Comparing two eccentric exercise programmes for the management of Achilles tendinopathy. A pilot trial

A Comparative Study of the Graston Technique and Alfredson Protocol in the Management of Achilles Tendinopathy

BACKGROUND AND OBJECTIVES

The Achilles tendon, the largest and strongest tendon in the human body, is frequently injured by overuse; this condition is known as Achilles tendinopathy (AT). It serves as a link between the heel bone and the calf muscles and is necessary for motions, such as walking, sprinting, and jumping. Evidence is presented to support the efficacy of the Graston technique and Alfredson protocol for pain reduction and improvement of function and calf muscle strength. The objective of this study is to compare the efficacy of the Graston technique versus the Alfredson protocol in patients with AT. Methods and data collection: After obtaining approval from the ethical review board of the Rawalpindi Medical University, all patients fulfilling the inclusion criteria are divided into two groups, A and B, by generating random identity numbers using Microsoft Excel for allocation. Group A comprises patients who undergo treatment with the Graston technique as conventional therapy with Alfredson protocol (12-week calf muscle eccentric exercises), while those in group B follow a Graston technique with sole heel lift. Individuals in the eccentric exercises group follow an Alfredson method-based 12-week eccentric exercise plan for their leg muscles. The workouts need to be done twice a day, seven days a week for 12 weeks. The plan includes two exercises: the first done with the knee straightened to work the gastrocnemius and the second done with the knee bent to work the soleus. Three sets of 15 repetitions with no rest interval for each exercise are completed twice a day on the affected limb to yield functional improvement.

RESULTS

The results showed that both the Alfredson protocol and the Graston technique were effective in managing AT symptoms. The study involved dividing 32 participants into two groups who received either treatment for four weeks. The main way to measure improvement was a score called the Villalta-Scanlon Achilles Tendonitis Index score. In both groups, these scores showed significant improvement (with a p-value less than 0.001, which means that the results are very statistically significant). For Group A (who received the Alfredson protocol), the average Villalta-Scanlon Achilles Tendonitis Index score before treatment was 29.25. This score increased to 31.25 at mid-treatment and 34.38 after the full four weeks of treatment. Group B (who received the Graston technique) started with an average Villalta-Scanlon Achilles Tendonitis Index score of 22.94. Their scores also increased throughout the treatment, reaching 34.94 at mid-treatment and 42.88 after four weeks. These findings provide evidence that both treatments can improve AT symptoms, with some suggestions that the Graston technique might be even more effective based on the higher average Villalta-Scanlon Achilles Tendonitis Index scores after treatment.

CONCLUSIONS

The Graston technique shows promising results, particularly in the mid- and post-treatment phases, indicating its potential efficacy in comparison to the Alfredson protocol in the treatment of AT.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Identifying characteristics of resistance-based therapeutic exercise interventions for Achilles tendinopathy: A scoping review

OBJECTIVE

This scoping review describes resistance-based therapeutic exercise intervention characteristics for Achilles tendinopathy (AT) treatment (e.g., therapeutic dose, underlying mechanisms targeted by exercise) and assesses participant reporting characteristics.

METHODS

Seven electronic databases were searched; studies delivering a resistance exercise-focused treatment for individuals with AT were included. The Template for Intervention Description and Replication (TIDieR) and the ICON 2019 'Recommended standards for reporting participant characteristics in tendinopathy research' checklists framed data extraction, and study quality was assessed using the Mixed Methods Appraisal Tool 2018 version.

RESULTS

68 publications (describing 59 studies and 72 exercise programs) were included. Results demonstrate that therapeutic exercise interventions for AT are well reported according to the TIDieR checklist, and participant characteristics are well reported according to the ICON checklist. Various underlying therapeutic mechanisms were proposed, with the most common being increasing tendon strength, increasing calf muscle strength, and enhancing collagen synthesis.

CONCLUSIONS

While evidence suggests that resistance-based therapeutic exercise interventions are effective in treating AT, more reporting on program fidelity, adherence, and compliance is needed. By summarizing currently published AT exercise programs and reporting key intervention characteristics in a single location, this review can assist clinicians in developing individualized resistance training programs for people with AT.

The effectiveness of "Dijital Steps" web based telerehabilitation system for patient with hindfoot pain: A randomised controlled trial

OBJECTIVE

The aim of the study was to evaluate and compare effective therapeutic options for hindfoot pain, develop and investigate the effectiveness of tele-rehabilitation systems, and ensure patients perform their exercises and preventive measures regularly and accurately, while monitoring results.

METHODS

Hindfoot pain (HP) patients (N = 77 with 120 feet) were admitted to this study and divided into two pathologies; Plantar Fasciitis and Achilles Tendinopathy. Patients in each pathology were randomized into three different rehabilitation programs-web-based telerehabilitation (PF-T & AT-T), -hands-on healing techniques combined with exercise (PF-C & AT-C)-unsupervised home exercise (PF-H & AT-H) program. Disability, activity restrictions, first-step pain, dorsiflexion-plantar flexion range of motion and kinesiophobia scores were recorded. The outcomes of the study groups were collected pre-post intervention (8thweek). Telerehabilitation system was developed via user-driven innovation and tested before using formally.

