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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.
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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.
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