The primary characterisation of chronic Achilles Tendinopathy is continuing onset of pain and dysfunction centred in one or both Achilles Tendons (1).
Chronic Achilles Tendinopathy can be very debilitating as it can cause severe pain, swelling and stiffness of the Achilles Tendon that joins your heel bone to your calf muscles. Even though tendonitis of the Achilles Tendon is often connected to sports activities, the ailment is also often found in people who do not practice sports (2).
Treatment
There are many prescriptions that can be used for Achilles Tendinopathy. There is clinical evidence to support the use of exercise in the chronic stage but the precise parameters to ensure effectiveness is not clear. Eccentric exercise is supported although some protocols use both concentric and eccentric exercises (3). Furthermore, research has shown that strength training, that is stimulated externally and is linked to a functional task, not only helps reduce tendon pain but regulates excitatory and inhibitory control of the muscle, and thus potentially tendon load (4). A popular and effective option is eccentric strength training as in the past decade, eccentric exercises have been shown to have positive effects on Achilles Tendinopathy and have become one of the main non-surgical choices of treatment for Achilles Tendinopathy (5).
There are also many adjunct therapies such as dry needling, electrotherapy, medications, injections such as Cortisone and Platelet-Rich Plasma (PRP), localised cryotherapy, and the use of deloading therapies such as anti-gravity treadmills. In this blog I am going to focus on Localised Cryotherapy, that can be used in conjunction with an eccentric gradual loading strength program.
Localised Cryotherapy
Icing and stretching are commonly deemed to be core elements of most injury management plans (6). In fact, ice is the most often applied therapeutic modality, even though there is minimal understanding regarding the actual physiological effects on soft tissue (6). However, the issues we have with ice, is its messy, can burn skin and we can’t control a consistent temperature. With Localised Cryotherapy we have no mess, can control the temperature and minimal chance of burning the skin. Localised Cryotherapy is like Whole Body Cryotherapy where nitrogen is used safely to cool the whole body for 3 minutes at around -110 to -140 degrees Celsius. However, Local Cryotherapy or Spot Cryotherapy only focusses on one area of the body in this case the Achilles Tendon where treatments last approximately 4 to 6 minutes with skin temperature maintained at around 5-7 degrees Celsius.
Studies have shown Localised Cryotherapy to be regarded as the single most useful intervention in the acute phase of Achilles Tendinopathy (7). The use of Localised Cryotherapy results in a reduction in cell metabolism and venous flow, a reduction in nerve conduction velocity, a decrease in muscle spindle activity, and a reduction of acute pain. This allowins the subject to better undertake a gradual eccentric loading strength training program, as inflamation and pain is reduced (8,9). In addition, using compression after localised cryotherapy was found to be effective at increasing further tendon oxygen saturation in patients with Achilles Tendinopathy increasing the healing process and allowing for faster recovery (9).
Conclusion
Cryotherapy can have an influence on key inflammatory events at a cellular and physiological level after an acute soft tissue injury such as Achilles Tendinopathy. Studies suggest using Localised Cryotherapy for Achilles Tendinopathy in conjunction with an eccentric gradual loading strength program will assist as an anti-inflammatory “add-on” effect, improve function and pain relief for better rehabilitation of Achilles Tendinopathy.
References
1. Miners, A. L., & Bougie, T. L. (2011). Chronic Achilles tendinopathy: a case study of treatment incorporating active and passive tissue warm-up, Graston Technique, ART, eccentric exercise, and cryotherapy. The Journal of the Canadian Chiropractic Association, 55(4), 269–279.
2. Wilson JJ, Best TM. Common overuse tendon problems: a review and recommendations for treatment. American family physician. 2005 Sep 1;72(5):811-8.
3. BC Physical Therapy Tendinopathy Task Force: Dr. Joseph Anthony, Allison Ezzat, Diana Hughes, JR Justesen, Dr. Alex Scott, Michael Yates, Alison Hoens. Achilles Tendinopathy Toolkit. A Physical Therapy Knowledge Broker project supported by: UBC Department of Physical Therapy, Physiotherapy Associaton of BC, Vancouver Coastal Research Institute and Providence Healthcare Research Institute. 2012
4. Wilson JJ, Best TM. Common overuse tendon problems: a review and recommendations for treatment. American family physician. 2005 Sep 1;72(5):811-8.
5. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes. Sports medicine. 2013 Apr 1;43(4):267-86.
6. MacAuley D, Best TM. Evidence-based sports medicine. 2nd ed. Malden, Mass: Blackwell Pub; 2007. p. 615.
7. Pankaj Sharma, Nicola Maffulli. Understanding and managing Achilles tendinopathy. British Journal of Hospital MedicineVol. 67, No. 2
8. Bélanger A. Evidence-based guide to therapeutic physical agents. Philadelphia: Lippincott Williams & Wilkins; 2002. pp. 263–98.
9. Knobloch K, Grasemann R, Spies M, Vogt PM. Midportion Achilles Tendon Microcirculation after Intermittent Combined Cryotherapy and Compression Compared with Cryotherapy Alone: A Randomized Trial. The American Journal of Sports Medicine. 2008;36(11):2128-2138.
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