A study published in the Journal of the American Medical Association, Jan. 13, 2010 gave disappointing results in using plasma rich protein to treat non-insertional Achilles tendinopathy. It showed no difference between using a sham injection of saline and combining it with a painful eccentric stretching protocol  in comparison with an injection of plasma rich protein injection along with the standard painful eccentric stretching protocol.

The authors note that previous studies did not have good control groups. In this small study, 27 patients were in the placebo group and 27 in the treatment group. The VISA-A score was used to assess improvement. Both groups improved somewhat without a significant difference between the two groups.

The study was called a “preliminary communication” which is often done with small studies. Other studies on similar topics with fewer than 30 individuals studies have also been billed as “preliminary studies”, but when they are talked up afterward, the “preliminary study” status is usually forgotten. As far as study design goes, the design, blinding, and performance of the study seems just right. I am not entirely convinced of the efficacy of the painful eccentric stretching protocol and would have not minded another study group omitting that treatment. Apparently it is not a panacea (or there would not be studies looking to add to the results), although the initial preliminary study made it sound as though it would be. Follow up journal articles by the primary author of the first study have been positive and are referenced below. Others have expressed reservations on the methodology. (see Woodley et. al. 2007 and Kingma et. al. 2006) Eccentric stretching and overload for tendinopathy has mixed results at best in other body areas.

Note: VISA-A is the Victorian Institute of Sports Assessment-Achilles

References:

Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy: A Randomized Controlled Trial
Robert J. de Vos; Adam Weir; Hans T. M. van Schie; et al. JAMA. 2010;303(2):144-149 (doi:10.1001/jama.2009.1986)

Alfredson H. Chronic midportion Achilles tendinopathy: an update on research and treatment. Clin Sports Med. 2003;22(4):727-741.

Alfredson H and Cook J (2007), A treatment algorithm for managing Achilles tendinopathy, new treatment options, British Journal of Sports Medicine, 41, 4, 211.

J J Kingma, R de Knikker, H M Wittink, T Takken. Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. Br J Sports Med 2007;41:e3 (http://www.bjsportmed.com/cgi/content/full/41/6/e3). doi: 10.1136/bjsm.2006.030916 (concludes: Studies on the effectiveness of eccentric overload training in patients with Achilles tendinopathy show many methodological shortcomings)

Woodley, B.L., R.J. Newsham- West, and D.B. Baxter, Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med, 2007. 41: p. 188-199.

Additional Information:

Pribut, S.M.,  Top 5 Running Injuries. Podiatry Management, 2008

Blog on: Heel Lifts and Achilles Tendinitis

Dr. Pribut on Achilles Tendinopathy

Dr. Pribut on The Science of Tendinopathy

Point / Counter Point: The Truth is Out There Somewhere (or maybe here)

Every now and then the “Fear Factor” comes to the Internet. And if you travel the running blogosphere, you’ll discover that sometimes it takes the form of a red alert for heel lifts for Achilles tendonitis. It seems that some would rather have you run in pain or give up because of the pain for fear that a 1/8″, 1/4″ or 3/8″ lift which alleviates the pain could cause a tendon to “pop”. There is evidence that the sound of a tendon popping may come after an indiscriminate intratendinous injection of steroid though. 

The truth is one should pay attention to what your body is telling you. Running in pain which causes an alteration in form is not good. It will most likely lead to both your original injury not improving, and a few additional injuries because of your altered gait.   

With the knowledge that medicine is an art and a science, it is probably best to avoid dogmatic opinions such as  ”no, no ,no” to a heel lift. While some will be helped with shoe and surface corrections, orthotics, stretching and strengthening alone, the addition of a 1/8 – 3/8″ heel lift can often make the difference in both comfort and eventual healing of this condition. The lift is used on both sides to avoid creating a longer leg and altering the gait in such a manner that could create low back pain, hip pain or other problems in the absence of the affected leg being a short limb. The lift is best made of a non-compressible material. It is extremely important to avoid compressible materials which will lead to continued slow stretch movement which could add to either activating the stretch reflex of the achilles tendon or allow for eccentric contraction of the muscle-tendinous complex. This may work to inhibit the healing of the tendon, and stop the individual from being able to run without pain. We certainly, and the ladies among us, especially, will vary our heels by much more than this over the course of a week. A slight change in the heel contact and foot angle should not put your Achilles tendon at greater risk of injury. 

