Management

Conservative treatment is the preferred choice for treating AT, especially for a period of 3-6 months (Alfredon & Cook 2007; Longo et al 2009; Ro we et al 2012).

 

 

 

 

Why are eccentric exercises proposed to be effective?

Eccentric exercise can be defined as an overall lengthening of a muscle as it develops tension and contracts to control motion (Camargo et al 2014). This type of training differs from a normal conventional training regimen as the tension generated in muscle fibres when lengthening is proposed to be considerably greater then when muscle fibres are shortening (Camargo et al 2014). These large forces produced eccentrically are hypothesised to induce remodelling response when applied chronically and progressively (LaStayo et al 2003).

 

However, controversy around this remains as studies have shown that peak tendon forces in eccentric loading are of an equal magnitude to concentric loading, thereby suggesting that the tendon force magnitude alone is not  responsible for the therapeutic effects seen with eccentric loading (Rees et al 2008). Furthermore, this study by Rees et al (2008) found that tendons are subjected to continual loading and unloading in a sinusoidal-type pattern during eccentric exercises with high-frequency oscillations in tendon force. This was noted to be largely absent with concentric exercises. They suggest that this pattern of loading and unloading with its force fluctuations may provide an important stimulus for tendon remodelling and may be in fact responsible for the therapeutic benefit associated with eccentric loading (Rees et al 2008). They compare this phenomenon to increases in bone density when bone responds to high-frequency loading.

 

Another possible mechanism is the effect of eccentric exercises in collagen synthesis. Langberg et al (2007) carried out a small study investigating the effect of eccentric exercises on collagen synthesis. All 12 subjects (6 with AT, and 6 healthy ATs) were elite male soccer players, and all 12 performed 12 weeks of heavy resistance eccentric training. Those with AT were found to have increased Type I collagen synthesis after the training while the healthy subjects were unchanged. Furthermore, there was no corresponding decrease in collagen degradation markers, while there was a corresponding decrease in pain levels and return to sport.

 

Another mechanism which has been proposed is ‘pain habituation’ due to completion of several weeks of pain-provoking eccentric exercises. In essence, the person decreases or ceases to respond to pain or pain-related stimuli due to the eccentric exercises (Murtaugh and Ihm 2013). Also, neuromuscular benefits through central adaptation of both agonist and antagonist muscles has been hypothesised (Rees et al 2008). It is clear several possible mechanisms exist, however, exact mechanisms as to why eccentric training appears to optimize the rehabilitation of a painful tendon is of yet not fully known.

 

 

Eccentric Exercise:

The use of eccentric exercise in AT has received considerable attention in the literature (Altman et al 2012). In 1984, Curwin and Stanish pioneered what they deemed ‘eccentric training’ for tendon injuries. Their programme consisted of 3 sets of 10 repetitions of eccentric loading which was progressed weekly according to the pain levels experienced between repetitions 20 and 30. It was reported that out of the 75 participants, 95% of them experienced symptom resolution within 6-8 weeks. Alfredson et al (1998) then made three essential modifications to this protocol. Firstly, they considered pain as part of the normal recovery process and advised patients to continue with the exercises even as pain worsened. If the patient could complete the exercises pain free, additional load was added until pain was provoked. The second moderation involved the exercise itself with no concentric component included in the heel drop which meant the unaffected contralateral limb returns the ankle to the starting position (Altman et al 2012). Additionally, two types of heel drops were included in the program, one with the knee flexed and one with it extended. The final alteration was the number of exercises carried out, Alfredson and colleagues (1998) advised on 180 heel drops a day (3x15 sets twice a day, once with knee flexed and once with knee extended). The control group were awaiting surgery. This 12 week programme resulted in all 15 eccentric exercise participants returning to full activity levels with a significant decrease in pain during activity and a significant improvement in calf muscle strength of the affected side for the intervention group. Consequently, the majority of studies investigating eccentric exercise for AT base it on the Alfredson model.

