Author Names
Jayaseelan, D. Kecman, M. Alcorn, D. Sault, J
Reviewer Name
Miranda Cano- SPT, LAT, ATC
Reviewer Affiliation(s)
Duke Doctor of Physical Therapy Division
Paper Abstract
Chronic Achilles tendinopathy (AT) is an overuse condition seen among runners. Eccentric exercise can decrease pain and improve function for those with chronic degenerative tendon changes; however, some individuals have continued pain requiring additional intervention. While joint mobilization and manipulation has not been studied in the management in Achilles tendinopathy, other chronic tendon dysfunction, such as lateral epicondylalgia, has responded well to manual therapy (MT). Three runners were seen in physical therapy (PT) for chronic AT. They were prescribed eccentric loading exercises and calf stretching. Joint mobilization and manipulation was implemented to improve foot and ankle mobility, decrease pain, and improve function. Immediate within-session changes in pain, heel raise repetitions, and pressure pain thresholds (PPT) were noted following joint-directed MT in each patient. Each patient improved in self-reported function on the Achilles tendon specific Victorian Institute for Sport Assessment questionnaire (VISA-A), pain levels, PPT, joint mobility, ankle motion, and single-leg heel raises at discharge and 9-month follow-up. The addition of MT directed at local and remote sites may enhance the rehabilitation of patients with AT. Further research is necessary to determine the efficacy of adding joint mobilization to standard care for AT.
NIH Risk of Bias Tool
Quality Assessment Tool for Case Series Studies
- Was the study question or objective clearly stated?
- Yes
- Was the study population clearly and fully described, including a case definition?
- Yes
- Were the cases consecutive?
- Yes
- Were the subjects comparable?
- Yes
- Was the intervention clearly described?
- Yes
- Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?
- Yes
- Was the length of follow-up adequate?
- Yes
- Were the statistical methods well-described?
- Cannot Determine, Not Recorded, Not Applicable
- Were the results well-described?
- Yes
Key Finding #1
For patients with chronic degenerative tendon changes, eccentric exercises have been shown to decrease pain and show improvements in functions, but those who have symptoms lasting for a longer period of time may require additional treatment.
Key Finding #2
Abnormal motion in the ankle or abnormal joint mobility can play a role in developing Achilles tendinopathy and causing it to be a chronic issue.
Key Finding #3
Joint mobilization and manipulation that were introduced along with eccentric exercises for patients with Achilles tendinopathy were seen to have immediate improvements in function and symptoms that lasted past discharge.
Key Finding #4
Manual therapy has been seen to be safe and effective when treating chronic tendinopathies.
Please provide your summary of the paper
This case series examined joint mobilization and manipulation in three runners with chronic Achilles tendinopathy. Joint mobilization and manipulation were performed locally and at nearby sites where immediate improvements were seen in pain levels, single leg calf raises and in PPT readings. At discharge, all three patients significantly improved their VISA-A questionnaire scores and their pain pressure threshold values as well as surpassed the MCID for the NPRS and GROC. Additionally, improvements in symptoms and function were maintained for at least nine months when reported in a follow up email.
Given that only three patients participated in this case series, these results cannot be easily generalized. With a lack of a control group and a non-experimental study design, it is possible that the joint thrust manipulation and non-thrust manipulation were not the only factors contributing to success. However, each patient did show immediate improvement in pain and function following this treatment which suggests instant benefit and positive reported outcomes over time.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Based on the results of this study, it has been found that tendinopathies can benefit from more than eccentric exercise. Given that patients with Achilles tendinopathy have seen improvements with manual therapy techniques, clinicians should incorporate both eccentric exercises and manual techniques such as joint mobilization and manipulation. It is important to perform an initial detailed examination on the patient in order to get a full picture of the patient and properly address any deficits in mobility that they may have which could be a root cause of their tendinopathy.
