Published online: 2021-03-29

Clinical Sciences Thieme

Immediate Effects of two Isometric Calf Muscle Exercises on

Mid-portion Achilles Tendon Pain

Authors
Ben Bradford1, Ebonie Rio2, Myles Murphy3, Jacob Wells1, Mizanur Khondoker4, Celia Clarke1, York Chan5,
Rachel Chester1

Affiliations Supplementary Material is available under http://doi.

1 Faculty of Medicine and Health Sciences, University of org/10.1055/a-1398-5501
East Anglia, Norwich, United Kingdom of Great Britain
and Northern Ireland Abs trac t
2 LASEM Research Centre, La Trobe University - Bundoora
The objectives of this randomized, cross-over pilot study were
Campus, Melbourne, Australia
to determine whether isometric plantarflexion exercises resul-
3 School of Physiotherapy, The University of Notre Dame
ted in an immediate change in Achilles tendon pain during a
Australia, Fremantle, Australia
loading task, and whether this differed in knee extension or

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4 Norwich Medical School, University of East Anglia,
flexion. Eleven participants with mid-portion Achilles tendino-
Norwich, United Kingdom of Great Britain and Northern
pathy were recruited from NHS community physiotherapy
Ireland
services and local running clubs. Participants were then rando-
5 Physiotherapy Department, Ipswich Hospital NHS Trust,
mized to complete an isometric calf muscle exercise with the
Colchester, United Kingdom of Great Britain and
knee fully extended or flexed to 80°. Participants switched to
Northern Ireland
the alternate exercise after a minimum seven-day period. Achil-
Key words les tendon pain during a specific, functional load test was mea-
tendinopathy, physiotherapy, exercise, pain sured on a 11-point numeric pain rating scale (NPRS) pre- and
post-intervention. There was a small, immediate, mean reduc-
accepted 01.02.2021 tion in pain following isometric plantar flexion performed in
published online 2021 both knee extension (1.6, 95 %CI 0.83 to 2.45, p = 0.001) and
knee flexion (1.3, 95 %CI 0.31 to 2.19, p = 0.015). There were
Bibliography no significant differences between the two positions. A non-
Int J Sports Med significant, potentially clinically relevant finding was a 20 %
DOI 10.1055/a-1398-5501 larger reduction in symptoms in knee extension versus flexion
ISSN 0172-4622 (p = 0.110). In conclusion, isometric plantarflexion holds gave
© 2021. Thieme. All rights reserved. an approximately 50 % immediate reduction in Achilles tendon
Georg Thieme Verlag KG, Rüdigerstraße 14, pain with a functional load test. There were no significant dif-
70469 Stuttgart, Germany ferences between the two positions and both were well tole-
rated.
Correspondence
Ben Bradford
Faculty of Medicine and Health Sciences, University of East
Anglia, Faculty of Medicine and Health Sciences,
Norwich Research Park
NR4 7TJ Norwich
United Kingdom of Great Britain and Northern Ireland
Tel.:  + 44 (0)1603 591515, Fax :  + 44 (0)1603 591515
[email protected]

Introduction more effective than wait-and-see in the management of mid-por-

Achilles tendinopathy is a musculoskeletal disorder characterized tion Achilles tendinopathy [4] and by 12 weeks appears to result in
by pain and loss of function [1, 2]. Exercise is the cornerstone of clinically meaningful improvements in tendon-pain related disabi-
management of tendinopathy, but pain experienced during or fol- lity [5]. For this reason, improving adherence to exercise and redu-
lowing exercise may present a barrier to adherence [3]. Exercise is cing transition to less efficacious, invasive procedures should be a

Bradford B et al. Immediate Effects of two,.  Int J Sports Med | © 2021. Thieme. All rights reserved.
 Clinical Sciences Thieme

