Physical Therapy in Sport 46 (2020) 234e242

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Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Original Research

“Does isometric exercise improve leg stiffness and hop pain in subjects
with Achilles tendinopathy? A feasibility study”
Lisa Mantovani a, *, Luca Maestroni a, b, c, Francesco Bettariga a, Massimiliano Gobbo e, f,
Nicola Francesco Lopomo d, e, f, Sionnadh McLean g
a
Studioerre, Via della Badia 18, 25127, Brescia, BS, Italy
b
Smuoviti, Viale Giulio Cesare, 29, 24121, Bergamo, BG, Italy
c
London Sport Institute, School of Science and Technology, Middlesex University, Greenlands Lane, London, United Kingdom
d
Department of Information Engineering, University of Brescia, Italy
e
Laboratory of Clinical Integrative Physiology, University of Brescia, Italy
f
Department of Clinical and Experimental Sciences, University of Brescia, Italy
g
School of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Broomhall Road, Sheffield, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Background: In Achilles tendinopathy (AT) the ability to store and recycle elastic energy during ground
Received 15 July 2020 contact phase is often altered. A measure of this function is represented by leg stiffness (LS). Immediate
Received in revised form responses in LS following therapeutic intervention have not been examined.
3 September 2020
Objective: The aim of this paper was to examine the feasibility of the protocol in participants with AT.
Accepted 5 September 2020
Design: Single cohort feasibility study.
Participants: Adults with persistent AT pain, symptoms on palpation and less than 80 points on the Visa-
Keywords:
A questionnaire.
Achilles tendinopathy
Isometric
Intervention: heavy isometric exercise sequence in plantarflexion.
Leg stiffness Outcome measures: Feasibility was assessed by evaluating: the willingness of participants to enroll into
Rate of perceived exertion the study, the number of eligible participants, the recruitment rate, adherence to the intervention, the
Stretch-shortening cycle drop-out rate, the tolerability of the protocol. LS, reactive strength index, pain and rate of perceived effort
were secondary outcomes.
Results: 22 AT were eligible for data collection and 19 entered the statistical analysis. The intervention
was well tolerated, no withdrawals. Pain scores were low during both the intervention and the assess-
ment. Immediate improvements in LS and pain were recorded.
Conclusions: The isometric exercise protocol was feasible. Future research should investigate its
effectiveness.
© 2020 Elsevier Ltd. All rights reserved.

1. Introduction alterations in tendon mechanical properties, plantar-flexor muscle

strength (Malliaras & O’Neill, 2017; O’Neill et al., 2019), stretch
Achilles tendinopathy (AT) affects around 2% of the general shortening cycle (SSC) performance, leg stiffness (LS) and rate of
population and 9% of the athletic population (de Jonge et al., 2011; force development (RFD) (Obst et al., 2018; Wang et al., 2011).
M.; Murphy et al., 2018). It can be debilitating and compromise These features have important connotations as potential risk fac-
physical and sports performance (Debenham et al., 2016). Cross- tors for AT, thus being potential targets for primary prevention
sectional studies of subjects with AT have demonstrated strategies. Moreover, they represent persistent deficits relevant for
both secondary and tertiary prevention strategies (Jacobsson &
Timpka, 2015; Maestroni et al., 2019). Alterations in the repetitive
SSC of the muscle-tendon unit occurring in activities such as
* Corresponding author.
E-mail addresses: [email protected] (L. Mantovani), lucamae@ jumping, running and walking, are associated with AT (Debenham
hotmail.it (L. Maestroni), [email protected] (F. Bettariga), et al., 2016). The ability to store and recycle elastic energy during
[email protected] (M. Gobbo), [email protected] (N.F. Lopomo), the ground contact phase is underpinned by LS (Maquirriain, 2012),
[email protected] (S. McLean).

https://doi.org/10.1016/j.ptsp.2020.09.005
1466-853X/© 2020 Elsevier Ltd. All rights reserved.
L. Mantovani, L. Maestroni, F. Bettariga et al. Physical Therapy in Sport 46 (2020) 234e242