While there are flaws in evidence based medicine and in the ability of us to accurately predict those most likely to become injured, there is  no evidence that 1/8 to 3/8 ” lifts cause ruptured Achilles tendons. Not even the slightest hint that muscles and tendons would be ruined by such a lift or adapted so much that you’ll never be the same. I do not know of any study that shows a 1/4″ lift used for a limited amount of time each day could shorten the muscle/tendon complex. There is adequate time spent in other shoes, barefoot, and even doing stretching exercises. 

Running in pain without a heel lift, or more dramatically running on a soft surfacer with a mushy, over cushioned shoe or a racing flat is far more likely to lead to chronic pain and disability. Proper orthotics are a must, along with avoiding over cushioned running shoes to prevent the tendon while functioning from being over stretched and causing eccentric working of the muscle-tendon complex . There seems to be no reason to avoid a heel lift, but it is not the be all and end all of a program to treat Achilles tendonitis. 

For more details:

Website article: Dr. Pribut on Achilles Tendon Injuries

 Previous Blog entry on Achilles Tendon and stretching

Quick Search of Textbook Comments On Heel Lifts:

I wasn’t sure what I’d find in the texts, but thought it would be interesting to see what other minds have come up with on this issue. I did not think that Noakes would agree with the heel lift, but he did. I do not know what is the scientific basis or aggregate clinical experience to imply that heel lifts are the worst possible therapy for this problem. 

Alfredson, H. and Cook, J. in Clinical Sports Medicine, 3rd Edition eds. Bruckner et. al. McGraw Hill 2006, reprinted 2007. Chapter 32 “Pain in the Achilles Region” p.  606 “A heel lift worn inside both shoes (0.5 – 1.0 cm, .25-0.5 “) is a good practical way of unloading the region. 

Alfredson is famous for his self termed “painful” eccentric stretching for non-insertional Achilles tendinopathy. He has published numerous articles on Achilles tendon problems and on the treatment of them. I am not convinced that eccentric stretching is appropriate in as many cases it is recommended. If you find something isn’t working, including the eccentric work is not helping, you need to change the approach. Measurements have shown that the calf is often weak in eccentric strength when one has Achilles tendonitis. One approach is to work on strengthening that (which can be painful). The other is to diminish the pain by lessening stresses which add to the eccentric contraction strength required. Both approaches and sometimes a combination may be appropriate for different patients and at different times for a specific patient.  I continue  to read Alfredson’s  articles with interest. 

Bradshaw, C. and Hislop, M. in Clinical Sports Medicine, 3rd Edition eds. Bruckner et. al. McGraw Hill 2006, reprinted 2007. Chapter 31 “Calf Pain” Since the calf includes the muscles which create the Achilles tendon, we’ll look at comments in this chapter also. “A heel raise should be used on the injured and uninjured side”. 

Title, C. and Schon, L. “Achilles tendon disorders including tendinosis and tears” in Baxter’s The Foot and Ankle In Sport, Second Edition. Mosby Elsevier. Eds. Porter, D. and Schon, L. 2008. “The initial treatment for Achilles tendinitis is nonoperative. The majority of symptoms respond to rest; activity modification; improved training techniques; stretching and at times, shoe modifications and heel lifts. Initial treatment should include …At times, a heel lift (one fourth to three eights inch)….”

Noakes “The Lore of Running, Fourth Edition”  Human Kinetics Press. 2003. Noakes feels a shoe with a heel height of higher than 12 – 15 mm and says “most authorities agree that a 7 to 15 mm heel-raise should be added to the running shoes”.