focus. For in-season athletes, interventions that target immediate Participants were eligible for inclusion, if they were over 18, had
reductions in symptoms may also be important. However, few in- mid-portion Achilles tendon pain for greater than 3 months (Sup-
terventions demonstrate an immediate, beneficial effect on ten- plementary File A: participant selection of Image B or D), had a
don pain [6, 7]. Studies that investigate the immediate effects of score of less than 80 points on the Victorian Institute Sport Assess-
calf muscle exercises and whether they are tolerable (and benefi- ment – Achilles (VISA-A), and reported only mid-portion Achilles
cial) to participants with Achilles tendinopathy may assist with exer- tendon pain during at least one of the following tests performed at
cise prescription and provide options for clinicians when faced with the initial physiotherapy appointment: I) double leg heel raise (II)
those who have irritable symptoms or fear of exercise, particularly single leg heel raise (III) double leg hop on the spot (IV) single leg
in the early phases of rehabilitation [8]. hop on the spot. All four tests were performed consecutively to es-
Isometric exercise has been investigated in a small case series tablish the test that reproduced the patient’s pain between 2–7/10
in people with Achilles tendon pain with variable effects on pain on the NPRS (Supplementary File B). This range was pre-defined
during a functional load test [9]. Currently most of the research on as our “clinical tolerance range” based on previous research
isometrics is based in patellar tendinopathy with variable results. [19, 20]. The test with the highest level of pain was documented,
Improvements were first demonstrated in a small laboratory based- as these tests represent increasing Achilles tendon load. Partici-
cross over study [7] and then a 4-week case series of 20 athletes pants were excluded, if they had pain outside the “clinical toleran-
[10]. Further, both isometric and isotonic exercises were shown to ce range” during any of the four tests above, a history of inflamm-
be beneficial in a 4-week RCT [11], indicating two potential options atory systemic disease or fluoroquinolone(s) usage and pain in any
for clinicians treating athletes with patellar tendon pain in-season. area other than the mid-portion of the Achilles tendon.
It has also been shown that short-duration isometric contractions Participants completed both interventions but were randomized

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were as effective as longer duration contractions in relieving patel- to one of two intervention groups, isometric plantar flexion with
lar tendon pain, potentially giving clinicians greater options in the the knee in flexion (FLX) or extension (EXT), at their first session of
prescription of isometric exercise [12]. data collection. The order of completion for the two interventions
Research suggests that of the two main calf muscles forming were randomized for all participants by the drawing of sealed,
the Achilles tendon, soleus weakness, more than gastrocnemius opaque envelopes containing the allocation sequence.
weakness, may be a feature of chronic Achilles tendinopathy [13, 14].
Evidence suggests that activities with the knee flexed at 80–90 de- Baseline strength assessment
grees inhibits the force production capabilities of the gastrocne- Isokinetic dynamometry was used to measure participant maximal
mius muscle [15] and may be considered a suitable method of bi- voluntary isometric contraction (MVIC) torque (Nm) for the two
asing the soleus muscle during the assessment of muscle strength test positions. The participant was positioned in long sitting, with
and subsequent exercise prescription [16]. Conversely, in full knee the back rest and hip joint range of movement standardized to 60
extension, the entire Triceps Surae (Gastrocnemius and Soleus) are degrees. This position demonstrates test retest reliability, accura-
recruited, and maximal force production may differ from that of cy and reproducibility [21–23]. The lateral malleolus was aligned
the flexed knee position [17]. Therefore, one position may be su- with the rotational axis of the dynamometer lever arm and the
perior to the other with respect to patient tolerance of load and re- ankle positioned in 10 degrees of dorsiflexion. This range of move-
sult in increased adherence to rehabilitation. The primary objecti- ment was selected because prior pilot testing demonstrated peak
ves of this pilot study were to determine whether isometric plantar MVIC torque between neutral and 20 degrees of ankle dorsiflexi-
flexion resulted in an immediate change in Achilles tendon pain du- on. The participant completed a five-minute stationary cycle and
ring a loading task and investigate whether differences exist bet- three sub-maximal isometric contractions as a warm-up. The high-
ween isometrics performed in a position of knee extension versus est recorded value from three, maximal efforts was then recorded
knee flexion. as the MVIC for that position. The guidance and encouragement
given during the procedure was standardized to reduce the risk of
performance bias.
Materials and Methods
This study was a participant-blinded, randomized, cross-over pilot Intervention
trial. We confirm that we have read and understood the journal’s Each participant completed two exercises for this study: isometric
ethical standards document [18] and confirm that the study meets ankle plantarflexion (at 10 degrees of dorsiflexion) with an exten-
the ethical standards of the journal. Ethical approval was obtained ded knee (EXT) and knee flexed to 80 degrees (FLX). The two test
from the National Research Ethics Service (NRES) in September positions are shown in ▶ Fig. 1 below. To ensure recovery of the
2018. calf muscle(s) there was a minimum of five minutes of rest following
the MVIC testing procedure. Each participant was positioned so
Participants that they could monitor the torque vs. time graph displayed on the
Participants were recruited from patients referred to the Norfolk computer monitor. The participant completed five isometric, ankle
Community Health and Care NHS Trust (NCH&C) physiotherapy plantarflexion contractions at 70 % of their MVIC each lasting 45
services by their GP and from local running clubs. Participants seconds. 70 % of MVIC was chosen as the target exercise intensity
wishing to take part provided written informed consent at their in- because in a previous laboratory study, an isometric quadriceps
itial assessment. exercise performed at 70 % of MVIC reduced patella tendon pain
immediately and for up to 45 minutes during a previously painful