RESULTS

Each group had significant improvements in pain, disability, functional status and kinesiophobia (p < 0.001). In terms of functional status, PF-C had a statistically significant difference from others (p < 0.001). There was no difference between the groups for the pain scores in both pathologies. (p > 0.001). However, web-based telerehabilitation (PF-T & AT-T) were found to be more effective on kinesiophobia compared to the other groups (p < 0.001).

CONCLUSIONS

The presented web-based telerehabilitation system for management of hindfoot pain is an effective way and might be preferred instead of unsupervised home exercise specially for kinesiophobia. Additionally, Foot and ankle stretching and strengthening exercises protocols, myofascial releasing and mulligan concept manual therapy are effective modalities in terms of ROM, VISA-A, FAAM, FFI, TSK and VAS scores for hindfoot pain. The results indicated that three promised different rehabilitation protocols could be an effective strategy for HP.

Comparability of the Effectiveness of Different Types of Exercise in the Treatment of Achilles Tendinopathy: A Systematic Review

Achilles tendinopathy (AT) is a common condition both in athletes and the general population. The purpose of this study is to highlight the most effective form of exercise in managing pain-related symptoms and functional capacity as well as in a return to life activities, ensuring the quality of life of patients with AT, and creating a protocol to be used in rehabilitation. We conducted a systematic review of the published literature in Pubmed, Scopus, Science Direct, and PEDro for Randomised Controlled Trials concerning interventions that were based exclusively on exercise and delivered in patients 18-65 years old, athletes and non-athletes. An amount of 5235 research articles generated from our search. Five met our inclusion criteria and were included in the review. Research evidence supports the effectiveness of a progressive loading eccentric exercise program based on Alfredson's protocol, which could be modified in intensity and pace to fit the needs of each patient with AT. Future research may focus on the optimal dosage and load of exercise in eccentric training and confirm the effectiveness of other type of exercise, such as a combination of eccentric-concentric training or heavy slow resistance exercise. Pilates could be applied as an alternative, useful, and friendly tool in the rehabilitation of AT.

Clinical effectiveness of pulsed electromagnetic field therapy as an adjunct treatment to eccentric exercise for Achilles tendinopathy: a randomised controlled trial

BACKGROUND

The Achilles tendon is the largest and strongest tendon in the human body. Achilles tendinopathy (AT) is a common clinical problem with Achilles overuse. Eccentric exercise is often used as an initial treatment for these patients. Most patients with AT experienced moderate to severe pain, limiting the incentive to perform eccentric exercise. It is difficult for them to complete eccentric exercise for 3 months consecutively to obtain significant improvements. Using PEMF as an adjunct, there could be immediate pain relief and improved response to eccentric exercise by modulating the mechanical properties of the Achilles tendon. Participants may experience less pain while performing eccentric exercises to increase compliance with the rehabilitation programme.

METHODS

This prospective randomised double-blinded, placebo-controlled trial aims to investigate the treatment effects of PEMF for participants with AT. All participants are randomised into two groups: the intervention group (n = 20; active PEMF treatment and eccentric exercise) and the control group (n = 20; sham treatment and eccentric exercise). Researchers perform self-reported, functional and ultrasonographic outcomes during baseline assessment, 4 weeks, 8 weeks follow-ups, and 3 and 6 months follow-ups after the commencement of the PEMF treatment.

DISCUSSION

AT is a common clinical condition affecting athletes and sedentary populations. It is essential to investigate treatment adjuncts to improve rehabilitation outcomes for these patients. This trial may demonstrate the effectiveness of PEMF in relieving pain, improving function, and restoring mechanical changes of the tendon in participants with AT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05316961. Registered on 7th April 2022.

Eccentric exercise is more effective than other exercises in the treatment of mid-portion Achilles tendinopathy: systematic review and meta-analysis

Achilles tendinopathy (AT) is one of the most frequent overuse injuries in the ankle. The evidence base for its conservative management AT continues to evolve, but there is still a gap in the evidence for the efficacy of any modality of treatment in high-quality studies. This systematic review and meta-analysis investigated the efficacy of EE in improving pain and function in adult patients with mid-portion Achilles tendinopathy compared to other forms of exercise. A search was performed in PubMed, BIREME, SportDiscus, Cinahl, Web of Science and PEDro, in November 2022. The methodological quality was evaluated using the Risk of Bias 2 tool (RoB2) of the Cochrane collaboration, and the meta-analysis was performed using the Review Manager 5.1 program. 2024 articles were identified and eight fulfilled the inclusion criteria. RoB2 presented a final score with 62.5% of the studies presented "some concerns", and 37.5% (five and three articles, respectively) presenting "high risk" of bias. EE was effective for the managment of AT. The only variable for which a meta-analysis was possible was pain (five articles), analysed with the visual analogue scale/numerical visual scale. The mean difference (MD) in treatment effect using EE was - 1.21 (- 2.72 to - 0.30) with a 95% of confidence interval (CI), thus identifying a significant positive effect for the improvement of pain in patients with AT in whom EE was used. EE is effective in the management of AT. The meta-analysis shows the need for appropriately powered randomized controlled trials with better design, the use of standard outcome measures and well-planned protocols for conservative management of AT.Level of evidence: Level 1.Registration: CRD42018118016.

