Interventions for treating acute and chronic Achilles tendinitis: Cochrane systematic review
Assessed as up to date: 2000/12/29
Achilles tendinitis is one of the most common of all sports injuries. There is no consensus on treatment.Objectives
To assess the effectiveness of various treatment interventions for acute and chronic Achilles tendinitis in adults.Search methods
The Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2000), Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2000), MEDLINE (1966 to December 2000), EMBASE (1980 to 2001 wk 04), CINAHL (1982 to December 2000), and reference lists of identified trials were searched.Selection criteria
Randomised or quasi-randomised trials of treatment interventions for acute and chronic Achilles tendinitis in adults. Studies focusing on pathological tendinitis were excluded. Excluded were those trials that compared different dosages of the same drug or drugs within the same class of drugs, for example different non-steroidal anti-inflammatory drugs (NSAIDs).Data collection and analysis
Three reviewers independently assessed trial quality, by use of a ten item check list, and extracted data. Requests were sent for separate data for Achilles tendinitis patients in studies within trials of mixed patient populations. Where possible, quantitative analysis and limited pooling of data were undertaken.Main results
Nine trials, involving 697 patients, met the inclusion criteria of the review. Methodological quality was adequate in most of the trials with regards to blinding but the assessment of outcome was incomplete and short-term.
There was weak but not robust evidence from three trials of a modest benefit of NSAIDs for the alleviation of acute symptoms. There was some weak evidence of no difference compared with no treatment of low dose heparin, heel pads, topical laser therapy and peritendonous steroid injection, but this could not be fully evaluated from the reports of four trials. The results of an experimental preparation of a calf-derived deproteinized haemodialysate, Actovegin, were promising but the severity of patient symptoms was questionable in the single small trial testing this comparison. The results of a comparison of glycosaminoglycan sulfate with a NSAID were inconclusive.Authors' conclusions
There is insufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate for the treatment of acute or chronic Achilles tendinitis. Further research is warranted.
McLauchlan George, Handoll Helen HG
Interventions for treating acute and chronic Achilles tendinitis
The Achilles tendon is at the back of the ankle. A swollen and painful Achilles tendon can result from a change in the type and intensity of activity. When severe, it is very painful to walk. Rest, restricted activity, drugs to relieve swelling and pain as well as wearing inserts in footwear are common treatments. Other remedies, including surgery, are used when the pain and swelling continue. The review of trials did not find enough evidence to show which methods of healing painful Achilles tendons are effective.
Implications for practice
There is insufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate for the treatment of acute or chronic Achilles tendinitis.
Implications for research
The fact that a common condition such as Achilles tendinitis has no agreed treatment suggests that none is particularly effective in changing the natural history of the condition. The lack of consensus could also result from the variety of underlying clinical entities.
Further randomised trials are necessary to help determine the most appropriate treatment for this condition. As well as adhering to good quality methodology including the allocation concealment, assessor blinding and intention to treat analysis, any such trials should include a clear definition of the condition under test. Where appropriate, at minimum such trials should stratify by acute and chronic tendinitis and conduct and present sub-group analyses of these two groups. Stratification based on previous athletic activity would probably also be beneficial. A reasonable length of follow-up (at least one year or above) is required to detect recurrence and long term outcome. Validated scoring systems for symptoms such as pain and tenderness as well as activity levels should be used. The resource implications of any interventions should be recorded. Since large sample sizes are likely to be required to provide conclusive evidence for most of the interventions in current use, multicentre trials should be considered.
Although the best treatment for Achilles tendinitis may be found to involve a combination of various therapies, it is more manageable and remains appropriate to conduct trials of individual interventions. Trials of physical interventions are often more difficult to do well compared with pharmaceutical interventions; blinding to treatment may not be possible and standardisation of interventions is often less easy to achieve. However, there is a particular need for comprehensive evaluation of commonly used physical interventions such as heel inserts, other devices aimed at the correction of malalignment, and physiotherapy including stretching and strengthening exercises. Surgical intervention for severe chronic cases also requires evaluation; any such trials should consider a longer term follow-up.Get full text at The Cochrane Library
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