Pain Enduring Eccentric Exercise for the Treatment of Chronic Achilles Tendinopathy

Claire Dixon Laureen Holloway Janice Meier Nick Lo Teresa Lee Supervisors: W Darlene Reid Ph.D. & Sunita Mathur Ph.D.

Outline
Introduction Methods Results Discussion Recent Research

Why we chose this topic

Increased interest in pain enduring eccentric exercise as a focus of treatment for chronic Achilles tendinopathy Closer examination of the literature needed due to ethical concerns of pushing patients through pain Update on current body of knowledge and consensus on treatment

Introduction to the Topic

Achilles Tendinopathy (Tendinosis, Partial Rupture, Tendinitis)

Background
One of the most common injuries in runners and other sports participants (Kvist, 1994); also seen in sedentary individuals
(Afredson & Lorentzon, 2000)

Risk factors, but no definitively known etiology

Predisposing factors
(McCrory et al., 1999)
1999)

Weak plantar flexors, larger inversion angle on touchdown, over-pronation Decreased dorsiflexion range (Kaufmann et al.,

Increase in level of activity (Cook et al., 2002) Running- inconsistent stretching, many years of running (McCrory et al., 1999) Poor footwear (Hess et al., 1989)

Pathology
Irregular tendon structure with collagen degeneration and increased glycosaminoglycans (Alfredson & Lorentzon, 2003) Neovascularization in area, with increase in glutamate and lactate levels (Ohberg & No inflammatory cells (Ohberg & Alfredson, 2004)

Alfredson, 2004)

Signs and Symptoms

Mild or severe pain Tenderness on palpation, nodule? Decreased strength Decreased range of movement Decreased function Pain may be gradual or more sudden; most often associated w/tendon loading

Conventional treatments
Joint and soft tissue mobilizations Concentric exercises Stretching exercises Ultrasound Ice Iontophoresis Laser Friction massage Splinting Orthotics NSAIDs Corticosteroids Activity modification Rest Surgery

Pivotal Article
Increased interest in 1998 with Alfredson et als study out of Sweden Initiated a series of studies

Methods

Chronic Achilles Tendinosis Operational definition

Chronic- greater than 3 months Degenerative changes 2-7cm above the calcaneal tendon

Literature Search
Electronic databases, reference lists, experts in the field, hand searches, gray literature searches Results:
4 RCTs 4 Cohorts

Not a lot of information, relatively new topic

Article Selection
259 articles found initially X 154 not Achilles X 32 not primary research X 21 not eccentric intervention X 20 inappropriate outcome measures X 15 surgical patients X 3 did not push through pain X 2 subjects not human X 2 in a language other than English X 2 same study, different journal! 8 appropriate articles

Quality Assessment and Levels of Evidence

Adapted Megens and Harris Scale
Scores of <5 were Weak Scores of 5, 6, 7 were Moderate Scores of 8, 9, 10 were Strong

Sacketts Levels of Evidence

1 to 5 scale

Results

Subjects
Age: Range 19-77 yrs, average 47 yrs Sex: average ratio of M:F 21:10 Location:
mid-portion 7/8 papers mixed mid and insertional 1/8 papers

Duration of Symptoms:
Average 16.4 months

Activity levels:
Wide variety but all appeared to be active prior to injury

Method of Diagnosis
Clinical exam and ultrasonography
5/8 studies

Clinical exam and MRI

1/8 studies

Clinical exam alone

2/8 studies

Intervention
Alfredson et al 1998 eccentric protocol:
3 sets of 15 reps eccentric heel drops 2x/day, 7days/week for 12 weeks Work through nondisabling pain Progressively add weight

Intervention
6/8 studies used the Alfredson eccentric protocol 1/8 used a variation of the Alfredson protocol
gradually increased reps to reduce soreness

1/8 used a 12 week series of primarily eccentric exercises

Control Groups
Conventional Treatments:
Surgery Pain free concentric exercises Pain free stretching Night splint Night splint with eccentric exercises

Others:
Insertional tendinopathies Contralateral tendon

No control!

Outcome Measures
Pain outcome measures:
VAS Questionnaires Subjective expression of pain

Function outcome measures:

Ability to return to pre-injury activity Jumping height Plantar flexion ROM at the ankle Calf muscle strength Global assessment

Results: Pain
At 12 weeks:
In 5/8 studies pain was significantly improved by an average of 42% In 2/8 studies a significant difference was not apparent at 12 weeks, but was apparent at 6 weeks, 6 months and 1 year In 1/8 studies pain was only qualitatively recorded; after an average of 3.8 years it did not interfere with subjects pre-injury activities

Results: Pain
In 5/8 studies improvements were seen in both the eccentric and control groups Results were on average 34% better in the eccentric groups 2/8 studies showed no difference between the groups; both of these studies involved stretching in the control group

Results: Function
At 12 weeks function improved an average of 42% from baseline in the eccentric groups The control groups also improved an average of 33% from baseline

Quality Assessment & Levels of Evidence

Alfredson et al 1998 Mafi et al 2001 Silbernagel et al 2001 Fahlstrom et al 2003 Ohberg et al 2004 Roos et al. 2004 Shalabi et al. 2004 Norregaard et al 2006 Quality 4/10 3.5/10 10/10 3.5/10 3.5/10 8.5/10 3.5/10 8/10 Levels of Evidence 4 2b 2b 4 4 2b 4 2b

