No Difference in Clinical Effects When Comparing Alfredson Eccentric and Silbernagel Combined Concentric-Eccentric Loading in Achilles Tendinopathy: A Randomized Controlled Trial

Efficacy of ultrasound-guided galvanic electrolysis technique and physical therapy in patients with Achilles' tendinopathy: A pilot randomised controlled trial

BACKGROUND

Ultrasound-guided galvanic electrolysis technique (USGET) is an innovative mini-invasive intervention with the potential to optimise outcomes in the treatment of Achille's tendinopathy (AT).

OBJECTIVE

The aim of this pilot study is to evaluate the efficacy of adding USGET to conventional eccentric exercise treatment in patients with chronic AT.

METHODS

Inclusion criteria were patients with unilateral non-insertional AT, pain lasting > 3 months, aged 25-60 years. Patients were randomised in two groups receiving the same physiotherapy treatment (2 sessions per week for 8 weeks). In addition, the experimental group received three USGET stimulations, one every 15 days. Outcome measures were assessment of Achilles tendinopathy severity using the Victorian Institute of Sport Assessment-Achilles (VISA-A) and pain intensity using the Visual Analogue Scale (VAS). Assessment points occurred at the onset of treatment (T0), its conclusion (T1), and subsequent follow-ups at one (T2) and two months (T3).

RESULTS

Out of the 52 patients who met the study inclusion criteria, two participants withdrew from the study, resulting in a total of 50 subjects who completed the research. None of the parameters showed a different distribution at T1 (p> 0.337). At T2, there was a statistical difference in VISA-A (p= 0.010) and its subscales and VAS (p= 0.002) in the USGET group. At T3, both groups improved with a statistical difference observed in VISA-A (p< 0.001) and its subscales Pain (p= 0.004), Function (p= 0.003) and Sport (p= 0.002), but the EG patients showed a greater improvement. No adverse events were reported.

CONCLUSION

The effect of USGET combined with eccentric exercise appears to be a safe and effective technique for achieving pain relief and functional recovery in the medium term, supporting the integrated use of USGET as a rehabilitative treatment option for patients with chronic AT.

Common Painful Foot and Ankle Conditions: A Review

Importance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are foot and ankle conditions that are associated with pain and disability, but they can respond to nonoperative treatment.

Observations

Morton neuroma, consisting of interdigital neuronal thickening and fibrosis, is characterized by burning pain in the ball of the foot and numbness or burning pain that may radiate to the affected toes (commonly the third and fourth toes). First-line nonoperative therapy consists of reducing activities that cause pain, orthotics, and interdigital corticosteroid injection; however, approximately 30% of patients may not respond to conservative treatment. Plantar fasciitis accounts for more than 1 million patient visits per year in the US and typically presents with plantar heel pain. Fifteen years after diagnosis, approximately 44% of patients continue to have pain. First-line nonoperative therapy includes stretching of the plantar fascia and foot orthotics, followed by extracorporeal shockwave therapy, corticosteroid injection, or platelet-rich plasma injection. Midportion Achilles tendinopathy presents with pain approximately 2 to 6 cm proximal to the Achilles insertion on the heel. The primary nonoperative treatment involves eccentric strengthening exercises, but extracorporeal shockwave therapy may be used.

Conclusions and Relevance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are painful foot and ankle conditions. First-line therapies are activity restriction, orthotics, and corticosteroid injection for Morton neuroma; stretching and foot orthotics for plantar fasciitis; and eccentric strengthening exercises for Achilles tendinopathy.

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.

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.

Determining the feasibility of exercise therapy and activity modification for treating adolescents with heel pain: a study protocol

Calcaneal apophysitis and Achilles tendinopathy are common overuse injuries characterised by insidious posterior heel pain with activity. Calcaneal apophysitis is commonly diagnosed in adolescents, although Achilles tendinopathy is understudied in the adolescent population and is therefore rarely considered until adulthood. Exercise therapy and activity modification have the highest level of evidence for treating Achilles tendinopathy, while calcaneal apophysitis is treated with anecdotal and passive treatment or complete rest. It remains unknown whether exercise therapy is effective for adolescents with heel pain related to either diagnosis.

