The Treatment of Achilles Tendonitis Using Therapeutic Laser
Many runners have experienced it—a burning pain in the heel caused by inflammation of the Achilles tendon. While conventional treatment relies on rest, ice packs and medications, recent studies have found that combining low-level laser therapy with these modalities can produce better results. William J. Kneebone, CRNA, DC, CNC, DIHom of Practical Pain Management discusses recent studies into this treatment and also offers advice on how treatment can be delivered.
Achilles tendonitis is a commonly occurring painful condition. It affects about 11% of all running injuries. Achilles tendonitis can be quite debilitating, preventing the sufferer from running and causing great difficulty walking, especially when acute. Achilles tendonitis tends to occur more in middle-aged recreational athletes than other age groups. The Achilles tendons, like other body tissues become more rigid, less flexible, and more susceptible to injury as we age. It is usually caused from overuse and associated with over-pronation of the foot or changes in footwear or running routine.
The primary presenting symptom is posterior heel pain. Pain is usually worse when first ambulating following period of inactivity. Diagnosis is made primarily from the symptom history and x-rays are of little value. Palpatory exam will help locate the exact area of involvement.1
Repeated episodes of Achilles tendonitis can lead to the development of Achilles tendinosis, a chronic degenerative condition of the tendon that can lead to tendon tearing or rupture which usually requires surgical repair.
Conventional treatment usually consists of RICE self-care (rest, ice packs, compression, and elevation) and non-steroidal anti-inflammatory medication along with stretching and exercises.2
Studies of Tendinopathy Laser Treatment
Therapeutic laser has been shown to produce promising results based on the data obtained from several published research studies.
Tumitty et al3 reviewed twenty-five controlled clinical trials of the treatment of tendinopathy with low level laser therapy. There were twelve positive studies and thirteen inconclusive studies. Effective dosages were apparent in the positive studies and absent in the inconclusive studies. In a lateral epicondylitis study, the laser group demonstrated a 9.59 kg higher grip strength than control and a decrease in visual analogue scale of 13.6 mm. They concluded that therapeutic laser can potentially be effective in treating tendinopathy when recommended dosages are used.3
Bjordal and Couppe4 performed a randomized controlled clinical trial for tendonitis. They found eight clinical trials that met the selection criteria out of seventy-seven. They, like Tumitty, found that adequate dosage was essential to achieving positive clinical results.
Bjordal and Couppe also conducted a separate review5 of four laboratory trials that investigated optimal doses for collagen inflammation reduction. They found that optimal doses were 38 joules/cm² with an intensity of 210 mW/cm². They also reviewed ten laboratory studies that investigated collagen proliferation and identified the optimal dose for stimulation of tendon regeneration as being from 0.24.0 joules/cm² and 210 mW/cm² intensity.5
Bjordal et al, in yet another study,6 observed the results of therapeutic laser in seven patients with bilateral Achilles tendonitis (14 tendons) who had aggravated symptoms after pain-inducing activity. A 904 nm GaAs laser was used to deliver 1.8 joules at each of three points along the Achilles tendon. Laser or placebo was applied randomly to each Achilles tendon with both the patients and therapists blinded. Inflammation was examined by minimally-invasive microdialysis for measuring PGE2 in peritendinous tissue, as well as Doppler ultrasound measurement of peri- and intra-tendinous blood flow, pressure algometry, and the single hop test. PGE2 was significantly reduced at 75, 90, and 105 minutes after active laser therapy as compared to the pre-treatment group or placebo group.6
Stergioulas et al13 observed enhanced outcomes in twenty subjects (twelve male and eight female) who received both GaAlAs laser and concentric exercises when compared to a group of twenty subjects (thirteen males and seven females) that received eccentric exercise and placebo laser treatment. Age, height, symptom duration, quantity of active ankle dorsiflexion, and weight was statistically similar. Treatment consisted of twelve sessions over an eight-week period in a blinded fashion. Six points were treated along the painful Achilles tendon in all subjects by the same therapist. An 820 nm wavelength infrared laser was used with an intensity of 0.9 joules/cm² per point. There was no statistical difference in perceived pain at the start of the study but a significant difference was reported at 4, 8, and 12 weeks. Secondary measure such as tenderness to palpation, crepitation, morning stiffness and active dorsiflexion also improved.13
Therapeutic laser can be effectively applied to injured Achilles tendons locally to the injury site or systemically (in-directly) to spinal nerve roots, lymph nodes, and/or acu-reflex points.14
There appears to be a synergistic effect when all of the above techniques are used together. Together, they seem to have an effect greater than each alone.
The first technique is to irradiate the primary lymph node that drains the area of complaint. Example: The lymphatic duct drains the right arm and shoulder. The inguinal lymph node would be irradiated in the case of Achilles tendonitis as it drains the lower extremity.
The second technique is laserpuncture stimulation. This may be applied to body acupuncture points, ear acupuncture points, or hand acupuncture points. It is convenient to start with body acupoints. You can progress to auriculotherapy or Korean hand therapy points if stimulation of the body points do not provide the desired effect.
The third technique is irradiation of the spinal nerve root that supplies the area of complaint, the cerebellar area, and the contra-lateral cortex. The area over the L5 nerve root on the side of involvement should be irradiated followed by irradiation over the cerebellar area on the side of involvement and finally the area over the opposite temporal cortex.
The fourth technique is local treatment to the area of complaint. Start by palpating the region in order to locate the area of maximum tenderness and initiate irradiation there followed by irradiation of all the additional tender points.
Evidence supports the proposition that therapeutic laser be utilized in the treatment and rehabilitation of Achilles tendonitis alone or in combination with more conventional therapies.
1. http://orthopedics.about.com/cs/ankleproblems/a/achilles.htm Accessed 5/10/10.
2. http://www.mayoclinic.com/health/achillestendinitis/DS00737/DSECTION=treatments%2Dand%2Ddrugs. Accessed 5/10/10.
3. Tumitty S, Munn J, Hurley DA, Basford JR, and Baxter GD. Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomed Laser Surg. Feb 2010. 28(1): 3-16.
4. Bjordal JM and Coupe C. Low level laser therapy can be effective for tendonitis: a meta-analysis. University of Bergan, Dept. of Physiotherapy Science. Bergan, Norway. 2008.
5. Ibid. ref 4.
13. Stergioulas A, Stergioula M, Aarskog R, Lopes-Martins RA, and Bjordal JM. Effects of low- level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles tendinopathy. Am J Sports Med. 2008.; 36: 881-887.
14. Tuner J and Hode L. The laser therapy handbook. Prima Book AG. Grangesberg, Sweden. 2007. p 84.
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