which is used as a measure of SSC function (Croix et al., 2017). In opportunity to ask questions and were assessed for eligibility.
most SSC activities LS depends primarily on ankle stiffness (Brazier Those that were eligible and willing to participate signed a written
et al., 2017), thus highlighting the importance of the ankle complex informed consent form prior to testing.
in human locomotion and dynamic tasks. In research, LS is often
calculated as the ratio between peak vertical ground reaction forces 2.3. Equipment used
and peak center of mass displacement during ground contact (Croix
et al., 2017). In clinical settings, the reactive strength index (RSI) is A TOTALGYM® Gravity Training System GTS (see Figs. 2 and 3,
widely employed to assess the SSC function. This provides insights supplementary file) was used to perform the jump task. The GTS
about the resistance to the deformation of the lower limb in is a commercial inclined machine used to reduce the bodyweight
response to an applied force (Flanagan & Comyns, 2008). A direct by altering the board inclination. This also allows plyometric ex-
correlation between lower extremity stiffness and risk of injury or ercise while the trunk is lying on the board. In our setting, the thigh
recurrence has not been established yet (Debenham et al., 2016; was fixed to the mobile board with a belt to focus the movement on
Lorimer & Hume, 2016; Pruyn et al., 2012). A variety of isometric, the ankle.
isotonic and eccentric loading programs have been shown to be Vertical and antero-posterior components of force, peak of force,
beneficial for patients with AT (Head et al., 2019; M.; Murphy et al., time to achieve force and impulse were measured using the PASCO
2018; M. C.; Murphy et al., 2019; Vlist et al., 2020) and isometric (PS-2142, PASCO, Pass-port PS-2142, Roseville, USA) force platform.
exercise have been shown to provide a heterogeneous response on This was attached to the base of the TOTALGYM®GTS (GTS) using a
pain without an overall clinically meaningful change (O’Neill et al., dedicated mechanical link (see Fig. 2, supplementary). PASCO PS-
2018; Vlist et al., 2020). 2142 has demonstrated good reliability, precision and accuracy in
To our knowledge, research investigating the immediate effect comparison to a gold standard platform in all variables (Silveira
of isometric contractions on SSC function during dynamic task et al., 2016) (Peterson Silveira et al., 2017).
performance in subjects with AT is lacking (Oranchuk et al., 2019). Finally, a Smith-machine (Multipla Technogym ®) (see Fig. 1,
This may reveal important implications for rehabilitation strategies supplementary) was used to manage the load with weights in a
because it reflects a more complex adaptation of the musculo- safe position during the administration of the isometric exercise
skeletal system in a specific task (Morin & Samozino, 2016). protocol.
Therefore, the primary aim of this study was to test the feasibility of
a heavy isometric exercise protocol in participants with persistent 2.4. Isometric exercise protocol
AT in a dynamic task.
Participants were asked to perform a heavy isometric contrac-
2. Methods tion in plantarflexion close to inner range, in standing position in
the Smith-machine. They were asked to hold the contraction for
2.1. Study design 45 s for five sets with 1-min rest between sets. During the rest
period, participants were asked if they wanted to raise, maintain or
A single group before-after study was designed to test the reduce the load.
feasibility of the protocol. This study complied with the Declaration
of Helsinki (2008) and an ethical approval for this study was ob- 2.5. Outcome measures
tained from the local ethics committee (Comitato Etico di Bergamo,
REG. SPERIM N 205/19) and the Sheffield Hallam University Ethics 2.5.1. Primary outcomes: feasibility
Committee. The study was reported following the CONsolidated The primary outcome of the study was related to the feasibility
Standard of Reporting Trials for pilot and feasibility studies (CON- for a future adequately powered trial. Feasibility was assessed by
SORT-PF) statement (Eldridge et al., 2016). evaluating: 1) the willingness of participants to enroll in the study,
2) the number of eligible participants, 3) the recruitment rate, 4)
2.2. Setting, participants and recruitment adherence to the intervention, 5) the drop-out rate, 6) the tolera-
bility was assessed by asking participants to rate on a 0e10 scale
The research was conducted in a private physiotherapy clinic in where “0” was not at all tolerable and “10” was very tolerable, a
Italy between May and August 2019. A convenience sample of value above 5 was considered tolerable (Calatayud et al., 2019).
voluntary subjects with AT was recruited through advertisement in The willingness to use this intervention was investigated asking
gyms, clubs, sports teams and physiotherapy services. Participants participants to answer “yes” or “no” whether they would adhere to
were eligible if they: were aged over 18, had experienced AT for at this intervention in a rehabilitation program. Patients were also
least 12 weeks, reported pain located on the Achilles Tendon, re- asked to verbally report about adverse events experienced,
ported pain on tendon palpation (Hutchison et al., 2013), scored discomfort, inconveniences during the data collection and the ex-
less than 80 points out of 100 on the VISA-A questionnaire ercise protocol.
(Robinson, 2001). Patients with both bilateral and unilateral
symptoms were recruited to maximize the sample size. Participants 2.5.2. Secondary outcomes
were excluded if they: had an injury in the last 6 months affecting Before and after participants completed the isometric exercise
the lower limb resulting in current disability, had undergone sur- protocol, the following data were collected.
gery in the affected lower limb in the last 6 months, had reported
pain in other areas of the lower quadrant (low back, hip, knee, foot 2.5.2.1. Physical function and capacity: Leg Stiffness (LS) and Reactive
& ankle), had co-existing pathology or other visual/motor impair- Strength Index (RSI). LS and RSI are used as a measure for SSC
ments, had received physiotherapy or specific exercise for AT in the function of the muscle-tendon unit (Brazier et al., 2017, 2014; Croix
last 3 months, had performed vigorous physical activity in the week et al., 2017). Both submaximal (SM) and maximal (M) hops have
prior to data collection. Participants voluntarily contacted the main been chosen here to assess the LS and RSI, as described in previous
author via email or phone to find out more about the study and to studies (Debenham et al., 2016) in sub-maximal jump. LS was
plan a date for possible recruitment and data collection. At this calculated using the data (body mass, ground contact time and
meeting participants received an information sheet; they had the flight time) collected during the jumps on the force platform and
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L. Mantovani, L. Maestroni, F. Bettariga et al. Physical Therapy in Sport 46 (2020) 234e242

