Protocols for
Posterior Tibial Tendon Dysfunction &
Achilles Tendinosis
Tara Bries, PT
Non-Operative Protocol for
Posterior Tibialis Tendon
Dysfunction
Based on research by Alvarez et al. (2006) entitled
“Stage I and II Posterior Tibial Tendon Dysfunction
Treated by a Structured Nonoperative Management
Protocol: An Orthosis & Exercise Program”
We were using at UIHC as early as 2003 because of Dr.
Charles Saltzman who is one of the co-authors.
Alvarez et al (2006)
Subjects
47 (37 female, 10 male)consecutive patients with stage I
or II posterior tibial tendon dysfunction
Inclusion criteria
Presence of a palpable & painful posterior tibial tendon, with
or without swelling
Movement of the tendon with passive and active NWB clinical
examination
Clinical strength deficit
Difficulty performing or inability to perform a single-support
heel rise (SSHR) test.
Passively correctable deformities or no hindfoot deformity
with standing
Alvarez et al (2006) cont.
Treatment
Orthotics
Short articulated ankle-foot orthosis (SAAFO): 33 patients
PTT pain present for more than 3 months
Unable to perform SSHR or ambulate more than one block
Foot orthosis (FO): 14 patients
PTT pain present for less than 3 months
Able to perform at least one SSHR & could walk more than one
block
Switched from SAAFO to FO when their strengths were within
10-15% of contralateral side & pain had subsided.
Alvarez et al (2006) cont.
Rehabilitation
Pretreatment Phase
HEP initiated consisting of sole-to sole exercises
25 reps/set, starting at 4 sets/day increasing to 12 sets by 10-14 days
Once 12 sets/day reached, combine sets until could easily do 300 at one
setting (taking 3-5 minutes)
Phase I
Patient Education
Decrease to ADLs for those unable to walk 1 block w/o pain
Swimming/biking permitted
Ice up to every 2 hours
No whirlpools, Epsom salt baths or heat
NSAIDS but no steroid injections
HEP
Red t-band inversion & eversion with controlled eccentric return
Begin 200 reps, 1-2 times per day
Alvarez et al (2006) cont.
Phase II
Isokinetic workout using Cybex, Biodex or Kincom
Inversion & Eversion, start at 200 reps/session, increased to 800
reps/session
Heel cord stretching
Gastrocnemius on slant board, 30 seconds x 3 sets
SSHR
Begin with double-support-heel-rise(DSHR) & progress to SSHR
with UE for support & eccentric control down (goal 50 SSHR)
BAPS board
CW & CCW 5 positions w/ 20 reps each (goal 200 reps ea total)
Toe Ambulation
Start 25-30 feet, goal of 150 feet
Progress HEP
Increase t-band resistance with goal of 200 reps with blue
Alvarez et al (2006) cont.
Phase III
Re-evaluation with isokinetic strength eval,
assessment of SSHR for 50 reps & assessment of toe
walk for distance
If subjective & objective progress: Phase II
continued with greater intensity for 4 more visits &
eval repeated
Treatment considered to have failed if plateau
reached, phase III couldn’t be passed or minimal
improvement was noted. These patients were
offered operative treatment.
Alvarez et al (2006) cont.
Results
42/47 (89%)patients were satisfied with their treatment
outcomes
though 3 of these were classified as treatment failures d/t
persistent tenderness, required bracing or had pain with
toe walking
5/47 (11%) had operative reconstruction
After a median of 10 PT visits during average of 4 months,
most patients had minimal or no pain, could walk on tip toes,
were not limited by walking distance & could perform a
painless SSHR. Orthotic devices generally became
unnecessary as symptoms & activity approached normal.
Why high-repetition exercise
program?
To train the muscles in an aerobic manner
for long-term endurance.
Low-rep with strong resistance trains
muscles anaerobically which is not
consistent with normal ankle function with
walking.
More Recent Research on PTTD
In 2009, Kulig et al published “Nonsurgical
Management of Posterior Tibial Tendon
Dysfunction with Orthoses & Resistive Exercise: A
Randomized Controlled Trial” in Physical Therapy
Journal.
1
st
RCT reporting on effectiveness of orthoses &
tibialis posterior tendon-specific exercise in the
management of PTTD.
Kulig et al (2009) cont.
36 adults with stage I or II PTTD were randomly
assigned to 1 of 3 groups
Orthoses wear & stretching (O group)
Orthoses wear, stretching & concentric PRE (OC group)
Orthoses wear, stretching & eccentric PRE (OE group)
Pre & Post intervention data were collected
Foot Functional Index
Distance traveled in 5-Minute Walk Test
Pain immediately after 5-Minute Walk Test
Kulig et al (2009) cont.
Results
Foot Functional Index scores (total, pain & disability)
decreased in all groups after the intervention
OE group demonstrated the most improvements in
each subcategory
O group demonstrated least improvement
Pain immediately after the 5-Minute Walk Test was
significantly reduced across all groups after the
intervention.
Kulig et al (2009) cont.
Conclusion
People with Stage I & II PTTD benefited from a program
of orthoses wear & stretching
Eccentric & Concentric exercises further reduced pain &
improved perceptions of function
OE group tolerated greater loading after intervention
Limitation
They used an exercise device (TibPost Loader) for OC &
OE groups that resisted horizontal foot adduction
Kulig TibPost Loader
Eccentric Strengthening for Chronic
Achilles Tendinosis
Protocol that I’ve been using since I was at UIHC was
based on the Alfredson et al, (1998) study out of
Sweden
This appears to be one of the 1
st
controlled studies on
eccentric calf muscle training in patients with Achilles
tendinopathies.
