ACHILLES TENDINOPATHY TREATMENT WITH TRIPLE THERAPY: A

PILOT STUDY

School of Specialities in PRM “G. d’Annunzio” University, Chieti-Pescara, Italy

R. G. BELLOMO, F. CAPOGROSSO, D. PORTO, L. DI PANCRAZIO, S. SANTINI, R. SAGGINI

ACHILLES TENDINOPATHY

- One of the most frequent pain diseases - Especially from the amateur sport - 11% from the runners - Average onset age: between 28 and 55 years old - Can be acute or chronic (3 weeks)

(Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy:new treatment options. Br J Sports Med 2007;41:211–6.)

ACHILLES TENDINOPATHYCLINIC

1. Heel pain: sudden, gradual or insidious 2. Increased pain just after inactivity 3. Functional limitation in foot dorsiflexion and plantarflexion 4. Tendon and pre-insertional pain 5. Swelling increased at pre-insertional portion 6. Antalgic lameness

ACHILLES TENDINOPATHY

HISTOPATHOLOGY • Opacification of the triangle of Kager • Tendon thickening • Degeneration of collagen tissue • Outbreaks of hyaline degeneration • Increased neovascularization • Increase in PGE2 • Increase of neurogenic inflammatory factors

(substance P; calcitonin gene-related peptide) • Increased fibroblasts proliferation

(Bjur D, Alfredson H, Forsgren S. The innervation pattern of human Achilles tendon: studies of the normal and tendinosis tendon with markers for general and sensory innervation. Cell Tissue Res 2005;320:201–6.)

DIAGNOSIS • CLINICAL EXAMINTAION • ULTRASONOGRAPHY • RMN

DIFFERENTIAL DIAGNOSIS

1. Os trigonum syndrome 2. Peroneal tendons deseases 3. Tenosynovitis of plantar flexors 4. Stress fractures in the hindfoot 5. Accessory soleus muscle miofascial syndrome 6. Tumors (Achilles tendon xantoma) 7. Bursitis 8. Sural neuroma COMPLICATIONS Tendon rupture

(Alfredson H. Conservative management of Achilles tendinopathy: new ideas. Foot Ankle Clin 2005;10:321–9.)

CURRENT THERAPIES • Corticosteroids inflitrations • Eccentric exercise • ESWT • Sclerotherapy • Electrocoagulation • Topic Trinitrato Glycerole (GTN)

• Triple Therapy : 2 laser sources • Source 1:

• Source 2:

• Scan time: 10-15 minutes • You can set Time, Power, Frequency, Spot

üGa Al As (Gallio, Alluminio, Arsenurio) üPower: 10 W üWavelenghts: 805-811 nm üFrequency: 1-10000 Hz üDuty cycle: 50%

üGa Al As (Gallio, Alluminio, Arsenurio) üPower: 15 W üWavelenghts: 1061-1067 nm üFrequency: 1-10000 Hz üDuty cycle: 50%

TRIPLE – THERAPY BY LEVEL

THERAPEUTIC EFFECTS

• Active hyperemia (increase in size

and decrease in the permeability of the blood and lymph vessels)

• Stabilization of the cell membrane

of mast cells • Activation of phagocytes

ANTI-INFLAMMATORY/EDEMA EFFECTS

wash-out effect on pro-inflammatory substances (histamine, bradykinin, cytokines, lymphokines)

greater supply of oxygen and nutrients

decreased histamine production

removing harmful substances

Barberis – 1996; Honmura – 1992-93; Sato – 1994.

THERAPEUTIC EFFECTS

• On the surface of the block, potential actions in nociceptive endings are inducted through changes in axonal membrane permeability (Belkin– 1994; Jimbo – 1998);

• The active hyperemia promotes the wash-out of the

algogenic substances; • Pain modulation by interaction with the large caliber

myelinated fibers; • Increase in morphine-mimetic substances (endorphins,

enkephalins) (Walker– 1983 Corti – 1986, Ponnudurai – 1988, Zati - 1997).

ANALGESIC EFFECT

THERAPEUTIC EFFECTS

• Increased production of ATP from ADP at the mitochondrial level;

• Promotion of cell replication; • Promotion of the RNA and proteins (collagen) synthesis with facilitation of repair processes (Smolianova– 1990; Manteifel’v – 2004, 2005, 2009).

