An Isometric and Functionally Based 4-Stage Progressive Loading Program in Achilles Tendinopathy: A 12-Month Pilot Study (original) (raw)
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Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy
Apunts. Medicina de l'Esport, 2018
Achilles and patellar tendons are commonly affected by tendinopathy. Injury to these tendons can severely impact upon sports, recreational and everyday activities. Eccentric musculotendinous loading has become the dominant conservative intervention strategy for Achilles and patellar tendinopathy over the last two decades. Eccentric loading involves isolated, slow lengthening muscle contractions. Systematic reviews have evaluated the evidence for eccentric muscle loading in Achilles and patellar tendinopathy, concluding that outcomes are promising but high-quality evidence is lacking. Eccentric loading may not be effective for all patients (athletes and non-athletes) affected by tendinopathy. It is possible that in athletes, eccentric work is an inadequate load on the muscle and tendon. A rehabilitation program aiming to increase tendon load tolerance must obviously include strength exercises, but should also add speed and energy storage and release. The aim of this paper is to document a rehabilitation protocol for Achilles and patellar tendinopathy. It consists of simple and pragmatic exercises designed to incorporate progressive load to the tendon: isometric work, strength, functional strength, speed and jumping exercises to adapt the tendon to the ability to store and release energy. This article would be the first step for an upcoming multicentre randomized controlled trial to investigate its efficacy.
Sports Medicine - Open, 2022
Background: Assuming that the mechanisms inducing adaptation in healthy tendons yield similar responses in tendinopathic tendons, we hypothesized that a high-loading exercise protocol that increases tendon stiffness and cross-sectional area in male healthy Achilles tendons may also induce comparable beneficial adaptations in male tendinopathic Achilles tendons in addition to improving pain and function. Objectives: We investigated the effectiveness of high-loading exercise in Achilles tendinopathy in terms of inducing mechanical (tendon stiffness, maximum strain), material (Young's modulus), morphological (tendon cross-sectional area (CSA)), maximum voluntary isometric plantar flexor strength (MVC) as well as clinical adaptations (Victorian Institute of Sports Assessment-Achilles (VISA-A) score and pain (numerical rating scale (NRS))) as the primary outcomes. As secondary outcomes, drop (DJ) and counter-movement jump (CMJ) height and intratendinous vascularity were assessed. Methods: We conducted a controlled clinical trial with a 3-month intervention phase. Eligibility criteria were assessed by researchers and medical doctors. Inclusion criteria were male sex, aged between 20 and 55 years, chronic Achilles tendinopathy confirmed by a medical doctor via ultrasound-assisted assessment, and a severity level of less than 80 points on the VISA-A score. Thirty-nine patients were assigned by sequential allocation to one of three parallel arms: a high-loading intervention (training at ~ 90% of the MVC) (n = 15), eccentric exercise (according to the Alfredson protocol) as the standard therapy (n = 15) and passive therapy (n = 14). Parameters were assessed pre-and-postintervention. Data analysis was blinded. Results: Primary outcomes: Plantar flexor MVC, tendon stiffness, mean CSA and maximum tendon strain improved only in the high-loading intervention group by 7.2 ± 9.9% (p = 0.045), 20.1 ± 20.5% (p = 0.049), 8.98 ± 5.8% (p < 0.001) and −12.4 ± 10.3% (p = 0.001), respectively. Stiffness decreased in the passive therapy group (−7.7 ± 21.2%; p = 0.042). There was no change in Young's modulus in either group (p > 0.05). The VISA-A score increased in all groups on average by 19.8 ± 15.3 points (p < 0.001), while pain (NRS) dropped by −0.55 ± 0.9 points (p < 0.001). Secondary
Introduction Achilles and patellar tendinopathy are overuse injuries that are common among athletes. Isolated eccentric muscle training has become the dominant conservative management strategy for Achilles and patellar tendinopathy but, in some cases, up to 45 % of patients may not respond. Eccentric-concentric progressing to eccentric (Silbernagel combined) and eccentric-concentric isotonic (heavy-slow resistance; HSR) loading have also been investigated. In order for clinicians to make informed decisions, they need to be aware of the loading options and comparative evidence. The mechanisms of loading also need to be elucidated in order to focus treatment to patient deficits and refine loading programmes in future studies. Objectives The objectives of this review are to evaluate the evidence in studies that compare two or more loading programmes in Achilles and patellar tendinopathy, and to review the non-clinical outcomes (potential mechanisms), such as improved imaging outcomes, associated with clinical outcomes.