Based on resent studies (2013 & 2014), they are still using
Alfredson’s study as the “gold standard” that other
protocols are being tested against.
Alfredson et al (1998)
Subjects
30 recreational runners with pain preventing running
Chronic Achilles Tendinosis (2-6 cm above insertion)
Failed conventional treatment (rest, NSAIDs, changes in
footwear/orthoses, PT & “ordinary training programs”
All selected for surgical treatment, but 15 underwent
eccentric calf muscle training program while waiting for
surgery.
Alfredson et al (1998) cont.
Group 1: 15 patients (12 men, 3 women)
Age 44.3 +/- 7 yrs
12 wk heavy load eccentric program
Group 2: 15 patients (11 men, 4 women)
Age 39.6 +/- 7.9 yrs
Treated surgically
This group had longer duration of symptoms
only because waiting time for surgery at
their clinic was 6-12 months
Alfredson et al (1998) cont.
Variables
Pain scale: VAS (0-100) during activity (running)
Concentric & eccentric calf muscle strength (Biodex
Isokinetic Dynamometer)
Group 1: evaluated week 0 & 12
Group 2: evaluted week 0 & 24
Alfredson et al (1998)
Results
Non-surgical patients
Activity levels: all returned to pre-injury activity levels by wk 12
Pain scale: from 81.2 to 4.8
Eccentric & concentric strength: returned to normal by wk 12
Follow up: (unpublished) at 2 years: 14 patients asymptomatic, 1
required surgery; further unpublished studies reported that out
of 66 patients, only 4 (6%) required surgery.
Surgical patients
Activity levels: all returned to pre-injury running levels by wk 24
Pain scale: from 71.8 to 21.2
Eccentric & concentric strength : significant deficits at wk 24
Time needed to regain full strength was 6 months
Alfredson’s Eccentric Program
2 times daily, 7 days/week for 12 weeks
Calf muscle was eccentrically loaded off step both with
the knee straight & (to maximize soleus activation,) also
with knee bent
Each exercise: 3 sets of 15 repetitions
Muscle soreness is expected, pain should not be
disabling
When they could perform without pain, they could
increase load by adding weight in backpack or using
weight machine
Why Eccentrics?
Exact mechanism is not completely clear
Stimulating mechanoreceptors
Increase collagen production
Alter or reverse tendinosis cycle
Improves tensile strength of tendon
Improves collagen alignment
Stimulates cross-link formation
Strong stretch
Lengthens muscle-tendon unit
Reduces load during dorsiflexion
Recent Achilles Tendinopathy Research
Alfredson’s Eccentric Program is still the comparison!
Stasinopoulos & Manias in 2013 compared eccentric &
static exercises as proposed by Stanish (who was 1
st
to
propose this in 1986) to Alfredson’s protocol.
Alfredson’s protocol was superior to Stanish model to reduce
pain & improve function at end of treatment & 6 mo f/u
Stevens & Tan in JOSPT February 2014 compared
Alfredson Protocol with a Lower Repetition-Volume
Protocol in a RCT
There was NO statistically significant difference in change
scores between Alfredson group & do-as-tolerated group for
VISA-A & VAS pain scores at end of 6 week intervention
Recent AT Research cont.
Ram et al in 2013 in Canada had 20 patients perform
Alfredson protocol with surprisingly low patient
satisfaction (only 2 were satisfied) despite symptom
improvement
This was may be due to a more varied patient population
Habets & van Cingel in February 2014 published “Eccentric
exercise training in chronic mid-portion Achilles
tendinopathy: A systematic review on different protocols
“Strong evidence for Alfredson exercise protocol”
As in every review, conclusion is “ further research comparing
the content of different exercise protocols is warranted!”
References
Alvarez R, Marini A, Schmitt C, Saltzman C. Stage I and II Posterior Tibial Tendon
Dysfunction Treated by a Structured Nonoperative Management Protocol: An Orthosis
and Exercise Program. Foot & Ankle International 2006:2-8.
Kulig K, Reischl S, Pomrantz A, Burnfield J, Mais-Requejo S, Thordarson D, Smith R.
Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and
Resistive Exercise: A Randomized Controlled Trial. Physical Therapy 2009: 89:26-37.
Alfredson H, Pietila T, Jonsson P, Lorentson R. Heavy-load eccentric calf muscle training
for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998: 26: 360-366.
Stasinopoulos D, Manias P. Comparing two eccentric exercise programmes for the
management of Achilles tendinopathy. A pilot trial. Journal of Bodywork & Movement
Therapies 2013: 17: 309-315
Stevens M, Tan CW. Effectiveness of the Alfredson protocol compared with a lower
repetition-volume protocol for mid-portion Achilles tendinopathy: a randomized
controlled trial. J Orthop Sports Phys Ther. 2014:44:45-57.
Ram R, Meeuwisse W, Patel C, Wiseman D, Wiley JP. The Limited Effectiveness of a
Home-Based Eccentric Training for Treatment of Achilles Tendinopathy. Clin Invest Med
2013: 36 (4): E197-E206.
Habets B, van Cingel REH. Eccentric exercise training in chronic mid-portion Achilles
tendinopathy: A systematic review on different protocols. Scand J Med Sci Sports 2014: 1-
13.