Physical modalities with eccentric exercise are no better than eccentric exercise alone in the treatment of chronic achilles tendinopathy: A systematic review and meta-analysis

BACKGROUND

To investigate the available evidence and conduct a systematic review with meta-analysis to determine the effectiveness of physical modalities combined with eccentric exercise (PMEE) with eccentric exercise (EE) alone for improvements in pain and function in individuals with chronic Achilles tendinopathy (AT) at short-term (4 weeks) and long-term (12-16 weeks) follow-ups.

MATERIALS AND METHODS

A systematic literature review identified 8 papers (from 6404 possible inclusions) that allowed the comparison of PMEE with EE alone, in the treatment of chronic AT. We extracted the mean and standard deviations for Victorian Institute of Sports Assessment Achilles Tendinopathy (VISA-A), Numerical Pain Rating Scale (NPRS), and load-induced pain (NRS). Standardized mean difference (SMD) of the included variables was presented, and all the studies had low risk of bias.

RESULTS

Non-significant results were achieved for short-term (pooled SMD = 0.03; 95% CI= -0.46 to 0.53, p = 0.89, I2 = 60%) and long- term follow-ups (pooled SMD =0.43; 95% CI= -0.05 to 0.92, p = 0.08, I2 = 82%) of VISA-A. Short-term (pooled SMD = -0.16; 95% CI= -0.72 to 0.40, p = 0.57, I2 = 40%) and long-term (pooled SMD = -0.39;95% CI= -1.11 to 0.32, p = 0.28, I2 = 62%) follow-up analysis of NPRS and long-term(pooled SMD = -0.46; 95% CI= -1.08 to 0.15, p = 0.14, I2 = 74%) follow-up of load induced pain also demonstrated non-significant improvements when comparing two groups.

CONCLUSION

Meta- analysis of the results published in the 8 papers that met theinclusion criteria showed no significant differences between PMEE and EE, in terms of load-induced pain (NRS) and numerical pain rating scales (NPRS) at 4 and 12-16 weeks. Thus, the meta-analysis reflects the other cited published work that PMEE shows no greater advantage than EE in the treatment of Chronic Achilles Tendinopathy.

Resistance Training Interventions for Lower Limb Tendinopathies: A Scoping Review of Resistance Training Reporting Content, Quality, and Scientific Implementation

The objectives of this scoping review were as follows: (1) to describe what exercises and intervention variables are used in resistance training interventions for lower limb tendinopathy,  (2) to assess the completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework, and (3) to assess the implementation of scientific resistance training principles. We searched MEDLINE, CINAHL, AMED, Embase, SPORTDiscus, and Cochrane Library databases. Randomized controlled trials, cohort studies, case series, case reports, and observational studies that reported using resistance exercises for lower limb tendinopathies were considered for inclusion, with 194 studies meeting the inclusion criteria. Completeness of the reporting of exercise descriptors and programme variables was assessed by the CERT and the Toigo and Boutellier framework. Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0 to 13, with an average score of 9/13, with only 9 studies achieving a full 13/13. Reporting of items from the CERT ranged from 0 to 18, with an average score of 13/19. No study achieved a full 19/19; however, 8 achieved 18/19. Scoring for resistance training principles ranged from 1 to 10, with only 14 studies achieving 10/10. Eccentric heel-drops were the most common exercise (75 studies), followed by isotonic heel raises (38), and single-leg eccentric decline squats (27). The reporting of exercise descriptors and intervention content was high across studies, with most allowing exercise replication, particularly for Achilles and patellar tendinopathy. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

Cross-cultural adaptation, reliability and validity of the Persian version of the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A)

PURPOSE

Achilles tendinopathy is a prevalent overuse injury among athletes and in those with a sedentary lifestyle. Current evidence indicates that the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire is a valid, reliable and disease-specific outcome measure for assessing the clinical symptoms in patients with Achilles tendinopathy. The objective of this study was to translate and cross-culturally adapt the VISA-A questionnaire into Persian (VISA-A-P) and evaluating its psychometric properties.