 

Sussmilch-Leitch et al (2012) completed a systematic review and meta-analysis of the literature for AT in line with the Preferred Reporting of Systematic Reviews and Meta-Analyses (PRISMA) statement. The review included randomized control trials evaluating the effect of at least one non-surgical, non-pharmalogical intervention on pain and/or altered function in AT. No restrictions were placed on the duration of participant symptoms or the length of treatment. Most studies used participants with chronic tendinopathy (3 months +) with the minimum intervention being 6 weeks ranging up to 12 months. A modified version of the PEDro scale was used to assess the methodological quality of the included articles which was shown to have good inter-rater reliability for systematic reviews (Bisset et al 2005). 19 studies were included for review after quality assessment scores and risk of bias were analysed. Criteria which were not met by the least number of studies were blinding of therapists and reporting of reliability and validity of outcome measures. The most commonly used outcome measures were the Visual Analogue Scale (79%) and the Victorian Institute of Sport Assessment –Achilles (VISA-A) questionnaire (37%).

 

Eccentric exercise was the most frequently investigated intervention (17/19 studies) in this systematic review. Effect sizes from a number of RCTs showed eccentric exercise to be effective (Sussmilch-Leitch et al 2012). Nine studies investigated eccentric exercise as a primary interest while the remaining eight studies used eccentric exercise as a control or adjunct intervention. One study (Rompe et al 2008) included participants with insertional tendinopathy and so the results are not applicable to this discussion. Modified PEDro scores ranged from 4/14 to 12/14. Rompe et al (2007) was the only study to compare eccentric exercise to a wait-and-see protocol with the results largely favouring a 12-week eccentric exercise programme with significant improvements in the VISA-A post-intervention (11/14 on modified PEDro scale). Knobloch et al (2007) similarly found significant improvements in pain (VAS) and paratendinous capillary blood flow for eccentric exercise when compared with cryotherapy alone for 12 weeks (7/14).

 

Silbernagel et al (2001) (6/14) compared two interventions for patients with chronic AT. The control group completed similar exercises to the intervention group including calf stretching and bilateral eccentric/concentric heel raises progressed onto unilateral heel raises except for the additional eccentric overload completed by the intervention group which involved eccentric heel drops over step. There was an overall better result for the intervention group who had significant improvements in pain, were satisfied with their activity level and considered themselves ‘fully recvoered’. Similarly, Herrington and McCulloch (2007) (8/14) assessed the benefit of adding eccentric exercise to a multimodal approach of deep friction massage, ultrasound and calf stretching. VISA-A scores showed that the eccentric exercise group experienced a significantly greater improvement in pain and function after 12 weeks compared to the control group. Mafi (2001) and Niesen-Vertommen (1992) compared eccentric exercise to concentric exercise. Mafi (2001) did not complete a between group comparison of pain however significant improvements in VAS scores were seen for both forms of loading, but this was only in the participants who were satisfied with treatment (8/14). Niesen-Vertommen (1992) found participants in the eccentric exercise groups had a significantly greater reduction in pain (4/14).  Costa et al (2005) (12/14) and Chester et al (2008) (7/14) are discussed below as these studies compared eccentric exercise to shockwave therapy and therapeutic ultrasound respectively.  In summary, Sussmitch-Leitch et al (2012) state that eccentric exercise should be an integral component in the management of AT.

 

The results from this systematic review correspond with the clinical practice guidelines for AT recommended by Carcia et al (2010) who found ‘strong’ evidence (a preponderance of level 1 and/or level 2 studies supporting the intervention with at least one level 1 study) for eccentric loading for AT.

 

As mentioned, the majority of studies on eccentric exercise for AT base it on the Alfredson model. Although significant improvements in pain and planter flexor strength were seen in this study, the protocol lacked scientific basis as it was primarily based on clinical experience (Woodley et al 2012). Consequently, different training programmes have originated and the optimum dosage for eccentric exercise remains unclear (Habets and van Cingel 2014).

