Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy
Publication Date: April 30, 2018
Last Updated: March 14, 2022
Summary of Recommendations
DIAGNOSIS/CLASSIFICATION
In addition to the arc sign and Royal London Hospital test, clinicians can use a subjective report of pain located 2 to 6 cm proximal to the Achilles tendon insertion that began gradually and pain with palpation of the midportion of the tendon to diagnose midportion Achilles tendinopathy. (C)
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EXAMINATION – OUTCOME MEASURES: ACTIVITY LIMITATIONS/ SELF-REPORTED MEASURES
Clinicians should use the Victorian Institute of Sport Assessment-Achilles (VISA-A) to assess pain and stiffness, and either the Foot and Ankle Ability Measure (FAAM) or the Lower Extremity Functional Scale (LEFS) to assess activity and participation in patients with a diagnosis of midportion Achilles tendinopathy. (A)
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EXAMINATION – ACTIVITY LIMITATIONS/PHYSICAL PERFORMANCE MEASURES
Clinicians should use physical performance measures, including hop and heel-raise endurance tests, as appropriate, to assess a patient’s functional status and document findings. (B)
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EXAMINATION – PHYSICAL IMPAIRMENT MEASURES
When evaluating physical impairment over an episode of care for those with Achilles tendinopathy, one should measure ankle dorsiflexion range of motion, subtalar joint range of motion, plantar flexion strength and endurance, static arch height, forefoot alignment, and pain with palpation. (B)
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INTERVENTIONS – EXERCISE
Clinicians should use mechanical loading, which can be either in the form of eccentric exercise, or a heavy-load, slowspeed (concentric/eccentric) exercise program, to decrease pain and improve function for patients with midportion Achilles tendinopathy without presumed frailty of the tendon structure. (A)
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Patients should exercise at least twice weekly within their pain tolerance. (F)
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INTERVENTIONS – STRETCHING
Clinicians may use stretching of the ankle plantar flexors with the knee flexed and extended to reduce pain and improve satisfaction with outcome in patients with midportion Achilles tendinopathy who exhibit limited ankle dorsiflexion range of motion. (C)
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INTERVENTIONS – NEUROMUSCULAR RE-EDUCATION
Clinicians may use stretching of the ankle plantar flexors with the knee flexed and extended to reduce pain and improve satisfaction with outcome in patients with midportion Achilles tendinopathy who exhibit limited ankle dorsiflexion range of motion. (F)
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INTERVENTIONS – MANUAL THERAPY
Clinicians may consider using joint mobilization to improve mobility and function and soft tissue mobilization to increase range of motion for patients with midportion Achilles tendinopathy. (F)
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INTERVENTIONS – PATIENT EDUCATION: ACTIVITY MODIFICATION
For patients with nonacute midportion Achilles tendinopathy, clinicians should advise that complete rest is not indicated and that they should continue with their recreational activity within their pain tolerance while participating in rehabilitation. (B)
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INTERVENTIONS – PATIENT COUNSELING
Clinicians may counsel patients with midportion Achilles tendinopathy. Key elements of patient counseling could include:
- theories supporting use of physical therapy and role of mechanical loading
- modifiable risk factors, including body mass index and shoewear and
- typical time course for recovery from symptoms.
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INTERVENTIONS – HEEL LIFTS
Because contradictory evidence exists, no recommendation can be made for the use of heel lifts in patients with midportion Achilles tendinopathy. (D)
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INTERVENTIONS – NIGHT SPLINTS
Clinicians should not use night splints to improve symptoms in patients with midportion Achilles tendinopathy. (C)
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INTERVENTIONS – ORTHOSES
Because contradictory evidence exists, no recommendation can be made for the use of orthoses in patients with midportion Achilles tendinopathy. (D)
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INTERVENTIONS – TAPING
Clinicians should not use therapeutic elastic tape to reduce pain or improve functional performance in patients with midportion Achilles tendinopathy. (F)
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Clinicians may use rigid taping to decrease strain on the Achilles tendon and/or alter foot posture in patients with midportion Achilles tendinopathy. (F)
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INTERVENTIONS – LOW-LEVEL LASER THERAPY
Because contradictory evidence exists, no recommendation can be made for the use of low-level laser therapy in patients with midportion Achilles tendinopathy. (D)
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INTERVENTIONS – IONTOPHORESIS
Clinicians should use iontophoresis with dexamethasone to decrease pain and improve function in patients with acute midportion Achilles tendinopathy. (B)
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INTERVENTIONS – DRY NEEDLING
Clinicians may use combined therapy of dry needling with injection under ultrasound guidance and eccentric exercise to decrease pain for individuals with symptoms greater than 3 months and increased tendon thickness. (F)
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Recommendation Grading
Overview
Title
Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy
Authoring Organization
American Physical Therapy Association
Publication Month/Year
April 30, 2018
Last Updated Month/Year
June 9, 2022
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
Review recent peer-reviewed literature and make recommendations related to midportion Achilles tendinopathy.
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital, Long term care, Outpatient
Intended Users
Podiatrist, physical therapist, occupational therapist, nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Rehabilitation, Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D052256 - Tendinopathy, D000125 - Achilles Tendon
Keywords
Midportion Achilles Tendinopathy, achilles pain, ankle pain