MATERIALS AND METHODS

Cultural adaptation of VISA-A-P was conducted according to Beaton's guideline. The final version of VISA-A-P was handed to 61 patients for analysis of psychometric properties. Test-retest reliability, internal consistency, concurrent validity, item-total correlation, and floor/ceiling effect were evaluated in patients with Achilles tendinopathy. To assess test-retest reliability, 35 patients refilled the VISA-A-P twice within 5-7 days. Known-group validity was evaluated using 50 healthy individuals.

RESULTS

VISA-A-P showed excellent test-retest reliability (ICC = 0.90), excellent internal consistency (Cronbach's alpha = 0.95), strong correlation with FAAM, and moderate to strong correlation with FAOS questionnaires. There was a significant difference between the average score of patients (34.55 ± 18.24) and the healthy group (73.1 ± 20.10). VISA-A-P showed neither ceiling nor floor effect.

CONCLUSIONS

The VISA-A-P is a reliable and valid instrument for measuring the symptoms in Persian speaking populations with Achilles tendinopathy.Implications for rehabilitationAchilles tendinopathy is a debilitating overuse injury that insidiously affects tendoAchilles.VISA-A-P revealed acceptable validity and reliability and it could be used by Persian speaking clinicians and researchers to assess pain and function in people with Achilles tendinopathy.

To Compare the Effect of Eccentric Exercises and Isometric Exercises for Achilles Tendinitis in Skaters

Background

Achilles tendinitis is one of the commonest injuries that happen to skaters. Roller skates traditionally have four wheels onto axles, one under the ball of the foot and one under the heel. Skaters have to maintain a closed kinematics chain which involves continuous trunk and hip flexion along with knee flexion and ankle dorsiflexion. It creates angular tension and strain in the muscles and tendons which can lead to different types of musculotendinous injuries. As not many studies has not been done on the prospect in India this study was done with a objective to compare the effect eccentric exercise and isometric exercise on Achilles tendinitis for skaters.

Methods

A Quasi-experimental study with 40 subjects of the age group between 15 and 25 was administered the VISA-A Questionnaire and VAS as outcome measures. A sample size of 40 was separated into two groups of 20 participants each into Group A (eccentric) and Group B (isometric). Pre-test and post-test were done using the VISA-A questionnaire and VAS Scale in the Study period- 4 weeks.

Results

There was a significant difference during the comparison between pre-test and post-test values (p < 0.005) of isometric exercise and eccentric exercise by VISA-A questionnaire and VAS scale but there was insignificance during the comparison of post-test values (p > 0.005) of the same.

Conclusion

The study concludes that there is a significant improvement in Achilles tendinitis when assessed with VISA-A questionnaire and VAS Scale for both the exercise; that is, eccentric and isometric, individually but it isn’t statistically significant enough to choose one method of intervention over the other.

The efficacy of loading programmes for improving patient-reported outcomes in chronic midportion Achilles tendinopathy: A systematic review

OBJECTIVE

Achilles tendinopathy is a common type of overuse condition, with isolated eccentric loading (ECL) programmes being the principal conservative treatment of choice. However, alternative protocols, involving different contraction types, have more recently been investigated. The purpose of the present review was to examine the evidence from studies comparing two or more different types of loading programmes in relation to patient-reported outcomes for people with Achilles tendinopathy.

METHODS

A systematic review was undertaken, and the risk of bias of included papers were assessed using the Cochrane Risk of Bias tool. An electronic search of CINAHL, MEDLINE, Embase and SPORTDiscus was undertaken from their inception to May 2018. The eligibility criteria for selecting studies were randomized controlled or clinical controlled trials investigating two or more different loading programmes for chronic (>3 months) Achilles tendinopathy.

RESULTS

Seven articles were included in the review. Low-quality evidence exists that a do-as-tolerated modification of the Alfredson programme is more effective than the standardized programme at improving function in the short term. Very-low-quality evidence suggests that ECL is superior at reducing pain levels than concentric in isolation, but no more effective at improving pain or disability than concentric-eccentric programmes.

CONCLUSIONS

There is conflicting evidence regarding the superiority of ECL over other contraction types, challenging the current approach to managing Achilles tendinopathy. There is also evidence that do-as-tolerated repetition volumes are more effective at improving function in the short term compared with those recommended by the standardized Alfredson protocol.

[The Management of Mid-Portion Achilles Tendinopathy from a Physiotherapeutic Point of View: A Systematic Review]

Tendinopathy of the mid-portion of the Achilles tendon is common in athletes and non-athletes. From a physiotherapeutic view, calf muscle training is the most recommended kind of treatment. However, there is no current systematic review evaluating the efficacy of physiotherapy in due consideration of the entire spectrum of therapeutic options. A systematic review of the literature in several databases and journals revealed 19 relevant studies. Good evidence was found for eccentric training compared to no therapy, satisfactory evidence for eccentric training compared to concentric training, satisfactory to good evidence for the same effect by using eccentric training and heavy slow resistance training, poor evidence for the same effect by using eccentric training and stretching, and poor to good evidence that eccentric training may have the same effect as several therapies applied by physicians. The Alfredson protocol and heavy slow resistance training may be the most recommendable types of calf muscle training. There is no high-quality evidence for the efficacy of other hands off or hands on treatment options.

