Novel Physical Therapy Protocol Results in Increased Compressive Strain and Improved Outcomes in Insertional

Achilles Tendinopathy

Meghan Kelly MD PhD, Mary A Bucklin, Ruth Chimenti PhD, Rachel

E Olsen, Michael S Richards PhD, John P Ketz MD, Mark R Buckley

PhD, A. Samuel Flemister MD

University of Rochester School of Medicine Department of Orthopaedics and

Rehabilitation, Department of Surgery, Department of Biomedical Engineering

Disclosures

 The authors state that there are no relevant disclosures related to this

presentation

Insertional Achilles Tendinopathy (IAT)

• Affects approximately 5% of the

general population

•  Increased prevalence in dancers

(10%) and runners (18%)

• Less common than midsubstance

Achilles tendinopathy

•  However less responsive to non-

surgical treatment

• Prior studies have examined treatment

with:

•  Heel lifts, PRP injections,

extracorporal shockwave therapy

and PT

Methods

• Patients with IAT recruited from 2

F&A clinics

• Underwent baseline assessment for

VISA-A and FAAM scores

•  Subset underwent ultrasound

elastography measurements (see

next slide)

• PT protocol (12 weeks)

•  Mix of isometric/eccentric exercises

• Post-protocol – repeat ultrasound

measurements and VISA-A/FAAM

assessment

Methods: Ultrasound Elastography

• Static and Dynamic assessment of

tissues •  Captures movements of tendon in the

axial and transverse axis

•  Can measure vascular flow (Richards et

al 2013)

• Use in disease states •  IAT patients - decreased compressive

and tensile strain (Chimenti et al 2017)

•  Compressive strain – force

transverse to the tendon fibers

•  Tensile strain – axial force in line

with the tendon fibers

Results: Patient Demographics

• No significant difference between the patient groups who

underwent outcomes only analysis and the subset that

underwent ultrasound elastography and outcomes

measurements

Outcomes measures

• 20/24 patients demonstrated a clinically significant

improvement in outcomes scores

VISA-A FAAM

Regional Differences

Heel lowering

Partial Squat

Compressive Strain Tensile Strain

supe

rficial

deep

-8

-6

-4

-2

0C

ompr

essi

ve S

train

(%)

p=0.0041

supe

rficial

deep

0

1

2

3

Tens

ile S

train

(%)

p=0.038

supe

rficial

deep

-25

-20

-15

-10

-5

0

Com

pres

sive

Stra

in (%

)

p=0.0382

supe

rficial

deep

0

2

4

6

8

10

Tens

ile S

train

(%)

p=0.17

visit 1

visit 2

-15

-10

-5

0

*

Com

pres

sive

Stra

in (%

)

visit 1

visit 2

-5

-4

-3

-2

-1

0

*

Com

pres

sive

Stra

in (%

)

Effect of Physical Therapy Heel lowering Partial Squat

Tensile Strain - deep

visit 1

visit 2

0.0

0.5

1.0

1.5

Tens

ile S

train

(%)

*

visit 1

visit 2

0

2

4

6

Tens

ile S

train

(%)

Compressive Strain - superficial

Conclusions

 IAT patients • Increased transverse compressive strain in the deep Achilles

tendon

• Decreased axial tensile strain in the deep Achilles tendon

 Physical therapy protocol • Increased transverse compressive strain – superficial portion

• Decreased axial tensile strain – deep portion

• 83% demonstrated improved outcomes measures

 Chimenti, RL; Bucklin, M; Kelly, M, et al.: Insertional Achilles tendinopathy associated with altered

transverse compressive and axial tensile strain during ankle dorsiflexion. J Orthop Res. 35(4):910-915, 2017.

 Chimenti, RL; Flemister, AS; Ketz, J, et al.: Ultrasound strain mapping of Achilles tendon compressive

strain patterns during dorsiflexion. J Biomech. 49: 39-44, 2016.

  Fahlstrom, M; Jonsson, P; Lorentzon, R; Alfredson, H: Chronic Achilles tendon pain treated with eccentric

calf-muscle training. Knee Surg Sports Traumatol Arthrosc. 11: 327-333, 2003

  Irwin, TA: Current concepts review: insertional achilles tendinopathy. Foot Ankle Int. 31: 933-939, 2010.

  Iversen, JV; Bartels, EM; Langberg, H: The victorian institute of sports assessment - achilles questionnaire

(visa-a) - a reliable tool for measuring achilles tendinopathy. Int J Sports Phys Ther. 7: 76-84, 2012.

  Jonsson, P; Alfredson, H; Sunding, K; Fahlstrom, M; Cook, J: New regimen for eccentric calf-muscle

training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. Br J Sports Med. 42:

746-749, 2008.

 Kedia, M; Williams, M; Jain, L, et al.: The effects of conventional physical therapy and eccentric

strengthening for insertional achilles tendinopathy. Int J Sports Phys Ther. 9: 488-497, 2014.

 Martin, RL; Irrgang, JJ; Burdett, RG; Conti, SF; Van Swearingen, JM: Evidence of validity for the Foot

and Ankle Ability Measure (FAAM). Foot Ankle Int. 26: 968-983, 2005.

 McCormack, J; Underwood, F; Slaven, E; Cappaert, T: The Minimum Clinically Important Difference on the

Visa-a and Lefs for Patients with Insertional Achilles Tendinopathy. Int J Sports Phys Ther. 10: 639-644, 2015.

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