Achilles tendinitis prevention and recovery are issues faced by many runners. As anyone knows who has spent time on my web site, I am not a fan of excessive stretching for this problem. In individuals who are experiencing pain, I advise against the stair stretch, particularly if you’ve been trying it already for 6 weeks or more and found only more pain, and no improvement. In early cases of pain, I like to restrict stretching, than  graduate to the wall stretch, and then the wall stretch with a bent knee.

Roxanne Darling of Beachwalks with Rox does an excellent job of demonstrating a variety of stretches from the hard to the easy. For those without pain, you may carefully follow Rox’s example of the stair stretch if you’d like. If you have pain, skip that one for now and start with the straight leg, wall stretch and about 3 weeks – 4 weeks later add the bent knee portion. Read the article on Achilles Tendonitis (and Achilles Tendinopathy). A small portion of that article is summarized below. In the meantime, if you need a little downtime and some chilling, visit Beachwalks With Rox for words of wisdom, thought and relaxation.

Stretching With Rox

Achilles Tendonitis / Achilles Tendinopathy Brief Summary of Treatment

Full Text (Achilles Tendonitis)

Exercises to Avoid
Excessive stretching is not good for your Achilles tendon. The stretch that I most often recommend is the “wall stretch”. I do not recommend the “stair stretch”, the “incline stretch”, or the “put a towel around your feet and pull up until it hurts stretch”. If any of these are working for you, that’s great, you don’t need any advice. In most cases, for the patients I see, these stretches put too much tension on the already tender achilles tendon. Contracting the muscle when it is in a stretched position, as initial therapy of an injured achilles tendon is not a good thing. However, as seen in Rox’s video, she demonstrates some super stretches, and if you are not in acutely painful phase, you may cautiously give them a go. But, if you have found the stair stretches to be painful and counter productive, skip them, and look at the others.

Treatment Outline:

Relative rest
Cut back mileage
Lower intensity
Avoid hills, speedwork, plyometrics

Avoid over-stretching
Gentle stretch after warm-up
Start with Straight leg calf stretch, build up much later to bent leg, consider eccentric stretch later.
Ice Massage 10 to 20 minutes after exercise

NSAIDs (some recommend avoiding NSAIDS)
– Alleve, Motrin, etc. 10 – 14 days.

Check Running Shoes
- Replace if heel is worn
-Replace if excessive heel shock absorption (soft air sole cushion, excessive gel shock absorption)
Replace if shoe is excessively stiff at the “break point” (ball of foot).
Consider using a “heel lift”

Physical Therapy Modalities
HVGS (electrical stimulation)
Ultrasound
Exercise instruction: Strength and flexibility

Current Concepts of Achilles Tendonitis and Achilles Tendinopathy

While Achilles tendon problems are widespread, the terminology used to describe them is often inaccurate and is undergoing a significant transition. First to be precise we must consider where along the course of the tendon does the problem exist. This may be in one of three main areas:

1. Insertion
2. Musculo-tendinous Juncture
3. Non-insertional (main body of tendon)

While the term that most people use and that most individuals will search for on the web is “tendonitis”, most Achilles tendon problems could better be called a tendinopathy and more specifically a tendinosis and are a non-inflammatory problem of the tendon. Inflammatory cells are not found on microscopic examination.

Clinically there may be two differing entities in acute achilles tendinopathy:

Peritendonitis

o Inflammation in the tissue surrounding the tendon
o Often 2 – 6 cm above insertion

o Possible crepitus with long standing injury (paratenon with fibrin exudate)
o In chronic tendinopathy approximately 20% of the injured peritendinous area are scar forming myofibroblast cells.

Tendinosis
o Impairment of circulation with resulting damage to tendon structure
o Focal areas of tendon degeneration

Much future research and better understanding of these injuries is needed. In spite of the vagaries of scientific understanding of these entities a successful approach using training modification, stretching, strengthening and appropriate return to exercise may be undertaken. At this time there are few significant clinical studies with valid results for treatment. There is often disagreement on approach and much is likely to be changed in the future. At this point treatment and treatment recommendations for this problem remain an art practiced with varying degrees of success. When evaluating new research, it is hard to recommend major paradigm changes in thought and recommendations based on studies of fewer then 20 cases or even 50 cases.