Injection with autologous conditioned serum has better clinical results than eccentric training for chronic Achilles tendinopathy

PURPOSE

Chronic Achilles tendinopathy is one of the most common causes of malfunction and pain, which can lead to a significant reduction of the quality of life. The hypothesis of this study argues that autologous conditioned serum (i.e. Orthokine) injections in chronic midportion Achilles tendinopathy have a better outcome than eccentric training.

METHODS

This study investigates, retrospectively, the effects of peritendinous autologous conditioned serum injections as compared to standard eccentric training in 50 patients with chronic Achilles tendinopathy between 2012 and 2015. Before injection or eccentric training and 6 weeks, 12 weeks and 6 months thereafter, the patients were assessed by means of the VISA-A-G score (Victorian Institute of Sport Assessment-Achilles questionnaire-German). An MRI was also performed before and 6 months after injection and eccentric training.

RESULTS

Both patient groups had statistically significant better VISA-A-G scores after injection or eccentric training compared to the baseline before injection (90 vs 40, respectively, P < 0.001) or eccentric training (81 vs 47, respectively, P < 0.001). Comparing the baseline corrected VISA-A-G scores, patients in the autologous-conditioned-serum-group had significantly higher changes in VISA-A-G scores than the eccentric-training-group after 12 weeks (40 vs 36, P = 0.018) and 6 months (50 vs 34, P = 0.034). Both patient groups had statistically significant (P < 0.001) reduction of tendon thickness (autologous conditioned serum: 0.32; eccentric training: 0.24) and length of bursa (autologous conditioned serum: 0.24; eccentric training: 0.21) as well as significant (P < 0.001) improvement of tendon quality in MRI (autologous conditioned serum: 14 vs 1; eccentric training: 14 vs 2). There were no statistical differences in MRI-findings between the two groups.

CONCLUSION

Both therapies led to improvement of MRI-findings, including reduction of tendon thickness and tendon quality. Autologous-conditioned-serum-injections show greater clinical long-term benefit as compared to eccentric training and, therefore, offers a good alternative to eccentric training.

LEVEL OF EVIDENCE

Therapeutic studies, Level III.

Conservative Treatment of Chronic Achilles Tendinopathy: A Systematic Review

Achilles tendinopathy is a common musculoskeletal disorder. Athletes, runners and jumpers, and the sedentary are frequently affected. Numerous are the therapeutic choices to manage these kinds of disorders. The aim of this review is to analyze the available literature to document the up-to-date evidence on conservative management of Achilles tendinopathy. A systematic review of two medical electronic databases was performed by three independent authors, using the following inclusion criteria: conservative treatment consisted of pharmacologic, physical therapy without operative treatment, with more of 6 months symptoms and a minimum average of 6-months follow-up. Studies of any level of evidence, reporting clinical results, and dealing with Achilles tendinopathy and conservative treatment were searched for. A total of n = 1228 articles were found. At the end of the first screening, following the previously described selection criteria, we selected n = 94 articles eligible for full-text reading. Ultimately, after full-text reading and a reference list check, we selected n = 29 articles. Achilles tendinopathy is a frequent musculoskeletal disorder and several conservative treatments have been proposed, but no therapy is universally accepted, except for eccentric exercise training, which is the gold standard and a commonly used protocol.

Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of heavy eccentric calf training (HECT) in comparison with natural history, traditional physiotherapy, sham interventions or other exercise interventions for improvements in pain and function in mid-portion Achilles tendinopathy.

DESIGN

A systematic review and meta-analysis were conducted as per the PRISMA guidelines.

DATA SOURCES

PUBMED, CINAHL (Ovid) and CINAHL (EBSCO) were searched from inception until 24 September 2018.

ELIGIBILITY CRITERIA

Randomised controlled trials comparing HECT to natural history, sham exercise, traditional physiotherapy and other exercise interventions were included. Primary outcome assessing pain and function was the Victorian Institute of Sports Assessment-Achilles.

RESULTS

Seven studies met the inclusion criteria. This review suggests HECT may be superior to both natural history, mean difference (MD) (95% CI) of 20.6 (11.7 to 29.5, one study) and traditional physiotherapy, MD (95% CI) of 17.70 (3.75 to 31.66, two studies). Following removal of one study, at high risk of bias, due to pre-planned sensitivity analysis, this review suggests HECT may be inferior to other exercise interventions, MD (95% CI) of -5.65 (-10.51 to -0.79, three studies). However, this difference is unlikely to be clinically significant.

CONCLUSION

Current evidence suggests that HECT may be superior to natural history and traditional physiotherapy while HECT may be inferior to other exercise interventions. However, due to methodological limitations, small sample size and a lack of data we are unable to be confident in the results of the estimate of the effect, as the true effect is likely to be substantially different.