Bradford B et al. Immediate Effects of two,.  Int J Sports Med | © 2021. Thieme. All rights reserved.
 EXT – the knee joint positioned in FLX – the knee joint positioned at 80
terminal extension and secured with degrees of flexion and secured
non-elastic strapping. aganist the thigh stabilizer with non-
elastic strapping

▶Fig. 1 EXT and FLX Isometric Exercise Position(s). EXT – the knee joint positioned in terminal extension and secured with non-elastic strapping.
FLX – the knee joint positioned at 80 degrees of flexion and secured against the thigh stabilizer with non-elastic strapping.

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functional load test [7, 10]. The participant was advised that it was Statistical methods
acceptable to maintain the isometric contraction within a range 5 % Data analysis was conducted using SPSS v25 (IBM Corp. released
above and below this value. Each set of 45 second contractions was 2017). Participant age, sex, height, weight, body mass index (BMI),
separated by a two-minute rest period [7, 24]. The guidance given symptom duration (months), baseline VISA-A and which side the
during each phase of data collection was standardized to reduce participant had symptoms were described using count, mean and
the risk of bias influencing performance (Supplementary File C). standard deviation (SD), where appropriate. The value for the NPRS
Participants were blinded to the hypotheses of the study but su- at each timepoint are reported as mean (SD). Changes in the NPRS
pervision of the exercise(s) and outcome measure assessment were which reduced pain are reported as a negative value. The effect of
completed by the principal investigator (BB). Participants switched isometrics on tendon pain, for both FLX and EXT were reported as
to the alternate exercise after a minimum of one week. absolute mean (SD), percentage mean (SD). Within-group diffe-
rences were determined using paired t-tests. A generalized estima-
Outcome measure ting equation (GEE) was used to determine whether there was a
The primary outcome measure was the level of patient-reported difference between plantar flexion isometrics performed with FLX
Achilles tendon pain during one of four specific, functional load versus EXT when controlling for confounding/ influencing factors.
test(s) on a Numeric Pain Rating Scale (NPRS). The intention was It has been suggested that clinically, people with Achilles tendon
to establish which of the four progressive Achilles tendon tests re- pain who have larger baseline NPRS may have a larger absolute
produced the patients Achilles tendon pain between 2 and 7/10 on value reduction in the NPRS following isometrics (Cook, personal
the NPRS. In the event that more than one test reproduced pain, communication, 2020). Therefore, in addition to testing order
the test with the highest level of pain was used as the pre and post- being included as a factor, baseline pain was reported as a covari-
intervention outcome measure as these tests represent increasing ate. To account for baseline pain as a possible influence, the relati-
Achilles tendon load. The guidance given during performance of ve effect (percentage change in the NPRS) with isometrics was as-
each Achilles tendon test was standardized (Supplementary File C) sessed in an additional GEE to determine whether there was a dif-
to reduce the risk of performance bias. The NPRS is an 11-point ver- ference between plantar flexion isometrics performed with the
bal, pain-rating scale ranging from 0 (no pain) to 10 (worst pain knee straight versus the knee bent when controlling for testing
ever) and has been shown to be a reliable, valid and responsive mea- order as a factor. Significance was set as  < 0.05.
surement of pain for musculoskeletal pain conditions [25].
Previous research in the patellar tendon have shown large effect
sizes ( > 0.8) for within-group change when performing isometrics Results
[7, 10] and between group change when comparing isometrics to Between January 1 and October 1, 2019, 42 patients with Achilles
isotonics [10]. However, the within-group change in the only paper tendon pain were screened for eligibility. Seventeen out of 42 pa-
examining Achilles isometrics displays a small effect size (0.27). As tients were not eligible to participate (seven patients had pain
the diagnostic criteria for this pilot study are more similar to those for  < 12 weeks, seven patients self-reported pain other than the
of the patellar tendon it was hypothesized that participants would mid-portion of Achilles tendon and three patients had a rheuma-
experience a large effect size ( > 0.8). Therefore, a minimum sam- tological condition). Fourteen participants declined to participate.
ple size of 12 was determined for paired t-tests using G.Power ver- Eleven participants with chronic, mid-portion Achilles tendinopa-
sion 3.1.9.4 based on detecting an effect size of 0.9 with 80 % power thy were recruited to study. There were no differences between the
and two-tailed significance set to 0.05. groups allocated to FLX first or EXT first in terms of age, height,