Quality Assessment & Levels of Evidence

Sacketts Levels of Evidence
4 low quality RCTs (Level 2b) 4 prospective cohort studies (Level 4) 100% interrater agreement

Adapted Megens and Harris Scale

3 studies considered strong 5 studies considered weak Average score of all 8 studies was 5.56/10 100% interrater agreement

Discussion

General Critique
Most studies NOT randomized, controlled or blinded - relatively low quality Many studies out of the same centers Varying methods of diagnosis Variety of control groups Variety of outcome measures used

Discussion points
Mid-portion vs. insertional tendinopathy
In 2/8 studies, eccentric exercise protocol LESS effective on insertional tendinopathy Why? More studies needed to confirm

Discussion points
Disproportionately higher number of men to women Is conventional treatment significantly less effective? What about stretching? Ethical responsibility?

Conclusions
Shift towards heavy-load eccentric exercise as a therapeutic intervention The evidence base on the whole is persuasive Suggesting that pain enduring eccentric exercise is superior to conventional treatments

Clinical Recommendations
Initial conservative, non-surgical treatment recommended As it stands evidence is not strong enough to ethically allow us, as practitioners, to encourage patients to push through pain

Update
Sayana & Maffuli, 2006 Determine effectiveness of eccentric exercise protocol for non-athletic patients with achilles tendinosis Prospective study, 34 patients

Update
Langberg et al, 2006 Proposed mechanism for why heavy load eccentric exercise is effective Suggest link between collagen metabolism and recovery from tendon injury

New Research
VISA-A questionnaire as outcome measure (Victorian Institute of Sports Assessment Achilles) Reliable and valid Available in Swedish and English Can be used in research, and clinically

References
Kvist M. Achilles tendon injuries in athletes. Sports Med 1994;18:173-201. Cook JL, Khan KM, Purdam C. Achilles tendinopathy. Man Ther 2002;7:121-130. Alfredson H, Lorentzon R. Chronic achilles tendinosis: Recommendations for treatment and prevention. Sports Med 2000;29:135-146. Maffulli N, Kader D. Tendinopathy of tendo achillis. J Bone Joint Surg Br 2002;84:1-8. McCrory JL, Martin DF, Lowery RB. Etiologic factors associated with achilles tendinitis in runners. Med Sci Sports Exerc 1999;31:1374-1381. Kaufman KR, Brodine SK, Shaffer RA, et al. The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med 1999;27:585-593. Brukner P, Khan K. Clinical Sports Medicine. 4th ed. Sydney, Australia: McGraw-Hill; 2001. Alfredson, H. Chronic midportion Achilles tendinopathy: an update on research and treatment. Clin Sports Med 2003;22:727-741. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic achilles tendinosis. Am J Sports Med 1998;26:360-366. Baechle TR, Earle RW. Essentials of Strength Training and Conditioning. 2nd ed. Champaign: Human Kinetics; 2000. Centre for Evidence-Based Medicine. Levels of Evidence and Grades of Recommendation. Available at: [Link] Accessed June 20, 2006.

References
Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther 2006; 86(7):955-973. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic achilles tendinosis. Knee Surg Sports Traumatol Arthrosc 2001;9:42-47. Silbernagel KG, Thomee R, Thomee P, Karlsson J. Eccentric overload training for patients with chronic achilles tendon pain - a randomized controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports 2001;11:197-206. Fahlstrom M, Jonsson P, Lorentzon R, Alfredson H. Chronic achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 2003;11:327-333. Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med 2004;38:8-11. Roos E, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion achilles tendinopathy - a randomized trial with 1 year follow-up. Scand J Med Sci Sports 2004;14:286-295. Shalabi A, Kristoffersen-Wilberg M, Svensson L. Eccentric training of the gastrocnemius-soleus complex in chronic achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by MRI. Am J Sports Med 2004;32:1286-1296.

References
Norregaard J, Larsen CC, Bieler T, Langberg H. Eccentric exercise in treatment of Achilles tendinopathy [serial online] 2006;4:[17 screens]. Available from: [Link] Accessed May 14, 2006. Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB. Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med 2003;13(1):11-15. Khan KM, Forster BB, Robinson J, Cheong Y, Louis L, Maclean L, Taunton JE. Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br J Sports Med 2003;37:149-153. strm M, Gentz CF, Nilsson P, Rausing A, Sjberg S, Westlin N. Imaging in chronic achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skeletal Radiol 1996;25:615620. Silbernagel KG, Thome R, Karlsson J. Cross-cultural adaptation of the VISA-A questionnaire, an index of clinical severity for patients with Achilles tendinopathy, with reliability, validity and structure evaluations. BMC Musculoskelet Disord 2005;6:12. Robinson JM, Cook JL, Purdam C, Visentini PJ, Ross J, Maffulli N, Taunton JE, Khan KM. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001;35(5):335-341. Sayana MK, Maffulli N. Eccentric calf muscle in non-athletic patients with Achilles tendinopathy. J Sci Med Sport 2006. Langberg H, Ellingsgaard H, Madsen T, Jansson J, Magnusson SP, Aagaard P, Kjaer M. Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports 2006.

Thank you