SYSTEMATIC REVIEW REGISTRY

PROSPERO registration number: CRD4201804493 PROTOCOL REFERENCE: This protocol has been published open access: Murphy M, Travers MJ, Gibson, W. Is heavy eccentric calf training superior to natural history, sham rehabilitation, traditional physiotherapy and other exercise interventions for pain and function in mid-portion Achilles tendinopathy? Systematic Reviews 2018; 7: 58.

Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis

BACKGROUND

Mid-portion Achilles tendinopathy is prevalent within both the athletic and non-athletic populations and loading protocols for Achilles tendinopathy are effective over time, though the rate of symptom change throughout rehabilitation is unknown.

OBJECTIVE

The objective of this study was to determine the rate of change in pain and function over time in patients while completing a loading protocol for mid-portion Achilles tendinopathy.

METHODS

A systematic review and longitudinal meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The databases PubMed, CINAHL (Ovid) and CINAHL (EBSCO) were searched for articles published from inception until 31 July, 2017. Our search focused on clinical trials and cohort studies examining changes in pain and function when completing a loading protocol for mid-portion Achilles tendinopathy. The primary outcome measure assessing pain and function was the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire.

RESULTS

A total of 31 separate cohorts (24 studies) were eligible, with follow-up ranging from 2 weeks to 6 months. The data were pooled to create the mean (standard deviation) of change from baseline at each time point. The data demonstrated an improvement in pain and function as early as 2 weeks that appeared to peak at 12 weeks with a mean (standard deviation) of 21.11 (6.61) points of change on the VISA-A.

CONCLUSION

The improvement in pain and function during rehabilitation suggests future research should be directed toward investigating contributing mechanisms as tendon structure on imaging does not change within 2 weeks and muscular hypertrophy is not seen for at least 4 weeks following the inception of a loading protocol. Systematic Review Registry: PROSPERO registration number: CRD42017062737 ( https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=62737 ).

Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta-analysis

OBJECTIVES

To assess the efficacy of exercise, orthoses and splinting on function, pain and quality of life (QoL) for the management of mid-portion and insertional Achilles tendinopathy, and to compare different types, applications and modes of delivery within each intervention category.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, CINAHL, Embase, AMED, WHO ICTRP, Web of Science, PEDro and Cochrane Library from inception to October 2017. Citation tracking of published studies and conference proceedings and contacting experts in the field.

STUDY ELIGIBILITY CRITERIA

Controlled clinical trials evaluating either exercise, orthoses or splinting for the management of Achilles tendinopathy.

METHODS

Independent reviewers undertook searches, screening and risk of bias appraisal. Primary outcomes of interest were function, pain and QoL.

RESULTS

Twenty-two studies were included (1137 participants). Moderate level evidence favoured eccentric exercise over control for improving pain and function in mid-portion tendinopathy. Moderate level evidence favoured eccentric exercise over concentric exercise for reducing pain. There was moderate level evidence of no significant difference in pain or function between eccentric exercise and heavy slow resistance exercise. There was low level evidence that eccentric exercise was not superior to stretching for pain or QoL. There was moderate level evidence that a combined exercise protocol was not superior to a lower dosage protocol for improving functional performance. There was moderate to low level evidence of a significant difference in pain (mean difference (MD) 6.3 mm, 95% CI -4.45 to 17.04, moderate) or function (MD 1.83 Victoria Institute of Sport Assessment points, 95% CI -7.47 to 11.12, low) between high-dose and low-dose eccentric training. There was high to moderate level evidence of no difference in pain (moderate) or function (high) between orthoses and control. There was low level evidence of no significant benefit in adding a night splint to an eccentric exercise programme for function, and moderate level evidence for no reduction in pain (MD -3.50, 95% CI -10.49 to 3.48). Eccentric exercise was not superior to splinting for pain (moderate evidence) or function (low level evidence).

SUMMARY

We conditionally recommend exercise for improving pain and function in mid-portion Achilles tendinopathy. The balance of evidence did not support recommendation of one type of exercise programme over another. We conditionally recommend against the addition of a splint to an eccentric exercise protocol and we do not recommend the use of orthoses to improve pain and function in Achilles tendinopathy.

The Consensus on Exercise Reporting Template (CERT) applied to exercise interventions in musculoskeletal trials demonstrated good rater agreement and incomplete reporting

OBJECTIVE

To determine inter-rater agreement and utility of the Consensus on Exercise Reporting Template (CERT) for evaluating reporting of musculoskeletal exercise trials.

STUDY DESIGN AND SETTING

Two independent reviewers applied the CERT to a random sample of 20 exercise trials published 2010 to 2015 identified from searches of PEDro, CENTRAL, and PubMed. Reviewers recorded whether each item criterion was met and detailed missing data, and appraisal time percent agreement and the Prevalence and Bias Adjusted Kappa (PABAK) statistic were used to measure inter-rater agreement.

