Effectiveness of acupuncture treatment and eccentric overloading exercises for chronic Achilles tendinopathy- A case study
Background: Much has been written in the scientific literature about the conservative management of Achilles tendinopathy (AT). However, the effects of acupuncture treatment in combination with eccentric calf loading exercises appeared not to have been extensively researched.
Objective: The objective of this study is to describe the subjective pain and functional improvements of a patient with chronic Achilles tendinopathy following a treatment plan incorporating acupuncture and eccentric calf muscle stretching exercises using a single case study
Methods: A single case report on a 35 year-old female runner with two months history of right ankle pain, at the back of the heel following a 10km twice weekly to three times a week run. The main findings of the subjective and objective assessments were functional limitation due to pain when running, decrease active and passive range of movements in dorsiflexion and eversion movements in the right ankle and thickening of the right Tendoachilles. The treatment approach consisted of acupuncture with manual stimulation, and eccentric calf training, and ankle stretching exercises. Patient was treated twice weekly for six weeks. Outcome measures included Verbal pain rating scale (VRS), Active and passive range of motion, Patient specific functional scale and a return to activities of daily living (ADLs). Assessments were carried out at the beginning of treatment, after six week of treatment and at 1 month and 4 month follow up.
Results: The outcome of the study showed improvement with pain reduction with a score of 7/10 on VRS in the first week to 0/10 after 4 months follow up. The results also showed increase in the active and passive range of movements in dorsiflexion and eversion from the first week of treatment (active dorsiflexion= 200, passive dorsiflexion =220, active eversion = 100and passive eversion=150) to full recovery at follow up periods. Patient was able to run at least 10 km twice a week without pain and standing up to walk from a prolonged sitting position was without pain.
Conclusion: The outcome of this study has shown that acupuncture combined with eccentric calf muscle loading may be effective in the management of Achilles tendinopathy.
Keywords: Achilles tendinopathy, Acupuncture, Eccentric overloading exercises
ROMPE JD, NAFE B, FURIA, JP and MAFFULLI, N (2007). Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med. 2007 Mar;35(3):374–83.
PETERSEN W, WELP R and ROSENBAUM D (2007). Chronic Achilles tendinopathy: a prospective randomized study comparing the therapeutic effect of eccentric training, then AirHeel brace, and a combination of both. Am J Sports Med. (10):1659–67
SCOTT A, HUISMAN E, KHAN K.(2011) Conservative treatment of chronic Achilles tendinopathy. CMAJ. 12;183(10):1159–65
HOLMES GB and LIN J. (2006) Etiologic factors associated with symptomatic achilles tendinopathy. Foot Ankle Int.;27(11):952–9.
ABATE M., GRAVARE-SILBERNAGEL K., SILJEHOLM C., DI LORIO A., De AMICIS D., SALINI V., WERNER S., and PAGANELLI, R. (2009) Pathogenesis of tendonopathies: inflammation of degeneration? Arthritis research & therapy. 11, 235
ALFREDSON H, PIETILA T., JONSON P., LORENTZON R., (2007). Heavy-load eccentric calf muscle training for the treatment of chronic achilles tendinosis. Am J Sports Med. 26(3):360–6.
ACKERMAMN P., SALO PT., and HART DA (2009). Neuronal pathways in tendon healing. Front Bioscience. 14 (1), 5165-8
KUBO K., YAJIMA H., TAKAYAMA M., IKEBUKURO T., MIZOGUCHI H., and TAKAKURA N. (2010) Effects of acupuncture and heating on blood volume and oxygen saturation of human Achilles tendon in vivo. European journal of applied physiology. 10(9), 545-550
van STERKENBURG MN and van DIJK CN. Mid-portion Achilles tendinopathy (2011): why painful? An evidence-based philosophy. Knee Surg Sports Traumatol Arthrosc. 19(8):1367–75
McNEILLY CM, BANES AJ, BENJAMIN M, (2013). Tendon cells in vivo form a three dimensional network of cell processes linked by gap junctions. J Anat 1996; 189(Pt 3 Genetics & performance, SASMA Congress Wild Coast, South Africa 24–27:593–600
MAGNUSSEN RA, DUNN WR and THOMSON AB. Nonoperative treatment of midportion achilles tendinopathy (2009): A systematic review. Clin J Sport Med:19(1):54– 64.