 

 

Training Parameters for Eccentric Exercise:

Habets and van Cingel (2014) completed a systematic review on 13 randomized and clinical control trials evaluating the effect of eccentric exercise for chronic mid-portion AT. The aim was to investigate which training parameters were most effective for pain and patient reported function. The systematic review was performed in accordance with the PRISMA guidelines. To assess the methodological value of the included studies the author’s used the PEDro scoring tool which has been shown to be reliable for use in systematic reviews (Maher et al 2003). PEDro scores ranged from 8/10 to 1/10. The authors’ state that none of the studies met the criteria regarding the blinding of subjects and therapists’, however blinding therapists or participants to a specific form of exercise is difficult to accomplish. The participants included ranged from 32.5 years to 53.5 years and were both athletes and non-athletes. Only one study reported deterioration in functional activities following an eccentric exercise intervention (Chester et al 2008). This study used a similar protocol to Alfredson et al (1998) but included a 10 second static hold in end range dorsiflexion before returning to the starting position (Chester et al 2008). However, this should be interpreted with caution as the study had a small sample size and limited methodological quality (5/10 Pedro).

 

 

6 out of 13 studies used the Alfredson protocol but only one study explicitly mentioned the weight that was used and information on the speed at which the exercise was performed is lacking in all studies. Alfredon (1998) stated that exercises were performed slowly but failed to provide further details. All studies which used the Alfredson protocol found significant improvements for both pain and function. However other protocols did achieve similar results. Rompe et al (2007) asked patients to perform 1x10 repetitions on the first day and progressed to 3x15 repetitions once daily on the seventh day. From weeks 2-12 they continued according to the Alfredson programme. There was a 49% improvement at 16 weeks follow-up according to the Victorian Institute of Sport Assessment- Achilles (VISA-A). Similarly, Roos et al (2004) gradually progressed exercises beginning with 1x15 for the first two days and progressing to 2x15 for days 3-4 and 3x15 on days 5-7. Exercises were performed with the knee extended for the first week and the original Alfredson protocol was introduced from weeks 2-12.  Significant results were reported but as the authors used a different outcome measure (Foot and Ankle Outcome Score) to other studies which followed the Alfredson procedure vigorously, a comparison to these studies is difficult.

 

 

A few studies used different eccentric training protocols. Petersen et al (2007) prescribed the Alfredson eccentric exercises thrice daily and reported significant improvements in pain and function as measured with the visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score. However, as this was the only study which used that AOFAS and also had some methodological shortcomings (5/10) it is difficult to interpret the results. Knobloch et al (2007) used 3x15 once a day and 2 second speed for the eccentric phase. Pain reduction was 50% but the study was underpowered with only 15 participants. In their other study Knobloch et al (2008) performed 3x15 exercises twice a day and found a 33% reduction in pain but had a more adequate sample size of 54.  Both studies were of moderate methodological quality (6/10). Habets and van Clingel (2014) conclude that that there is no consensus regarding the effectiveness of different training parameters for eccentric exercise programmes. This is due to the heterogeneity in study populations and outcome measures. A lack of data on training compliance also prevents the magnitude of the intervention from being calculated. Habets and van Clingel (2014) acknowledge that no studies have directly compared different eccentric exercise programmes with different training parameters or compared eccentric exercise with other exercise regimens such as concentric-eccentric exercise training, isometric training or heavy-slow resistance training, identifying a gap for future research.

 

 

Is eccentric training the only loading option?

Isolated eccentric muscle training has become the dominant conservative management for AT. Sussmitch-Leitch et al (2012) commented on this prominence in their systematic review as only one of the included studies did not use an eccentric exercise programme as their primary intervention, as a comparison intervention or as a component of a multi-model approach. But in some studies, up to 45% of sedentary participants have not responded to eccentric strengthening (a less than 10 point improvement in the VISA-A) (Sayana and Maffulli 2007). In Maffulli et al (2008) only 60% of participants in an athletic population responded to an intensive heavy load eccentric heel drop regimen alone. Both these studies indicate that eccentric loading may not be effective for all patients with tendinopathy. A systematic review by Malliaras et al (2013) compared clinical outcomes and identified potential mechanisms for effectiveness in Achilles and patellar tendinopathy loading programmes. The four most common loading programmes in articles included in this review can be seen in Table 2.4; eccentric, Silbernagel-combined, Curwin and Stanish and heavy slow resistance (HSR). The Silbernagel-combined programme involves progression from eccentric-concentric to eccentric load and finally faster eccentric-concentric and plyometrics. Stanish and Curwin involves both eccentric and concentric contractions while HSR involves slow double leg isotonic eccentric-concentric contractions with added weight according to the weight you can lift for a defined number of repetitions. Table 2.4 also lists the number of articles which focused on a specific tendon according to the loading programme used.