RESULTS

The trials included a range of musculoskeletal conditions (back/neck pain, hip/knee osteoarthritis, tendinopathies). For percent agreement, inter-rater agreement was high (13 items ≥80%) and for PABAK substantial (nine items: 0.61-0.80) and excellent (three items: 0.81-1.0). Agreement was lower for starting level decision rule (percent agreement: 55%, PABAK 0.30); tailoring of exercise (%A: 65%, PABAK 0.40 [95% CI: 0.00 to 0.80]); exercise equipment (percent agreement: 70%, PABAK 0.30); and motivation strategies (percent agreement: 70%, PABAK 0.40). Sixty percent of descriptions were missing information for ≥50% of CERT items. Mean appraisal time was 30 minutes, and the majority of interventions required access to other published papers.

CONCLUSIONS

The CERT has good inter-rater agreement and can comprehensively evaluate reporting of exercise interventions. Most trials do not adequately report intervention details, and information can be difficult to obtain. Incomplete reporting of effective exercise programs may be remedied by using the CERT when constructing, submitting, reviewing, and publishing articles.

[Effect of different intensity treadmill training on repair of micro-injured Achilles tendon in rats]

Objective

To explore the effect of different intensity treadmill training on the repair of micro-injured Achilles tendon induced by collagenase in rats.

Methods

Seventy-two 8-week-old male Sprague Dawley rats (weighing, 200-250 g) were selected. After adaptive treadmill training for 1 week, rats were injected with 30 μL type I collagenase solution (10 mg/mL) into both Achilles tendons to make micro-injured Achilles tendon models. After 1 week of cage feeding, the rats were randomly divided into 3 groups: the control group, the low-intensity group, and the high-intensity group, 24 rats each group. The rats in control group could move freely, and the rats underwent daily treadmill training at the intensity of 13 m/min and 20 min/d in the low-intensity group and at the intensity of 17 m/min and 60 min/d in the high-intensity group. At immediate, 1 week, and 4 weeks after training, bilateral Achilles tendons were collected from 8 rats of each group for gross observation, histological analysis, and mechanical testing.

Results

At immediate after training, there was no significant difference in the gross observation, histological observation, and biomechanical properties of the Achilles tendon between groups ( P>0.05). The gross observation showed connective tissue hyperplasia near Achilles tendon and lackluster tendon in each group at 1 week; hyperplasia significantly reduced in the low-intensity group when compared with the control group, and there were more connective tissue and a large number of neovascularization in the high-intensity group at 4 weeks. At 1 week, there was no significant difference in the semi-quantitative histological total score between groups ( P>0.05), but there were significant differences in vascularity between low-intensity group or high-intensity group and control group ( P<0.05). At 4 weeks, the semi-quantitative histological total score was significantly higher in high-intensity group than control group and low-intensity group ( P<0.05), and in control group than low-intensity group ( P<0.05). There were significant differences in collagen arrangement, cell morphology, abnormal cells, and vascularity between low-intensity group and high-intensity group or control group ( P<0.05). And there was significant difference in abnormal cells between high-intensity group and control group ( P<0.05). The mechanical testing showed that there was no significant difference in cross-sectional area of the Achilles tendon, the ultimate force, tensile strength, and elastic modulus between groups at 1 week ( P>0.05); the low-intensity group was significantly higher than the control group in the ultimate force and the tensile strength ( P<0.05), and than high-intensity group in the ultimate force and elastic modulus ( P<0.05), but no significant difference was found in the other indexes between groups ( P>0.05) at 4 weeks.

Conclusion

Low-intensity treadmill training can promote the repair of rat micro-injured Achilles tendon induced by collagenase.

Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial

BACKGROUND

Previous studies have shown that eccentric training has a positive effect on Achilles tendinopathy, but few randomized controlled trials have compared it with other loading-based treatment regimens.

PURPOSE

To evaluate the effectiveness of eccentric training (ECC) and heavy slow resistance training (HSR) among patients with midportion Achilles tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 58 patients with chronic (>3 months) midportion Achilles tendinopathy were randomized to ECC or HSR for 12 weeks. Function and symptoms (Victorian Institute of Sports Assessment-Achilles), tendon pain during activity (visual analog scale), tendon swelling, tendon neovascularization, and treatment satisfaction were assessed at 0 and 12 weeks and at the 52-week follow-up. Analyses were performed on an intention-to-treat basis.

RESULTS

Both groups showed significant (P < .0001) improvements in Victorian Institute of Sports Assessment-Achilles and visual analog scale from 0 to 12 weeks, and these improvements were maintained at the 52-week follow-up. Concomitant with the clinical improvement, there was a significant reduction in tendon thickness and neovascularization. None of these robust clinical and structural improvements differed between the ECC and HSR groups. However, patient satisfaction tended to be greater after 12 weeks with HSR (100%) than with ECC (80%; P = .052) but not after 52 weeks (HSR, 96%; ECC, 76%; P = .10), and the mean training session compliance rate was 78% in the ECC group and 92% in the HSR group, with a significant difference between groups (P < .005).