the formula described previously by Brazier and colleagues (Brazier 2.7. Data collection
et al., 2014, 2017). Reactive strength index (RSI) was calculated as
the quotient of the jump height and contact time (jump height (m)/ Data collected via the force platform software were processed
ground contact time (sec)) (Struzik et al., 2016). using Matlab (Matlab 2019b; The Mathworks USA). For each trial
raw normal force was normalized with respect to the body weight.
2.5.2.2. Pain and disability levels. Pain and disability were assessed Time moments corresponding to the peak force landing and take-
at the beginning, as one of the inclusion criteria, with the Victorian off phases were identified for each hop (Fig. 4, supplementary
Institute of Sport Assessment- Achilles (VISA-A), a disease specific file). A signal was analyzed through the entire trial from the first
outcome (Robinson, 2001). Pain during the SM and M hop tasks instant of take-off. The force signal was used to calculate several
were collected before and after the intervention for each jump parameters related to each hop including: hop time (s), contact
using the Numerical Pain Rating Scale (NPRS), a subjective measure time (s), flight time (s), peak force (N), LS (kN/m) as defined by
in which participants rate their pain on an eleven-point numerical Dalleau and colleagues (Dalleau et al., 2004) (considering the
scale, where “0” equals not pain at all and “10” equals the worst inclination angle); mechanical power (W), as defined by Dalleau
imaginable pain (Haefeli & Elfering, 2006). Pain intensity during and colleagues (Dalleau et al., 2004), taking into account the
the 5 sets of the intervention (NPRSiso) was measured and recor- inclination angle; net impulse (N*s) (Kirby et al 2011), RSI (m/s)
ded. The mean value was then calculated. Pain variation during the (Flanagan & Comyns, 2008). Every parameter was evaluated for
intervention was also calculated (DNPRSiso). each hop and then averaged on the whole trial. Mean and standard
deviation (SD) values were reported for LS and RSI.
2.5.2.3. Effort during the intervention. Rate of perceived effort (RPE)
is a quantitative measure (0e10 modified Borg scale) of perceived 2.8. Statistical analysis
effort during physical activity, training or competition (Grant et al.,
1999). It was recorded at the end of each of the 5 sets. Subjects were The statistician was blinded to the recruitment, data collection
asked how much effort they perceived on a scale from 0 to 10, and intervention. Sigmaplot 11 (Systat Software) was used for data
where 0 were “no exertion” and 10 was “maximal exertion, the analysis. The data were analyzed using descriptive statistics (e.g.
hardest they have ever experienced”. The variation of RPE during mean, standard deviation). The normality of data distribution was
the intervention was also calculated (DRPE). examined using the Kolmogorov-Smirnov test. Despite not being
the main aim of our study, we included information regarding
2.5.2.4. Other measures. The amount of load used during the inferential statistics when the sample size was appropriate to
intervention (kg) was collected during the 5 sets. The load provide the readers with an understanding of the magnitude of the
normalized to bodyweight (%bodyweight) and its variation during effect generated by our intervention. Differences between baseline
the intervention (D%bodyweight) were also calculated. and follow-up LS and pain data for SM jump were tested with a
paired t-test. To determine the magnitude of differences, Cohen’s
2.6. Procedure d effect size (ES) was calculated and interpreted using the following
thresholds: ES > 0.2 ¼ small; ES > 0.5 ¼ moderate; ES > 0.8 ¼ large.
After signing the consent form, age (years), gender, standing