​

 

 

 

Are isolated eccentric contractions justified clinically?

Rowe et al (2012) completed a mixed methods study incorporating a systematic review of the literature along with clinical reasoning from experts for the conservative management of mid-portion AT. It was found that eccentric loading exercises have the strongest supporting evidence of all the conservative modalities (Rowe et al 2012). Incorporating the second pillar of evidence based practice-clinical expertise, it was also found that clinicians nearly always used eccentric loading exercises for mid-portion AT patients. However, clinicians reported using complex clinical reasoning to adapt the protocols used in research for their individual patients. For example, the need to change regimented eccentric protocols due to patient’s pain and incorporate mixed concentric/eccentric or isometric loading initially (Rowe et al 2012).

 

Malliaras et al (2013) suggest that clinical improvement is not dependent on isolated eccentric loading in AT but do state that other mechanisms of eccentric muscle contraction which do not relate to load potential were not examined in this review. For example two studies (Henriksen et al 2009; Rees et al 2008) found that there are tendon force fluctuations (8-12Hz) with eccentric contraction that are not present during a concentric contraction. It is not known whether this influences muscle tendon adaption or is simply related to motor control differences.

 

The highest level of evidence supported eccentric and Silbernagel-combined loading in the Achilles (moderate evidence) and HSR loading in the patellar (strong evidence). There was limited evidence for Stanish and Curwin and isokinetic loading in the Achilles.  Although eccentric loading is frequently associated with greater muscle-tendon unit load and adaption, Malliaras et al (2013) did not identify any evidence of this among tendinopathy patients. A systematic review by Roig et al (2009) showed that eccentric training resulted in greater muscle strength gains and hypertrophy than concentric loading in healthy patients. However, this did not remain true when the load was equalized suggesting that load intensity rather than contraction type is the stimulus for greater muscle tendon load.

 

In terms of muscle tendon unit compliance and length-tension relationship of the tendon, Malliaras et al (2013) state that clarifying whether contraction type, load intensity or loading range of motion influence outcomes such as ankle range of motion (dorsi and planter flexion) and reduced resistance to passive stretch (muscle-tendon unit compliance) relates to clinical outcomes in tendinopathy may improve effectiveness in rehabilitation. For example, a loading programme which achieves increased muscle-tendon unit compliance may lead to better clinical outcomes in patients with AT who have reduced muscle tendon unit compliance.

Pain

Alfredson et al (1998) hypothesized that painful eccentric calf drops have a direct effect on neurovascular ingrowth which may influence pain. In Sussmitch-Leitch et al (2012), 89% of the studies included in their review adopted the Alfredson approach of allowing pain during exercise. Malliaras et al (2013) did not identify any evidence that a change in glutamate may explain clinical outcomes in tendinopathy. They did state that the popular approach of exposing tendons to progressive eccentric loading whilst monitoring tendon irritability is likely to have some effect on pain perception (Malliaras et al 2013). Pain during exercise may influence patient compliance and Sussmitch-Leitch et al (2012) advise on the use of diaries for monitoring this in future studies so as to determine its effect on patient outcomes.

 

 

Practice Point: Clinicians should consider eccentric-concentric loading alongside or instead of eccentric loading in AT. The gradual progression from eccentric-concentric to eccentric followed by faster loading used in the Silbernagel combined loading programme may benefit patients who are unable to start with an Alfredson eccentric programme due to pain or calf weakness (Malliaras et al 2013). Heavy slow resistance training may be more likely to achieve tendon adaption and may be better suited to patient subgroups such as those with less irritable symptoms or athletes who have high-load demands (Malliaras et al 2013). However, caution is needed in interpreting findings as only two studies, both in the patellar tendon, investigated this mechanism of loading.

  

Maintenance Programmes

Some studies reported neuromuscular and jump performance deficits at 12 months and 5 years, questioning the length of current loading programmes and suggesting that maintenance programmes may be required on return to sport (Malliaras et al 2013). Continued sport, as long as symptoms allow, appears to have a specific positive effect on calf-power and jump performance which is not gained with the Silbernagel loading programme alone even though it includes faster calf loading and stretch-shorten cycle rehabilitation (Malliaras et al 2013). Continued sports may lead to specific gains such as improved jump performance (Silbernagel et al 2007a), however this should be implemented carefully alongside a pain monitoring system (Malliaras et al 2013). Pain was acceptable in rehabilitation programmes in most studies included in this systematic review but the clinician must educate patients about acceptable loading-related pain (Malliaras et al 2013).