BMC Musculoskeletal Disorders, 2021
Background Achilles tendinopathy (AT) is a common overuse injury in running-related sports where patients experience pain and impaired function which can persist. A graded rehabilitation program has been successful in reducing pain and improving function to enable a return to sport. The aim of this study is to compare the effectiveness of a criteria-based rehabilitation program including strength and reactive strength targets, with a previously successful rehabilitation program on changes in pain and function using the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire. Secondary aims will be to assess changes in calf strength, reactive strength, and lower limb running and forward hop biomechanics over the course of a 12-week rehabilitation program, and long-term follow-up investigations. Methods Sixty eligible participants with chronic mid-portion AT who train in running-based sports will be included in this study. They will be randomly assigned to a group that...
Isokinetics and Exercise Science, 2006
This review assessed the effectiveness of eccentric exercise training for patients with Achilles tendinopathy. The authors concluded that eccentric exercise training resulted in modest but significant post-treatment clinical benefits. Owing to the uncertain quality of the included studies and the poor reporting of some of the review processes, these conclusions should be interpreted with caution. Authors' objectives To determine whether eccentric exercise training is effective in the treatment of patients with Achilles tendinopathy. Searching The authors searched the following internet sources and websites: PubMed, the Cochrane Library, PEDro, Evidence-Based Medicine and Hooked on Evidence. They also searched the reference lists of key research studies. The searches were restricted to clinical studies published within the last 10 years and basic science research published within the last 15 years. The authors did not state whether any language restrictions were applied. Study selection Study designs of evaluations included in the review Clinical studies of any design and basic science research were eligible for inclusion in the review. Specific interventions included in the review Studies that assessed eccentric exercise training, a physical therapy intervention, were eligible for inclusion. The patients in the included studies were given eccentric exercises, eccentric overload, eccentric/concentric stretching, or eccentric exercises and a splint for 12 weeks' duration. The control interventions, where present, were rest/surgery, exercise without pain, night splint and concentric exercises. Participants included in the review Studies of patients with Achilles tendinopathy were eligible for inclusion. Where reported, the studies included patients who were minimally active, were recreational athletes, or were active in competitive sports. In the included studies, the average age of the patients ranged from 44 to 51 years and the duration of their symptoms ranged from over 4 weeks to 20 years, where reported. Outcomes assessed in the review The outcomes of interest were pain reduction, return to normal activity in the short term, rehabilitation of the tendon, and prevention of re-injury in the long term. The included studies assessed concentric plantar flexion, pain, pain at rest, pain with activity, pain on palpation, toe raise, tendon thickness and tendon volume. Pain was assessed using a visual analogue scale or by scoring from 1 to 6 or 0 to 100. Tendon thickness was measured using ultrasound, while tendon volume was measured using magnetic resonance imaging.
International Journal of Sports Physical Therapy, 2012
Background: Achilles tendinopathy (AT) is a common pathology and the aetiology is unknown. For valid and reliable assessment The Victorian Institute of Sports Assessment has designed a self-administered Achilles questionnaire, the VISA-A. The aim of the present study was to evaluate VISA-A as an outcome measure in patients with AT. Methods: A systematic search of the literature was conducted using MEDLINE, EMBASE, CINAHL, PEDro, Web of Science, and Cochrane Controlled trials to identify trials using VISA-A for patients with AT. This was followed by data mining and analysis of the obtained data. Results: Twenty-six clinical trials containing 1336 individuals were included. Overall mean VISA-A scores ranged from 24 (severe AT) to 100 (healthy). Mean VISA-A scores in patients with AT ranged from 24 to 96.6. Healthy subjects scored a minimum of 96. Only two groups of participants from two different studies had a post-VISA-A score as high as healthy individuals, indicating full recovery of the AT. Conclusions: A VISA-A score lower than 24 is rarely attained in AT. Only few patients with AT reach an equivalent VISA-A score compared to uninjured healthy subjects following treatment. The VISA-A is a reliable tool when assessing AT patients, providing a good assessment of the actual condition from very poor, (score around 24) to excellent (a score of 90), which based on this systematic review and previous studies could be considered full recovery from AT.