height (meters) and weight (kilograms) were collected for each 3. Results
participant. The duration of the symptoms was determined by
asking participants, “How long have you had your pain for?“, re- 3.1. Recruitment and characteristics of the sample
sponses were converted into months. Total activity level was
assessed with the International Physical Activity Questionnaire Twenty-three potential participants were invited to participate
(IPAQ score) (Wolin et al., 2009). Participants completed the VISA-A in this study from May to August 2019 (see Fig. 1), two patients with
score. The included participants were asked to participate in bilateral symptoms were included for a total of twenty-five AT
baseline objective evaluations. The objective evaluations were cases. Patients were mainly invited through external contacts
taken by the same assessor with the help of a second one where within the sports field and rehabilitation centers. Three partici-
required. To begin with participants lay on the board of the GTS pants were excluded because they did not fulfill the inclusion
machine where the head, trunk and lower limb were comfortably criteria. The sample were heterogeneous in terms of duration of
supported (see Figs. 2 and 3, supplementary). The affected leg was symptoms, VISA-A score and amount of total physical activity per
fixed by a belt at the level of the mid-thigh which prevented knee week. Participants’ characteristics are reported in Table 2.
and hip flexion/extension moment and isolated the movements at
the ankle. The GTS was inclined at 22
(see Fig. 3, supplementary 3.2. Primary outcomes: feasibility of the intervention
file) with the aim to reduce body weight to 60% and the impact
while jumping. The platform was reset before each application of 22 AT were eligible for data collection, three traces from the plot
the test. Participants were instructed on the performance of the had insufficient quality for consequent analysis, therefore the final
two jump tasks: SM and M jumps on the GTS. They could try three statistical analysis was performed on 19 AT (17 participants in
jumps to gain confidence with the task before starting the data which only two participants had bilateral symptoms) (see Table 3).
collection. In the SM jump participants hopped at a level that could The intervention was quite well tolerated (mean 6.3 ± 2.2) and
be sustained for an “indefinite” amount of time on their affected leg there were no withdrawals (see Table 4). Furthermore, during both
for a 15-s trial, before a 30-s rest period. Two trials were repeated. the intervention and the assessment the pain scores were low on
Then the two M hop tasks were assessed. In this task, participants average (NPRSiso 2.8 ± 2.6; NPRS SM before 2.35 ± 2.6, SM after
were asked to jump as high as they could for 5 consecutive times. A 1.1 ± 1.5; NPRS M before 2.39 ± 2.2, SM after 1.2 ± 1.5). At the end of
30-s rest period separated the two trials. Following the baseline the procedure 5 out of 19 participants reported an uncomfortable
assessment, the patient moved to the Smith Machine for the feeling in their neck and upper limbs caused by the load employed.
intervention. After that, the baseline measures were repeated, SM Only three subjects reported discomfort in the calf or the lower
and M jumps were tested again (after) using the same standardized limb due to the contraction during the exercise. All participants (17/
sequence (see Table 1). 17) considered this protocol potentially useful for their
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Table 1
Intervention description according to the Modified Consensus on Exercise Reporting Template (CERT) for Therapeutic Exercise Interventions (Page et al., 2017).