 

 

Future Research:

• Should focus on variables within the eccentric training programme such as speed of exercises, duration, rate of progression and loading, chronicity and severity of condition (Rowe et al 2012).

• Future studies need to investigate how load intensity, time under tension, speed, contraction type and other factors influence clinical and mechanistic outcomes rather than accepting isolated eccentric loading as the gold standard for tendinopathy rehabilitation (Malliaras et al 2013).

 

 

 

 

Concentric Exercise

Moderate evidence from Mafi et al 2001 and Niesen-Vertommen et al 1992 suggests that concentric calf muscle training is not as effective as an eccentric training programme. These studies have been discussed in more detail under the ‘Eccentric Exercise’ heading as both studies compared concentric and eccentric programmes and found significantly better reductions in pain for the eccentric group. However, in both studies the concentric group did register some improvement and clinicians frequently use combined eccentric-concentric exercises for patients who cannot tolerate eccentric exercises due to pain or weakness (Rowe et al 2012). This is similar to the work of Silbernagel et al (2007) where patients progressed from combined eccentric-concentric to eccentric exercises.

Future research:

• Guidance on when to introduce combined concentric-eccentric exercises.

 

 

 

Practice Point:

If patient is too sore to complete eccentric loading exercises, consider concentric or isometric loading.

 

 

Shock-wave Therapy

A meta-analysis revealed that shockwave therapy (SWT) and eccentric exercise have similar effects (Sussmitch-Leitch et al 2012). Five studies evaluated the effects SWT on AT using the VISA-A with a mean methodological quality of 11.2 +/- 0.4 out of 14 according to the modified PEDro scale. One study compared SWT to eccentric exercise alone and there were no significant effects for outcome on pain or function at 16 weeks (Rompe et al 2007). In addition, Rompe et al (2007) also had a wait & see group allowing comparisons between control and SWT groups with the results significantly favouring SWT at 16 weeks. Rompe and colleagues (2009) also analysed the combined effects of SWT and eccentric exercise compared to eccentric exercise alone after 16 weeks with moderate significant effects favouring the combined approach. This suggests that utilising SWT in combination with eccentric exercise is likely to have better patient outcomes than SWT or eccentric exercise alone. However, at 12 months follow-up there was no difference in outcomes between the groups. This corresponds with the findings of two high quality double-blind placebo controlled trials (Costa et al 2005, 12/14; Ramussen et al 2008, 11/14) which found that when sham SWT was compared to standard SWT there were no significant differences, suggesting a placebo effect. Furthermore, there are practical considerations regarding the use of SWT. Considering the need for specialised equipment and practitioner training, SWT is an intervention which is not as easy to use or apply when compared to eccentric exercise. Sussmitch- Leitch et al (2012) suggest the use of SWT for patients who cannot or will not use eccentric exercise.

 

 

 

Practice point:

Implementing SWT may be considered an inappropriate addition to the treatment of AT with eccentric exercises being as effective in the long run. But, it may be desirable for athletic patients requiring a quicker recovery and return to sport (Rowe et al 2012).

 

 

Laser

According to Rowe et al (2012) findings, clinicians do not use laser therapy in the treatment of AT as it is perceived as more applicable to acute inflammation and as an expensive device with no good quality evidence to support its use.  However, Rowe et al (2012) found moderate evidence for the addition of laser therapy to an eccentric exercise programme for AT. Stergioulas et al (2008) (8/10 on PEDro) compared eccentric exercise and laser therapy to eccentric exercise plus sham laser therapy over a period of 8 weeks. There was a significant difference in pain according to the VAS at 4, 8 and 12 weeks for the combined group and not the sham group.