Bradford B et al. Immediate Effects of two,.  Int J Sports Med | © 2021. Thieme. All rights reserved.
 Clinical Sciences Thieme

▶Table 1 Baseline Data.

All participants (n = 11) Randomized to EXT first (n = 6) Randomized to FLX first (n = 6)
Gender (Male / Female)1 9/2 5/1 4/1
Age (years)2 48.2 (10.5) 52 (15.2) 46.4 (7.3)
Height (cm)2 176.1 (11.2) 177.3 (13.3) 172 (9.2)
Weight (kg)2 84 (17.3) 82.7 (24.2) 79.1 (15.0)
BMI (kg/m2)2 27 (3.8) 25.9 (5.3) 26.6 (4.0)
Symptom duration (months)2 26.8 (35.3) 22.2 (21.6) 34.8 (48.0)
Baseline VISA-A2 60.2 (15.9) 60.8 (14.7) 60.4 (18.3)
Achilles Tendon Symptoms (Right / Left)1 7/4 5/1 2/3

EXT = extension, FLX = flexion, BMI = body mass index, VISA-A = Victorian Institute of Sport Assessment- Achilles. 1data are presented as number, 2data
are presented as mean (SD).

▶Table 2 Within-group differences of pain with isometric plantar flexion.

Intervention Baseline mean Post-intervention Within group mean Mean percentage T-value p-value
(SD) mean (SD) difference (SD) improvement
EXT 3.18 (1.66) 1.55 (1.51) − 1.64 (1.21) 52 % 4.50 0.001 * 

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FLX 2.41 (1.6) 1.27 (1.19) − 1.14 (1.31) 47 % 2.89 0.016 * 
 *  Significance of p < 0.05.

▶Table 3 Generalized estimating equation of absolute change in pain with

isometric plantar flexion. duction in symptoms (p = 0.001) whereas isometric ankle plantar
flexion with FLX resulted in a 47 % mean reduction in symptoms
Variable β estimate SE 95 %CI p-value (p = 0.016).
Intercept − 0.17 0.58 − 1.31 to 0.98 0.775
Knee extensiona − 0.15 0.24 − 0.062 to 0.32 0.540 Between group differences
Extension Firstb 0.24 0.50 − 0.74 to 1.22 0.634 The GEE using the absolute change value on the NPRS (▶Table 3)
Baseline Pain − 0.47 0.15 − 0.16 to 9.14 0.002 *  showed that there was an additional 0.47 point reduction in pain
β = beta, SE = standard error, 95 %CI = 95 % confidence interval. a Knee on the NPRS during a functional loading task for every 1-point in-
flexion set to 0, bIsometric plantar flexion in knee flexion first set to crease of the baseline NPRS (p = 0.002). Due to this influence a sub-
0.  *  Significance of p < 0.05. sequent GEE was performed using the relative change score (percen-
tage change) instead of the absolute score (raw-value) (▶ Table 4).
▶Table 4 Generalized estimating equation of relative change in pain with
This subsequent GEE showed that there was no significant effect of
isometric plantar flexion. the knee position or testing order on the percentage of pain change
when completing isometric plantar flexion. However, while not si-
Variable β estimate SE 95 %CI p-value gnificant (p = 0.110) isometric plantar flexion in knee extension ap-
Intercept − 45.022 20.25 − 84.71 to − 5.33 0.026 peared to provide a 20 % larger reduction in pain when compared
Knee extensiona − 20.20 12.64 − 44.97 to 4.58 0.110 to isometric plantar flexion in knee flexion.
Extension Firstb 12.90 20.50 − 27.28 to 53.07 0.529