CYRIAX JH (993) Orthopaedic medicine 2nd Edition Butterworth and Heinemann 113-117.
FU, S., Rolf C., CHEUK Y., LUI P and CHAN K. (2010) Deciphering the pathogenesis of tendinopathy: a three-stages process. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology. 2, 30.
OHBERG L and ALFREDSON H (2007). Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion achilles tendinosis? Knee Surg Sports Traumatol Arthrosc. ;12(5):465–70
KINGMA JJ., de KNIKKER R., WITTINK HM and TAKKEN T (2007). Eccentric overload training in patients with chronic achilles tendinopathy: A systematic review. Br J Sports Med. ;41(6)
COOK JL. and PURDAM CR. (2008) Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine. 43, 409-416
BRADNAM, L. (2007). A proposed clinical reasoning model for western acupuncture, Journal of the Acupuncture Association of Chartered Physiotherapists, 21-30.
ACKERMANN P., SALO PT., and HART DA. (2009). Neuronal pathways in tendon healing. Front Bioscience. 14 (1), 5165-8
. PAAVOLA M., KANNUS P., JARVINEN T., KHAN K., JOZSA L and JARVINEN M (2002) . Current concepts review: Achilles tendinopathy. J Bone Joint Surg.;84(11):2062–2076
MAFULLI N., WONG J and ALMMEKINDERS LC (2003). Types and epidemiology of tendinopathy. Clin J Sports Med. 22, 675-692
SALSICH GB., MUELLER MJ and SHARMAN SA ( 2000): Passive ankle stiffness in subjects with diabetes and peripheral neuropathy versus age matched comparison group. Physical Therapy 80:352-362
MUELLER MJ., DAMOND JE., DELLITO A and SINACCORE DR, (1989) Insensivity, limited joint mobility and planter ulcers in patients with diabetes mellitus. Phys Ther 69:453-462
PETTY N and MOORE A (1998), Neuromusculoskeletal examination and aseessment. A hand book for therapists Churchill Livingstone, the Bath Press:313-334
ROBERTSHAWE P (2009) Effects Of Acupuncture On Delayed-Onset Muscle Soreness Journal of the Australian Traditional-Medicine Society. 15(1), 27
CHINN L,and HERTEL J (2010). Rehabilitation of ankle and foot injuries in athletes. Clin Sports Med. ;29(1):157–67.
KNOBLOCH K, KRAEMER R, LICHTENBERG A, JAGODZINSKI M, GOSSLING T, RICHTER M, ZEICHEN J, HUFFNER T, KRETTEK C (2006). Achilles tendon and paratendon microcirculation in midportion and insertional tendinopathy in athletes. Am J Sports Med. ;34(1):92
KNOBLOCH K (2007). Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports.;17(3):298–9
Wilson M and Stacy J. Shock wave therapy for Achilles tendinopathy (2010). Curr Rev Musculoskelet Med. 26;4(1):6–10
SANDERS TG and RATHUR SK (2008). Impingement syndromes of the ankle. Magn Reson Imaging Clin N Am. ;16(1):29–38
YIM Y-K., LEE H., and Hong K-E, (2007) Electro-acupuncture at acupoint ST36 reduces inflammation and regulates immune activity in collagen-induced arthritic mice. Evidence-Based Complementary and Alternative Medicine.;4(1):51.
DEADMAN P., AL-KHAFAJI M., and Baker K (2007). A Manual of Acupuncture. 2nd edition. Oakland, Calif, USA: Journal of Chinese Medicine Publications