This is a pilot and feasibility study. Thirty participants between the ages of 7 years and 17 years with posterior heel pain will be recruited from the local community and club sports team and local physicians, school nurses, and athletic trainers through flyers and social media. Participants will be asked to complete evaluations and treatment sessions every 4 weeks with three virtual visits every 2 weeks in between for 12 weeks. All participants will receive standardised treatment consisting of daily Achilles tendon loading exercises and education on pain-guided activity modification. Feasibility outcomes will include recruitment, enrolment, retention and compliance. Clinical outcomes will include the measures of symptom severity, quality of life, tendon morphology and lower extremity function.

This protocol will provide preliminary data to inform a larger clinical trial based on the feasibility of the proposed intervention and methodology. Additionally, the results will provide preliminary evidence on whether Achilles tendon injury occurs in the adolescent population.

The trial is registered with clinicaltrials.gov (ID:1652996).

Foundational Principles and Adaptation of the Healthy and Pathological Achilles Tendon in Response to Resistance Exercise: A Narrative Review and Clinical Implications

Therapeutic exercise is widely considered a first line fundamental treatment option for managing tendinopathies. As the Achilles tendon is critical for locomotion, chronic Achilles tendinopathy can have a substantial impact on an individual's ability to work and on their participation in physical activity or sport and overall quality of life. The recalcitrant nature of Achilles tendinopathy coupled with substantial variation in clinician-prescribed therapeutic exercises may contribute to suboptimal outcomes. Further, loading the Achilles tendon with sufficiently high loads to elicit positive tendon adaptation (and therefore promote symptom alleviation) is challenging, and few works have explored tissue loading optimization for individuals with tendinopathy. The mechanism of therapeutic benefit that exercise therapy exerts on Achilles tendinopathy is also a subject of ongoing debate. Resultingly, many factors that may contribute to an optimal therapeutic exercise protocol for Achilles tendinopathy are not well described. The aim of this narrative review is to explore the principles of tendon remodeling under resistance-based exercise in both healthy and pathologic tissues, and to review the biomechanical principles of Achilles tendon loading mechanics which may impact an optimized therapeutic exercise prescription for Achilles tendinopathy.

Assessment of the reporting quality of resistance training interventions in randomised controlled trials for lower limb tendinopathy: A systematic review

OBJECTIVES

1. To describe what exercises and intervention variables are used in resistance training interventions in randomised controlled trials for lower limb tendinopathy 2. To assess completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework. 3. To assess the implementation of scientific resistance training principles. 4. To assess therapeutic quality of exercise interventions with the i-CONTENT tool.

DATA SOURCES

We searched MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, and the Cochrane library databases.

REVIEW METHODS

Systematic review of randomised controlled trials that reported using resistance exercises for lower limb tendinopathies.

RESULTS

We included 109 RCTs. Eccentric heel drops were the most common exercise (43 studies), followed by isotonic heel raises (21), and single leg eccentric decline squats (18). Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0-13, with an average score of 9/13, and only 7 studies achieved a full 13/13. Reporting of items from the CERT ranged from 0-18, with an average score of 14/19. No study achieved a full 19/19, however 5 achieved 18/19. Scoring for resistance training principles ranged from 1-10, with only 11 studies achieving 10/10. Reporting across studies for the i-CONTENT tool ranged from 2-7, with an average score of 5 across included studies. A total of 19 studies achieved a full 7/7 score. Less than 50% of studies achieved an overall low risk of bias, highlighting the methodological concerns throughout studies.

CONCLUSION

The reporting of exercise descriptors and intervention content was generally high across RCTs for lower limb tendinopathy, with most allowing exercise replication. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

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.