BIOSTIMULANT EFFECT

CONTROINDICATIONS

ABSOLUTE • Areas that are near the

eye; • Bleeding diathesis area; • Areas that are near the

uterus (in women of childbearing potential);

• Cancer patients; • Epilepsy.

RELATIVE

• Cardiac area in cardiac

patients; • With infectious

inflammation or allergy in progress;

• Patients with very dark skin.

It is important that both the patient and the operator use the appropriate protective eyewears that filter the light in an appropriate manner to the wavelength of the laser source

CLINICAL INDICATIONS:

• Analgesic and anti-inflammatory therapy for

musculoskeletal (tendonitis, bursitis, bruising, injury, muscle spasms)

• Trigger points: miofascial syndrome • Tender points: fibromialgy • Neuralgia (trigeminal and post-herpetic neuralgia) • Ulcers

TRIPLE – THERAPY BY LEVEL

MATERIALS AND METHODS

5 PATIENTS (average 49 years; 3 M and 2 F) ENROLLMENT: between February 2012 and May 2012 INCLUSION CRITERIA: • Chronic tendinopathy present at least 3 months • Clinical and ultrasonography diagnosis • Between 28 and 55 years • Usual non competitive sports activities • Drug therapy not in progress EXCLUSION CRITERIA: • Ongoing pregnancy • Cancer patients • Bleeding diathesis area

MATERIALS AND METHODS 1. 3 treatments per week for 3 weeks T0/T1 2. Treatment duration: 15 minutes 3. 41 J for each session 4. 8 W at 200 Hz (10J) for the diode of 808 nm and 12 W

in continuos mode (31J) for the diode of 1064 nm

MATERIALS AND METHODSPre- and post-treatment evaluation :

1. VAS 2. Fischer algometer 3. Ultrasonography 4. Termography

RESULTSVAS Pre-treatment: 8.2 (range between 6 and 9) Post-treatment: 1.4 (range between 1 and 2) REDUCTION OF 83%

RESULTS

0

2

4

6

8

10

PRE POST

8,2

1,4

VAS

RESULTSFISCHER

ALGOMETER Pre-treatment: 5 kg/cm2

(range between 3 and 7)

Post-treatment: 18 kg/cm2

(range between 16 and 20)

RESULTS

0 5 10 15 20

POST

PRE

18

5

FISCHER ALGOMETER (kg/cm2)

RESULTS

ULTRASONOGRAPHY Pre-treatment: accentuation of

hypoechogenicity Achilles tendon and peritendinous components

Post-treatment: significant reduction of

ultrasonographic hypoechogenicity of evaluated structures

Pre-treatment T0= 30.1° C

THERMOGRAPHY

Post-treatment T0= 34.4° C

27.1°C<30°C<31°C

Pre T0

Post T0

27.7°C<33.1°C<34.3°C

Pre-treatment at sessione 5 =29.3° C

• Pre T 1/2

26.8°C<29.3°C<30.1°C

Pre-treatment T1=28.1° C

27.1°C<28.7°C<30.8°C

Pre T1

RESULTS

THERMOGRAPHY T0: Δt= 4.3° C

RESULTS

THERMOGRAPHY T0= 30.1° C T1= 28.2° C

RESULTS

THERMOGRAPHY T0: Δt= 4.3° C (with inflammation) T1: Δt= 4.1° C (healthy)

4,3

4,14

4,1

4,2

4,3

PRE POST

THERMOGRAPHY (ΔT) C°

CURRENT PROTOCOL • Treatment duration of 15 minutes • 41 J for each session • 8 W at 200 Hz (10J) for the diode of 808 nm • 12 W in continuos mode (31J) for the diode of 1064

nm

DISCUSSION At the end of 9 sessions of treatment, carried

out over a period of 3 weeks, a significant reduction of the inflammatory Achilles framework has been highlighted, resulting in reduction of pain symptoms (assessed by VAS and Fischer algometer) and improvment of the ultrasound and thermografic framework.

None of the 5 patients experienced adverse reactions.

CONCLUSIONSBased on the obtained results, even considering

the small number of treated patients, we can consider the Triple Therapy appropriate in Achilles tendinopathy, even without combination with any other therapeutic aids, taking less time than using other methods.

Today we are testing it in larger and heterogeneous groups of patients.

Thanks