β = beta, SE = standard error, 95 %CI = 95 % confidence interval. a Knee

flexion set to 0, bIsometric plantar flexion in knee flexion first set to Discussion
0  *  Significance of p < 0.05. This pilot study demonstrated that two positions for isometric exer-
cise were well tolerated for people with mid-portion Achilles ten-
dinopathy, resulting in pain reduction of approximately 50 % in a
weight, BMI and baseline VISA-A score with all baseline data pre- functional task. For this small study, a 20 % reduction in tendon pain
sented in ▶ Table 1 below. The difference in the mean symptom was observed with EXT compared to FLX, but this was not statisti-
duration was likely due to the randomization to FLX first of a parti- cally significant. However, the clinical significance of these chan-
cipant who had had episodic Achilles tendon pain for six years. ges is uncertain and this warrants further investigation in a larger
RCT.
Within-group differences
Complete rest is detrimental for musculoskeletal capacity. So
Individual patient data are presented in Supplementary File D. ensuring the musculoskeletal system is getting as much load as to-
Isometric ankle plantarflexion in FLX and EXT resulted in a signifi- lerated, as soon as possible, is vital for effective rehabilitation [26].
cant reduction of pain when performing a load test (▶Table 2). Iso- Isometric holds may provide a well-tolerated start point for reha-
metric ankle plantar flexion with EXT resulted in a 52 % mean re- bilitation, especially if patients have a fear of movement/loading,

Bradford B et al. Immediate Effects of two,.  Int J Sports Med | © 2021. Thieme. All rights reserved.
which has been demonstrated in tendinopathy [27]. The immedi- look to implement isometric exercise as the starting point for re-
ate pain relief observed following isometric plantar flexion in this habilitation, to demonstrate to the fearful patient that loading the
study may assist the management of the patient with Achilles ten- tendon with exercise is safe or as a means of promoting self-effica-
don pain in several ways. First, it may allow completion or partici- cy and adherence with any ongoing strengthening program. Finally,
pation in a previously painful task or activity. Second, as a non-phar- isometric exercise should never be expected to provide compre-
macological treatment, exercise is not associated with the side ef- hensive rehabilitation and restoration of function in those with
fects of medications that may typically be taken for tendon pain Achilles tendinopathy, and immediate analgesia is not the only re-
(e. g. non-steroidal anti-inflammatory medications) [28]. Further- ason to provide an exercise to a patient with Achilles tendinopathy.
more, exercise is likely to have many other, general positive impacts If exercise is truly going to be used as medicine then studies should
for the patient that will not occur with medication use [29]. Finally, seek to identify what exercise suits which patient, and with what
if patients had strategies to independently manage their pain, it dosage and progression. This requires adequate description of par-
may improve adherence with any further rehabilitation [30]. ticipants to identify sub-groups of responders and non-responders
This study differs from a previous case series study [9] investi- to aid clinical interpretation [31].
gating the efficacy of isometric exercise in Achilles tendinopathy in
several respects. Only 9 of the 16 participants in O’Neil’s study
(2019) [9] reported pain during a bilateral or unilateral heel raise Funding
or subsequent hopping test, the loading test(s) used for inclusion Ben Bradford is funded by a National Institute for Health Research
within our study. O’Neil et al. [9] placed a stronger emphasis on (NIHR) pre-doctoral Clinical Academic Fellowship for this research
palpatory pain. Other differences between the two studies include project. Dr Ebonie Rio is a National Health and Medical Research

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how MVIC torque was assessed, the apparatus used for assessment Council funded post-doctoral fellow. This publication presents in-
and treatment and the range of dorsiflexion in which isometrics dependent research funded by the National Institute for Health Re-
were performed. The diagnostic criteria for tendinopathy are not search (NIHR).
universal [31]. It is not clear from the current literature whether
there is a heterogenous response to isometric (or any) exercise or,
alternatively, whether there is heterogeneity in the included parti- Acknowledgements
cipants and procedures. In this study, participants demonstrated The views expressed are those of the author(s) and not necessarily
increasing pain with increasing load that remained localized and those of the NHS, the NIHR or the Department of Health and Soci-
the clinical take-home is that isometric exercise is well tolerated in al Care.
people with that phenotype. Whether this can be applied to peo-
ple that have pain with Achilles tendon palpation and imaging
change (common inclusion criteria used) is not known [32]. Conflict of Interest
Although we primarily sought to recruit participants through
the NHS, we struggled to recruit the numbers expected. Therefo- The authors declare that they have no conflict of interest.
re, any interpretation of our data must acknowledge that the sam-
ple size was small. Despite these difficulties, it was felt that the ro-
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