CONCLUSION

The results of this study show that both traditional ECC and HSR yield positive, equally good, lasting clinical results in patients with Achilles tendinopathy and that the latter tends to be associated with greater patient satisfaction after 12 weeks but not after 52 weeks.

Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols

Although eccentric exercise training has shown favorable results in chronic mid-portion Achilles tendinopathy, the optimum dosage remains unknown. A systematic review of the literature was performed in accordance with the PRISMA guidelines, in order to describe different exercise protocols and to determine the most effective training parameters. An extensive search in MEDLINE, EMBASE, CINAHL, and CENTRAL revealed 14 randomized and clinical controlled trials. Strong evidence was found for the Alfredson exercise protocol. In this 12-week protocol, exercises are performed 3 × 15 repetitions twice daily, both with a straight and bent knee. Exercises are performed at slow speed, and load is increased when exercises are without pain. Strong evidence was also found for gradual onset of exercises during the first week of the Alfredson program, but no uniformity of protocols exists. Other exercise protocols did achieve similar results, but many studies had some methodological shortcomings or lacked a detailed description of their training parameters. Because of the heterogeneity of study populations and outcome measures, and lack of reporting of training compliance data, a definitive conclusion regarding the most effective training parameters could not be made. Further research comparing the content of different exercise protocols is warranted.

Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To compare the effectiveness of the Alfredson eccentric heel-drop protocol with a "do-as-tolerated" protocol for nonathletic individuals with midportion Achilles tendinopathy.

BACKGROUND

The Alfredson protocol recommends the completion of 180 eccentric heel drops a day. However, completing this large number of repetitions is time consuming and potentially uncomfortable. There is a need to investigate varying exercise dosages that minimize the discomfort yet retain the clinical benefits.

METHODS

Twenty-eight individuals from outpatient physiotherapy departments were randomized to either the standard (n = 15) or the do-as-tolerated (n = 13) 6-week intervention protocol. Apart from repetition volume, all other aspects of management were standardized between groups. Tendinopathy clinical severity was assessed with the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire. Pain intensity was assessed using a visual analog scale (VAS). Both were assessed at baseline, 3 weeks, and 6 weeks. Treatment satisfaction was assessed at week 6. Adverse effects were also monitored.

RESULTS

There was a statistically significant within-group improvement in VISA-A score for both groups (standard, P = .03; do as tolerated, P<.001) and VAS pain for the do-as-tolerated group (P = .001) at week 6, based on the intention-to-treat analysis. There was a statistically significant between-group difference in VISA-A scores at week 3, based on both the intention-to-treat (P = .004) and per-protocol analyses (P = .007), partly due to a within-group deterioration at week 3 in the standard group. There were no statistically significant between-group differences for VISA-A and VAS pain scores at week 6, the completion of the intervention. There was no significant association between satisfaction and treatment groups at week 6. No adverse effects were reported.

CONCLUSION

Performing a 6-week do-as-tolerated program of eccentric heel-drop exercises, compared to the recommended 180 repetitions per day, did not lead to lesser improvement for individuals with midportion Achilles tendinopathy, based on VISA-A and VAS scores.

Biomechanics of the heel-raise test performed on an incline in two knee flexion positions

BACKGROUND

Although single-legged heel-raise cycles are often performed on an incline in different knee flexion positions to discriminate the relative contribution of the triceps surae muscles, detailed kinematic and kinetic analyses of this procedure are not available. Our study characterizes and compares the biomechanics and clinical outcomes of single-legged heel-raise cycles performed to volitional exhaustion on an incline with the knee straight (0°) and bent (45°), considering the effect of sex and age.

METHODS

Fifty-six male and female volunteers, with equal numbers of younger (20 to 40 years of age) and older (40 to 60 years of age) individuals, completed a maximal number of heel-raise cycles on an incline at both nominal knee angles. Kinematic and kinetic data were acquired during testing using a 3D motion capturing system and multi-axial force plate. The impact of fatigue on performance was quantified using changes in maximal voluntary isometric contraction force and biomechanical performance of cycles.

FINDINGS

Overall, participants completed three more cycles and maintained better biomechanical performance with 45° than 0° of knee flexion. More precisely, the decreases in maximal heel-raise heights, plantar-flexion angles at maximal height and ranges of ankle motion per cycle were all smaller with the knee bent. However, several outcomes indicated similar plantar-flexion fatigue at both knee angles. Males demonstrated a more rapid decline in peak ground reaction forces during testing; but otherwise, neither sex nor age significantly impacted outcomes.

INTERPRETATION

It is concluded that the differences discerned here in the biomechanics of single-legged heel-raise cycles performed at 0° and 45° of knee flexion to volitional exhaustion on an incline may be too small to identify in clinical settings or reflect substantial alterations in the relative contribution of the triceps surae muscles.