Achilles tendinopathy treatment with triple therapy: pilot study

1. 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

2. 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.)

3. ACHILLES TENDINOPATHY
CLINIC
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

4. 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.)

5. DIAGNOSIS
• CLINICAL EXAMINTAION
• ULTRASONOGRAPHY
• RMN

6. 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.)

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

8. • 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

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. MATERIALS AND METHODS
Pre- and post-treatment evaluation :
1. VAS
2. Fischer algometer
3. Ultrasonography
4. Termography

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

18. RESULTS
0
2
4
6
8
10
PRE POST
8,2
1,4
VAS

19. RESULTS
FISCHER
ALGOMETER
Pre-treatment: 5 kg/cm2
(range between 3 and 7)
Post-treatment: 18 kg/cm2
(range between 16 and
20)

20. RESULTS
0 5 10 15 20
POST
PRE
18
5
FISCHERALGOMETER(kg/cm2)

21. RESULTS
ULTRASONOGRAPHY
Pre-treatment: accentuation of
hypoechogenicity Achilles tendon
and peritendinous components
Post-treatment: significant reduction of
ultrasonographic hypoechogenicity
of evaluated structures

22. Pre-treatment T0= 30.1° C
THERMOGRAPHY

23. Post-treatment T0= 34.4° C

24. 27.1°C<30°C<31°C
Pre T0

25. Post T0
27.7°C<33.1°C<34.3°C

26. Pre-treatment at sessione 5 =29.3° C

27. • Pre T 1/2
26.8°C<29.3°C<30.1°C

28. Pre-treatment T1=28.1° C

29. 27.1°C<28.7°C<30.8°C
Pre T1

30. RESULTS
THERMOGRAPHY
T0: Δt= 4.3° C

31. RESULTS
THERMOGRAPHY
T0= 30.1° C
T1= 28.2° C

32. RESULTS
THERMOGRAPHY
T0: Δt= 4.3° C
(with inflammation)
T1: Δt= 4.1° C
(healthy)
4,3
4,1
4
4,1
4,2
4,3
PRE POST
THERMOGRAPHY (ΔT)C°

33. 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

34. 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.

35. CONCLUSIONS
Based 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.

36. Thanks