Eccentric overload training for patients with chronic Achilles tendon pain – a randomised controlled study with reliability testing of the evaluation methods

Abstract

The purpose was to examine the reliability of measurement techniques and evaluate the effect of a treatment protocol including eccentric overload for patients with chronic pain from the Achilles tendon. Thirty-two patients with proximal achillodynia (44 involved Achilles tendons) participated in tests for reliability measures. No significant differences and strong (r=0.56-0.72) or very strong (r=0.90-0.93) correlations were found between pre-tests, except for the documentation of pain at rest (P<0.008, r=0.45). To evaluate the effect of a 12-week treatment protocol for patients with chronic proximal achillodynia (pain longer than three months) 40 patients (57 involved Achilles tendons) with a mean age of 45 years (range 19-77) were randomised into an experiment group (n=22) and a control group (n=18). Evaluations were performed after six weeks of treatment and after three and six months. The evaluations (including the pre-tests), performed by a physical therapist unaware of the group the patients belonged to, consisted of a questionnaire, a range of motion test, a jumping test, a toe-raise test, a pain on palpation test and pain evaluation during jumping, toe-raises and at rest. A follow-up was also performed after one year. There were no significant differences between groups at any of the evaluations, except that the experiment group jumped significantly lower than the control group at the six-week evaluation. There was, however, an overall better result for the experiment group with significant improvements in plantar flexion, and reduction in pain on palpation, number of patients having pain during walking, having periods when asymptomatic and having swollen Achilles tendon. The controls did not show such changes. Furthermore, at the one-year follow-up there were significantly more patients in the experiment group, compared with the control group, that were satisfied with their present physical activity level, considered themselves fully recovered, and had no pain during or after physical activity. The measurement techniques and the treatment protocol with eccentric overload used in the present study can be recommended for patients with chronic pain from the Achilles tendon.

Iontophoresis with or without dexamethazone in the treatment of acute Achilles tendon pain

“…Khan and co-workers (2003b) The literature describes various types of treatment including rest, modalities, orthotics, anti-inflammatory medication, exercise and surgery (Józsa and Kannus, 1997, Kader et al, 2002, Paavola et al, 2002a, Alfredson, 2003c. Despite the high incidence of Achilles tendon disorders and the various recommended treatments only nine randomized treatment trials can be found in the literature (Lowdon et al, 1984, Niesen-Vertommen et al, 1992, Mafi et al, 2001, Silbernagel et al, 2001, Neeter et al, 2003, Peers, 2003a, Paoloni et al, 2004, Roos et al, 2004, Alfredson and Öhberg, 2005d. The type of treatment that is most effective for patients with Achilles tendinopathy and the criteria that should be used when choosing treatment are also unclear (Józsa and Kannus, 1997, Kader et al, 2002, Paavola et al, 2002a, Alfredson, 2003c.…”

“…Studies of the effect of strengthening exercise on tendon are almost non-existent, apart from a study by Simonsen and coworkers (1995), who found no effect from strength training on tendon in rats. Strength training has, however, been shown to have positive effect on injuries to the Achilles tendon (Niesen-Vertommen et al, 1992, Alfredson et al, 1998b, Mafi et al, 2001, Silbernagel et al, 2001, Alfredson et al, 2001a, Roos et al, 2004. Endurance type exercise might, however, not have the same effect as strengthening exercise on tendon.…”

“…Several studies report that the incidence of Achilles tendinopathy in runners accounts for 6-18% of all injuries (James et al, 1978, Clement et al, 1984, Lysholm and Wiklander, 1987, Soma and Mandelbaum, 1994, Józsa and Kannus, 1997. The highest incidence is usually reported to occur in middleaged individuals, but the exact age to which age this refers is usually not documented (Kvist, 1994, Paavola et al, 2000a, Silbernagel et al, 2001, Paavola et al, 2002a, Alfredson, 2003c. When studying Achilles tendon injuries in athletes, Kvist (1991) found that the mean age of subjects with Achilles tendon disorders was 28±9 years, while it was 20±8 years in those without these disorders.…”

“…Even with other types of treatment such as surgery, sclerosing injections, modalities and medication, some type of exercise is recommended as a complement to the treatment (Schepsis et al, 1994, Paavola et al, 2000b, Testa et al, 2002, Paavola et al, 2002b, Neeter et al, 2003, Alfredson, 2005a. It has been suggested that the eccentric type of strength training programs are particularly effective in improving muscle function and/or aiding in the healing process of the tendon (Fyfe and Stanish, 1992, Alfredson et al, 1998b, Silbernagel et al, 2001, Roos et al, 2004, Öhberg et al, 2004b. The basis of exercise as treatment is to address possible deficiencies in strength, range of motion, balance, proprioception and function.…”

“…The Achilles tendon and calf muscle strengthening protocol was based on our previous study but has been modified at the clinic over the years ( Figure 27) (Silbernagel et al, 2001). The exercises were performed once a day and the intensity and number of repetitions were based on the patients' status.…”