Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (HEALTHY): a randomised trial.

OBJECTIVES: To compare the efficacy of in-shoe heel lifts to calf muscle eccentric exercise in reducing pain and improving function in mid-portion Achilles tendinopathy. METHODS: This was a parallel-group randomised superiority trial at a single centre (La Trobe University Health Sciences Clinic, Discipline of Podiatry, Melbourne, Victoria, Australia). One hundred participants (52 women and 48 men, mean age 45.9, SD 9.4 years) with clinically diagnosed and ultrasonographically confirmed mid-portion Achilles tendinopathy were randomly allocated to either a (1) heel lifts (n=50) or (2) eccentric exercise (n=50) group. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire at 12 weeks. Differences between groups were analysed using intention to treat with analysis of covariance. RESULTS: There was 80% follow-up of participants (n=40 per group) at 12 weeks. The mean VISA-A score improved by 26.0 points (95% CI 19.6 to 32.4) in the heel lifts group and by 17.4 points (95% CI 9.5 to 25.3) in the eccentric exercise group. On average, there was a between-group difference in favour of the heel lifts for the VISA-A (adjusted mean difference 9.6, 95% CI 1.8 to 17.4, p=0.016), which approximated, but did not meet our predetermined minimum important difference of 10 points. CONCLUSION: In adults with mid-portion Achilles tendinopathy, heel lifts were more effective than calf muscle eccentric exercise in reducing pain and improving function at 12 weeks. However, there is uncertainty in the estimate of effect for this outcome and patients may not experience a clinically worthwhile difference between interventions. TRIAL REGISTRATION NUMBER: ACTRN12617001225303.

Foot orthoses for plantar heel pain: a systematic review and meta-analysis.

OBJECTIVE: To investigate the effectiveness of foot orthoses for pain and function in adults with plantar heel pain. DESIGN: Systematic review and meta-analysis. The primary outcome was pain or function categorised by duration of follow-up as short (0 to 6 weeks), medium (7 to 12 weeks) or longer term (13 to 52 weeks). DATA SOURCES: Medline, CINAHL, SPORTDiscus, Embase and the Cochrane Library from inception to June 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies must have used a randomised parallel-group design and evaluated foot orthoses for plantar heel pain. At least one outcome measure for pain or function must have been reported. RESULTS: A total of 19 trials (1660 participants) were included. In the short term, there was very low-quality evidence that foot orthoses do not reduce pain or improve function. In the medium term, there was moderate-quality evidence that foot orthoses were more effective than sham foot orthoses at reducing pain (standardised mean difference -0.27 (-0.48 to -0.06)). There was no improvement in function in the medium term. In the longer term, there was very low-quality evidence that foot orthoses do not reduce pain or improve function. A comparison of customised and prefabricated foot orthoses showed no difference at any time point. CONCLUSION: There is moderate-quality evidence that foot orthoses are effective at reducing pain in the medium term, however it is uncertain whether this is a clinically important change.

Where is Your Pain? Achilles Tendinopathy Pain Location on Loading Is Different to Palpation, Imaging and Recall Location.

OBJECTIVE: To describe and compare pain maps reported during Achilles tendon loading exercises with recall pain location, in people with pain on palpation in their Achilles tendon and tendon pathology on imaging. DESIGN: Cross-sectional analysis of baseline RCT. METHOD: Participants were recruited from a larger Achilles tendinopathy clinical trial. Inclusion criteria were at least 2-month self-reported history of Achilles tendinopathy, midtendon palpation pain, and pathology on ultrasound tissue characterization. Participants were asked to identify their Achilles tendon pain location on a pain map with 8 prespecified locations while at rest prior to loading (recall pain), and subsequently during tendon loading exercises (loading pain). Participants could select multiple locations or select "other" if the locations did not represent their pain. RESULTS: Ninety-three participants were included (93% of participants from a clinical trial). The locations of pain on loading were diverse; all 8 pain locations (and an "other" option) were represented within this sample. Twenty-five percent of participants did not report pain with loading (n = 23 of 93). Of the 70 participants with loading pain, recall pain location differed to loading pain location in 40% (n = 28 of 70) of the participants. CONCLUSION: Palpation pain location, recall pain location, or location of pathology on imaging were not valid proxies for load-related pain in the Achilles tendon. How different pain locations respond to treatment is unknown. Some pathologies (eg, plantaris) have clear pain locations (eg, medial tendon), and assessing pain location may assist differential diagnosis. J Orthop Sports Phys Ther 2024;54(1):1-9. Epub 7 December 2023. doi:10.2519/jospt.2023.12131.

Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (the HEALTHY trial): study protocol for a randomised trial.

BACKGROUND: Mid-portion Achilles tendinopathy is a common musculoskeletal condition characterised by degeneration of the Achilles tendon, which causes pain and disability. Multiple non-surgical treatments have been advocated for this condition including calf muscle eccentric exercise and in-shoe heel lifts. Although adherence is challenging, there is evidence to suggest that calf muscle eccentric exercise is effective in decreasing pain and improving function in people with Achilles tendinopathy. Heel lifts reduce ankle joint dorsiflexion and Achilles tendon strain, however their efficacy in the management of Achilles tendinopathy is unclear. This article describes the design of a parallel-group randomised trial comparing the efficacy of heel lifts to calf muscle eccentric exercise for Achilles tendinopathy. METHODS: Ninety-two participants with Achilles tendinopathy will be randomised to one of two groups: (i) a heel lift group that will receive pre-fabricated 12 mm in-shoe heel lifts (Clearly Adjustable®), or (ii) an exercise group that will be advised to carry out a calf muscle eccentric exercise program (twice a day, 7 days a week, for 12 weeks). Outcome measures will be obtained at baseline, 2, 6 and 12 weeks; the primary endpoint for assessing efficacy being 12 weeks. The primary outcome measure will be the total score of the Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire. Secondary outcome measures will include thickness and integrity of the Achilles tendon (using ultrasound tissue characterisation [UTC]), participant perception of treatment effect on pain and function (using the 7-point Patient Global Impression of Change scale), severity of pain at the Achilles tendon (using a 100 mm visual analogue scale) in the previous week, health status (using the EuroQol-5D-5L™ questionnaire), physical activity levels (using the 7-day Recall Physical Activity Questionnaire) and calf muscle function (using the standing heel rise test). Data will be analysed using the intention to treat principle. DISCUSSION: The HEALTHY trial (Heel lifts versus calf muscle eccentric Exercise for AchiLles TendinopatHY) is the first randomised trial to compare the efficacy of heel lifts to calf muscle eccentric exercise in reducing pain and improving function in people with Achilles tendinopathy. A pragmatically designed trial was developed to ensure that if the interventions are found to be effective, the findings can be readily implemented in clinical practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12617001225303. Registered on August 22nd, 2017.

Effects of heel lifts on lower limb biomechanics and muscle function: A systematic review.

BACKGROUND: Heel lifts, placed inside footwear are recommended for the management of numerous musculoskeletal conditions. Despite the potential therapeutic benefit of heel lifts, the mechanism(s) by which they exert their effects is unclear. The aim of this systematic review was to synthesise reported findings and summarise the effects of heel lifts on lower limb biomechanics and muscle function. RESEARCH QUESTION: Do heel lifts affect lower limb biomechanics and muscle function during walking and running? METHODS: Electronic databases (MEDLINE, EMBASE, CINAHL, SPORTDiscus, AMED) were searched from inception to April 2018. Studies were included if they (i) included participants without a limb length discrepancy or neurological condition, (ii) evaluated the effect of bilateral heel lifts that were removable (attached to the participants' foot (barefoot) or inserted inside footwear) or an existing feature of a shoe, and (iii) assessed lower limb biomechanics or muscle function during walking or running in asymptomatic or symptomatic participants. RESULTS: A total of 23 studies (377 participants) were included. Study quality, assessed using a Modified Quality Index, ranged from 5 to 13 out of 15. A large number of biomechanical parameters were assessed, but few effects were statistically significant. The differences that were significant and had a large effect size are described below. In asymptomatic participants, heel lifts of 10 mm decreased duration of swing phase (standardised mean difference [SMD] = -1.3) and heel lifts of at least 5 cm decreased velocity (SMD = -0.93) during walking. In asymptomatic participants, heel lifts of 15 mm decreased maximum ankle dorsiflexion angle (SMD = -1.5) and heel lifts of 12 and 18 mm decreased gastrocnemius muscle tendon unit length (SMD = -0.96) during running. In participants with restricted ankle joint dorsiflexion, heel lifts of 6 and 9 mm increased medial gastrocnemius electromyography amplitude (SMD between 0.68 and 0.98) during walking. In participants with haemophilia, heel lifts of 9 mm increased ankle joint maximum range of motion (SMD = 1.6) during walking. SIGNIFICANCE: Heel lifts affect specific lower limb biomechanical and muscle function parameters during walking and running. The clinical relevance and potential therapeutic benefits of these effects needs further investigation.