Manual therapy and eccentric exercise in the management of Achilles tendinopathy

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.

Level of evidence: Case series. Therapy, Level 4.

Keywords: Ankle; Manipulation; Mobilization; Running injury; Tendon.

Figure 1

Talocrural joint long-axis thrust manipulation. With the patient in supine, the therapist grasps the plantar aspect of the foot with his thumbs, while grasping the talus with the ring fingers. Talocrural distraction is added, while simultaneously dorsiflexing the ankle. Ankle inversion and eversion is added, as needed, to increase tissue resistance. A long-axis thrust is performed. Source: Author

Figure 2

Subtalar joint lateral glide mobilization. With the patient sidelying on the involved side, the therapist stabilizes the distal tibia and fibula with one hand. With the other hand, the therapist grasps the calcaneus, distal to the talus, and provides a mobilization force perpendicular to the ground. Source: Author

Figure 3

Talocrural joint weight bearing mobilization with movement (anterior to posterior glide). The therapist places the web space of the application hand over the anterior aspect of the talus, while the other hand is placed proximally on the posterior aspect of the tibia. The patient lunges forward to the involved leg, while the therapist applies a posteriorly directed force to stabilize the talus. The opposite hand can guide the tibia into anterior translation as needed. A mobilization belt can also be applied to help guide motion. Source: Author