Laser for Treating Tendinopathy

 

Problem:

Your client is a 40 yo male with Achilles tendon pain that has been present for 1 week following the Cherry Blossom 10 mile race. His longest training run was 5 miles, but had been running 2-3 times per week for 2 months prior to the race. He presents with antalgic gait and is tender to palpation over the Achilles tendon, with mild swelling.

 

Justification:

A randomized controlled trial performed by Bjordal et al found that low level laser therapy (LLLT) has the prospect to influence the management of inflammatory conditions, resulting in reduced pain and inflammation of activated Achilles tendonitis at a dose of 5.4J per point. This was tested in a population of patients that were 20-60 years old whose pain was provoked with physical activity, much like the runner presented for this rationale. Tumilty et al sought to clarify the effectiveness of LLLT in a randomized controlled trial that yielded no significant difference between laser and placebo groups. However, the duration since symptom onset of the participating subjects was never addressed. Furthermore, the study was limited by the ineffective dosing of the power density complicated by modifications to the laser probe. This highlighted the importance of using appropriate parameters to obtain the desired affect. Stergioulas et al found in a randomized controlled trial of 52 recreational athletes with chronic Achilles tendinopathy that LLLT in combination with eccentric exercises accelerated recovery more so than eccentric exercises alone. This was indicated by significantly improved pain intensity, decreased crepitation severity, improved tenderness to palpation, improved morning stiffness, and increased active dorsiflexion.

 

Procedure:

The treatment guidelines outlined by Stergioulas et al will be utilized due to the strength of the study and the significance of its findings.  The patient will be positioned in prone with his hips and knees extended and his ankle in maximal extension.3 Alcohol will be used to clean the area of the Achilles tendon.3 The patient and the therapist will wear darkened glasses to protect the eyes from the laser. Six irradiation points will be treated around the painful nodule in the Achilles tendon at a dose of 0.9J per point for a total per session energy of 5.4J.1,3 Irradiation points will be separated by 1 cm between any two points.3 Parameters of the LLLT will be set to a wavelength of 820 nm, an optical output of 30 mW, and a power density on the skin of 60mW/cm2.3 Treatment will be administered over a course of 8 weeks with the patient receiving LLLT 2x/wk in the first four weeks and 1x/wk in the following four weeks.3 This intervention will be performed in conjunction with an eccentric training regiment targeting the soleus and gastrocnemius and designed for the patient to reach 12 sets of 12 reps with a 1 minute rest between sets by the fourth week of treatment.3  The patient will practice this exercise 4x/wk for 8 weeks.3

 

Outcomes:

Severity of functional effect due to Achilles tendinopathy will be assessed using the Victorian Institute of Sport and Design’s VISA-A questionnaire where a score of “100” represents a normally functioning tendon and  a score of “0” indicates a painful tendon with severely affected function.2 This will be administered before the first session on the first day and again after receiving treatment for 8 weeks.  A 100 mm Visual Analogue Scale (VAS) will be used to determine the 24 hour pain pattern, pain intensity, severity of morning stiffness, and crepitation.2,3 Lastly, active and passive ankle dorsiflexion will be measured using a goniometer to determine increases in tissue length.2 This will be measured at the initial evaluation and once a week  thereafter for the 8 weeks of treatment.

 

References:

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1. Bjordal JM, Lopes-Martins RAB, Iverson VV. A randomized, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 concentrations. Br J Sports Med. 2006; 40(1): 76-80.

2. Tumilty S, McDonough S, Hurley DA, Baster GD. Clinical Effectiveness of Low-Level Laser Therapy as an Adjunct to Eccentric Exercise for the Treatment of Achilles’ Tendinopathy: A Randomized Controlled Trial. Arch Phys med Rehabil. 2012;93(5):733-9

3. Stergioulas A, Stergioula M, Aarskog R, Lopes-Martins RA, 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(5):881-7.