BMC Musculoskeletal Disorders
Background: Midportion Achilles tendinopathy (AT) is a common overuse injury, usually requiring several months of rehabilitation. Exercise therapy of the ankle plantar flexors (i.e. tendon loading) is considered crucial during conservative rehabilitation. Alfredson's isolated eccentric and Silbernagel's combined concentric-eccentric exercise programs have both shown beneficial results, but it is unknown whether any of these programs is superior for use in clinical practice. Therefore, the primary objective of this study is to compare the effectiveness of both programs on clinical symptoms. Secondary objectives are to compare the effectiveness of both programs on quality of life and functional outcome measures, to investigate the prognostic value of baseline characteristics, to investigate differences in cost-effectiveness. Methods/Design: Eighty-six recreational athletes (21-60 years of age) with unilateral chronic midportion AT (i.e. ≥ 3 months) will be included in this multicenter assessor blinded randomized controlled trial. They will be randomly allocated to either a group performing the Alfredson isolated eccentric training program (n = 43), or a group performing the Silbernagel combined concentric-eccentric program (n = 43). In the Alfredson group, participants will perform eccentric heel-drops on their injured side, twice daily for 12 weeks, whereas in the Silbernagel group, participants perform various concentric-eccentric heel-raise exercises, once daily for 12 weeks. Primary outcome measure will be the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire. Secondary outcomes will be a visual analogue scale (VAS) for pain during daily activities and sports, duration of morning stiffness, global perceived effect, the 12-item Short Form Health Survey and the Euroqol instrument, and functional performance measured with the heel-raise test and the countermovement jump. Additionally, alongside the RCT, a costeffectiveness analysis will be performed. Assessments will be performed at baseline and after 12, 26, and 52 weeks. Discussion: This study is the first to directly compare the Alfredson and the Silbernagel exercise program in a randomized trial. The results can further enlarge the evidence base for choosing the most appropriate exercise program for patients with midportion AT.
Introduction: Tendinopathy is a term used commonly to describe any painful condition occurring within or around a tendon. It can result from overuse and is experienced as pain with activity, focal tenderness to palpation, and decreased ability to tolerate tension, which results in decreased functional strength. Achilles tendinopathy is one of the most common tendinopathies which athelete and non-athlete individuals or recreational individuals suffer. Treatment of tendonitis begins with avoidance of aggravating movements. Other means of treatment include icing the injured tendon, ultrasound therapy, and physical therapy. To prevent and avoid tendonitis in the future, slowly increase the intensity and type of exercise. Eccentric loading have become an important therapeutic regimen and broadly used in case of tendinitis. Material and Method: The study was of a single blind, randomized clinical trial with 30 subjects, 19 were female, 11 were male, and all subjects were assigned according to criteria (inclusion & exclusion) and carried out at physiotherapy OPD of CSS Hospital, Meerut. Severity of Achilles tendon & pain were assessed by using the VISA-A & VAS score respectively. The subjects were reassessed after completion of 3 weeks of intervention. The collected data were of mean and standard deviation of VISA-A questionnaire and VAS score and has been analyzed using SPSS software. The study was done to find out the efficacy of eccentric loading in reducing pain and severity in patients with Achilles tendinopathy. Results: The results showed that there was significant difference in pain and severity with their VAS and VISA-A score (p=0.01)respectively. Conclusion: Study concluded that the difference from 1st to 21st day in VAS & VISA-A score which shows that eccentric loading is effective to decrease pain and severity in patients with Achilles tendinopathy.
Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review
British Journal of Sports Medicine, 2007
Background: Eccentric overload training seems to be a promising conservative intervention in patients with chronic Achilles tendinopathy. The efficacy of eccentric overload training on the outcome measures of pain and physical functioning are not exactly clear. Study design: Systematic review of the literature. Methods: Electronic databases were searched for randomised clinical trials concerning eccentric overload training in patients with chronic Achilles tendinopathy. The Delphi list was used to assess the methodological quality of the studies. Results: Nine clinical trials were included. Only one study had sufficient methodological quality. The included trials showed an improvement in pain after eccentric overload training. Because of the methodological shortcomings of the trials, no definite conclusion can be drawn concerning the effects of eccentric overload training in patients with chronic Achilles tendinopathy. Conclusion: The effects of eccentric exercise training in patients with chronic Achilles tendinopathy on pain are promising; however, the magnitude of the effects cannot be determined. Large, methodologically sound studies from multiple sites in which functional outcome measures are included are warranted.