 

 Tumilty et al (2008) also compared laser therapy with sham laser therapy in addition to an eccentric exercise programme. Sussmilch-Leitch et al (2012) completed a meta-analysis of the data from Tumilty et al (2008) (10/10 on PEDro) and Sterigoulas et al (2008) which did not support the use of laser therapy in conjunction with eccentric exercise at 4 weeks but did find significant effects favouring the use of laser therapy at 12 weeks. More recent evidence from Tumilty et al (2012) (10/10 on PEDro) found no evidence for the use of laser therapy in conjunction with eccentric exercise according to the VISA-A and VAS, even at 12 weeks follow-up.

 

 

 

Practice point:

Further research is warranted for the use of laser therapy in conjunction with eccentric exercise as the evidence is conflicting.

 

 

Ultrasound

Chester et al (2008) completed a pilot RCT comparing eccentric exercise and ultrasound to eccentric exercises alone for the treatment of AT. At twelve weeks there were no significant differences or clear trends between groups for pain or function according to the VAS and functional index of the leg and lower limb. This was attributed to the small sample size (n=16) and the results for pain and function were deemed inconclusive (Rowe et al 2012).

 

Future research

• Further high-quality research is required to confirm the effectiveness of ultrasound for patients with AT.

 

 

 

Braces/Splints

 Sussmitch-Leitch et al (2012) also conducted a meta-analysis on the results of two studies (McAleenan et al 2010; de Jong et al 2010) which investigated the effects of a night splint to an eccentric exercise programme and found no significant results in terms of function or pain at 12 weeks. There was also no evidence found for the addition of a heel brace to a 12 week eccentric exercise programme (Knobloch et al 2007).  However, Rowe et al (2012) found that clinicians would consider the use of splinting or bracing for patients with failed healing or late-stage tendinopathies.

 

 

 

Practice Point:

There is currently no evidence to support the use of splinting or bracing for AT. However, clinicians have used it as a last resort (Rowe et al 2012)

 

 

Stretching

Stretching has anecdotally been recommended as an intervention for patients with AT and there is little evidence to support its use for preventing or managing AT (Altman et al 2010). One study by Norregaard et al (2006) compared an eccentric exercise programme to a calf-stretching programme for twelve weeks in 45 patients with chronic AT. Although subjects were randomly assigned, there was a lack of methodological quality as the reliability for the outcome measures was not stated and it was unclear how many subjects were ultimately in each group. Follow-up was completed at 3,6,9,12 and 52 weeks. Both groups gradually improved according to the parameters (tendon, tenderness, tendon thickness, self-report symptoms and patient’s global assessment) but it is unclear if this was due to the passage of time, the intervention or a combination of both as there was no control group (Altman et al 2010). 

 

Stretching has been used as an adjunct to some interventions identified in the literature but it has not been investigated as a separate modality (Rowe et al 2012). Range of movement was not considered an important element for AT unless specific joint or muscle restriction were identified by the clinicians in Rowe et al (2012). Some clinicians reasoned for not including stretches so as to avoid compression of the tendon, a loss of strengthening and exacerbating pain (Rowe et al 2012).

 

 

 

Practice Point:

No evidence currently exists to support the use of stretching for AT but equally there is no evidence to confirm that this ‘compresses’ the tendon or that you ‘run the risk’ of making the tendon weaker by doing so. It has been suggested that stretching exercises can be used to reduce pain and improve function in patients who have limited dorsiflexion range of motion in AT.

 

 

Prognosis

The long-term prognosis of AT is generally good when conservative management is used. 4-6 months of conservative management is recommended for before exploring the possibility of surgical management (Carcia et al, 2010). Conservative management generally consists of a 12 week program of heavy-load eccentric exercises, to which up to 90% of individuals are satisfied with results and capable of returning to previous tendon-loading activities (Alfredson & Cook, 2007). A long term follow up (3.8 years mean) post 12 week Alfredson eccentric exercise protocol found reduced tendon thickness and more normal ultrasound imaging , with decreased tendon volume on magnetic resonance imaging (MRI) and 23% decrease in signal intensity (Alfredson & Cook, 2007).

