
INTERVENTIONS -- STRETCHING: Stretching exercises can be used to reduce pain and improve function in patients who exhibit limited dorsiflexion range of motion with Achilles tendinopathy. (Recommendation based on weak evidence).
INTERVENTIONS -- FOOT ORTHOSES: A foot orthosis can be used to reduce pain and alter ankle and foot kinematics while running in patients with Achilles tendinopathy. (Recommendation based on weak evidence).
INTERVENTIONS -- MANUAL THERAPY: Soft tissue mobilization can be used to reduce pain and improve mobility and function in patients with Achilles tendinopathy. (Recommendation based on expert opinion).
INTERVENTIONS -- TAPING: Taping may be used in an attempt to decrease strain on the Achilles tendon in patients with Achilles tendinopathy. (Recommendation based on expert opinion).
INTERVENTIONS -- HEEL LIFT: Contradictory evidence exists for the use of heel lifts in patients with Achilles tendinopathy. (Recommendation based on conflicting evidence).
INTERVENTIONS -- NIGHT SPLINT: Night splints are not beneficial in reducing pain when compared to eccentric exercise for patients with Achilles tendinopathy. (Recommendation based on weak evidence).