 

Similar results were found in other studies where long-term follow up were applied. After 4.2 years, Gardin et al (2010) found that from using 3 months eccentric exercise program, 95% of patients reported decreased pain, with 65% of these experiencing none or very mild pain on strenuous activity. At follow-up, 85% had improved performance, and 60% had normal performance. Pain and functional measures were significantly better at long-term follow up than before commencement of treatment and immediately after the 3 month exercise program (Gardin et al, 2010). In the same study, 4 patients who did not follow the eccentric exercise protocol showed no improvements in pain or function at 17 month follow-up. This suggests good long-term prognosis following eccentric training and conservative management (Gardin et al, 2010).

 

Since the popularisation of the eccentric strengthening protocol for AT, conservative management has become a more effective means of treating the condition. Alfredson & Cook (2007) reported that when eccentric strengthening was used 82% of patients return to their previous level of physical activity, whereas when concentric strengthening was chosen, only 36% of patients report satisfaction and return to full previous levels of physical activity. This is evident when the management from the 1990s and early 2000 is brought into question. When patients were treated with relative rest and activity modification, as well as stretching of the triceps surae and peritendinous corticosteroid injections 24%-49% of AT patients were treated surgically (Paavola et al, 2000). Within their own population 29% required surgical management between onset of symptoms and 8 year follow up due to failure of conservative management (Paavola et al, 2000). At a similar time, when a 12 week eccentric exercise protocol was adhered to, just 7% of patients required surgical intervention at 2-year follow up (Alfredson & Lorentzen, 2000). This is comparable to results found 7 years later using the same protocol, when 90% of individuals were satisfied with their treatment results (Alfredson & Cook, 2007).

 

Surgical management is an invasive procedure which involves the removal of fibrotic adhesions and degenerative nodules to restore vascularity (Carcia et al, 2010). Surgery is normally a percutaneous tenotomy, or an open procedure, which is designed to irritate the tendon and initiate a chemically mediated healing response (Alfredson & Cook, 2007). Percutaneous tenotomy leads to good/excellent results at 18 month follow up, with 67% of individuals returning to full physical activity within 7 months. It has been suggested that the results of surgical intervention are dependent on the extensive rehabilitation post-surgery, and that the results may not be as favourable for those who do not perform adequate rehabilitation to gain full strength and functional capacity (Alfredson & Cook, 2007).

 

Future Directions

Though evidence strongly supports eccentric based exercise interventions, other loading protocols have been introduced, with potentially promising results. The implementation of Heavy Slow Resistance (HSR) has begun in the treatment of both patellar and the Achilles tendinopathies. The research surrounding the use of HSR is in its infancy, though promising results have been shown in the patella (Kongsgaard et al, 2009; Kongsgaard et al, 2010). A systematic review by Malliaras et al (2013) identified a strong potential for the use of HSR in patellar tendinopathy, though suggested that research evidence was currently lacking for its application in AT due to no RCTs being carried out on this. Further research focussing on HSR as a treatment modality for AT is currently underway, and the results of this study are anticipated.

 

Though little research evidence exists for its clinical application, some clinicians believe that isometric contractions have an analgesic effect on tendon pain associated with AT. Their use has been identified to load the tendon without increasing pain in reactive and painful tendinopathy, and to continue loading a tendon which has become increasingly painful following eccentric exercises for the treatment of AT. Information gathered around this was from clinical expertise, though research into the subject area and clinical utility of this contraction type is currently underway.

 

 

Key References

• Sussmilch-Leitch, S.P., Collins, N.J., Bialocerowski, A.E., Warden, S.J. and Crossley, K.M. (2012) ‘Physical therapies for Achilles tendinopathy: systematic review and meta-analysis’ Journal of Foot and Ankle Research, 5(1), 1-15.

• Malliaras, P., Barton, C.J., Reeves, N.D. and Langberg, H. (2013) ‘Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness’ Sports Medicine, 43(4), 267-286.

• Rowe, V., Hemmings, S., Barton, C., Malliaras, P., Maffulli, N. and Morrissey, D. (2012) ‘Conservative management of midportion Achilles tendinopathy; A mixed methods study, integrating systematic review and clinical reasoning’ Sports Medicine, 42(11), 941-967.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.1 Prevalance

76

3.2 Risk Factors

76-80

3.3 Clinical Presentation

80

3.4 Assessment and Diagnosis

81-85

3.5 Differential Diagnosis

85-87

3.6 Treatment and Management

88-106

3.7 Outcome Measures

107-109