Exercise intervention: 45 s x 5 repetitions of isometric contractions in ankle plantarflexion

Item category Item n. Abbreviated Description Details

What: materials 1 Smith Machine In this study a machine MULTIPLA® Technogym was used. A similar tool from another
brand can be used
Who: provider 2 Physiotherapist In this study a physiotherapist followed each patient individually
How: delivery 3 Exercise individually performed In this study a physiotherapist assisted each patient. Once trained, the patient can
perform the exercise programme without supervision
4 Exercise: supervised In this study the exercise was supervised. However, the patient can perform this
intervention unsupervised in a gym
5 Measurement and reporting of adherence Amount of load used: Kg
RPE (rate of perceived exertion)
VAS or NPRS
6 Details of motivation strategies A physiotherapist can verbally motivate the patient to keep the position requested using
the following sentence:
“Maintain as high as you can, hold it … hold it … hold it”
7 Decision rules for the progression of After each repetition, the physiotherapist asked the patient: “Do you want to maintain,
the exercise increase or decrease the amount of weight?”
8 Exercise description Detailed instruction: the Smith machine is initially set at 50% of the patient’s
bodyweight taking into consideration that the machine bar weights 9 kg
The patient is standing on two feet while unlocking the machine bar. Then the patient
moves in maximal heel-raise position with both feet (full plantarflexion). When the
patient feels ready, he/she goes back to the starting position where he/she maintains the
affected leg almost fully in plantar-flexion and flexes the other leg at 90 degrees of hip
flexion and 90 degrees of knee flexion.
The patient maintains this position for 45 s. At the end of the 45 s the patient comes back
to the standing position on two feet. After having repositioned the bar in the lock
position he/she is allowed to move around during the 60-s rest period.
Then the patients can decide to maintain, increase or decrease the load for the next
repetition.
The load is adjusted accordingly, and the same aforementioned procedure starts again.
The patient repeats the exercise for 5 times with a 60-s rest period in between.
At the end of each repetition the patient is asked about the pain and the rate of perceived
exertion experienced.
9 Non exercise component The patient needs to be instructed on how to unlock the bar and how to reach the right
position for the exercise
10 How adverse events that occur during exercise Pain during the exercise is monitored.
are documented and managed Patients are instructed on the use of the machine and the correct position to be adopted
Where 11 Setting for the exercise Rehabilitation centre or gym
When How much 12 Detailed description of the exercise 5 repetitions of 45 s of isometric contractions near full plantarflexion position
The starting load is 50% of the bodyweight. After each repetition maintain, increase or
decrease the amount of weight according to the patient’s choice
Tailoring 13 Exercise is tailored to the individual The patient starts with an amount of load calculated on his/her bodyweight. Each
patient can manipulate the amount of weight during the following repetitions.
The position is standardized at the patient’s maximal plantarflexion.
14 Content of any home programme Not required for the study
15 Decision rules that determines the starting The amount of load used is tailored to the patient’s bodyweight. A standard initial load
level of the exercise (50% bodyweight) was used to provide a sufficient training stimulus.
How well 16 Exercise is delivered and performed as planned The effort during the isometric contractions needs to provide a sufficient training
stimulus (usually quantified as RPE 6)

rehabilitation process (see Table 4). No adverse events were Over the 5 sets there was a statistically significant reduction in pain
detected during the data collection and no complaints were during the heavy isometric exercise (DNPRSiso 1.3 ± 2.1, ES ¼ 0.57,
registered. p ¼ 0.02) (see Table 4).

3.3. Secondary outcomes 3.3.3. Effort during the intervention

During the intervention RPE was on average 5.8 ± 1.8 with a
3.3.1. Physical function and capacity mean increment of 1.4 ± 1.9 at the end of the 5 sets (ES ¼ 0.72
Leg Stiffness and RSI There was a significant increase in LS after p ¼ 0.006) (see Table 4).
the intervention in the SM jumps only (þ1100.59 kN/m ±1258.45;
ES ¼ 0.87, p  0.001). Varied responses in LS during SM hop task are 3.3.4. Other analyses
depicted in Fig. 2. Mean Changes in LS are depicted in Fig. 3. RSI During the intervention participants employed a mean load
showed a trend of improvement (SM RSIbefore: 0.17 m/s ±0.12 vs normalized to body weight (%BW) of 48.74% ± 6.4 with a mean
RSIafter 0.24 m/s±0.16; M RSIbefore 0.67 m/s±0.43 pre vs RSIafter reduction of 0.45% ± 19 during the 5 sets. Sample size was esti-
0.73 m/s±0.47). mated on the pre/post mean values and standard deviations of the
LS in SM obtained in this study (alpha ¼ 0.05 and a power of 80%
3.3.2. Pain with 95% CI) (Bhalerao & Kadam, 2010). The sample size resulted in
Pain levels reached a statistically significant reduction in SM 14 participants; moreover, considering a 24% of total dropouts (6/
(ES ¼ 0.49, p ¼ 0.047) and in M (ES ¼ 0.58, p ¼ 0.02) after the 25: 3 ineligible cases and 3 who were not included in the statistical
intervention. Individual responses are depicted in Fig. 4a and b. analysis due to poor traces), the final number calculated for a future
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L. Mantovani, L. Maestroni, F. Bettariga et al. Physical Therapy in Sport 46 (2020) 234e242

Fig. 1. Flow chart of the study according to CONSORT 2010 (Eldridge et al., 2016).

Table 2 4. Discussion
Demographics and characteristics of the sample.

Sample n ¼ 19 Mean (SD) The isometric exercise protocol was feasible and produced a
Gender 32% Female
meaningful improvement in LS in SM jump task. Pain levels
Affected limb 6 (L) 13(R) decreased, although they did not reach clinically meaningful im-
Dominance 6 (L) 13(R) provements. Other outcomes are discussed in this section as
Age 39.2 (11.2) exploratory data for future studies.
Weight (kg) 76.8 (13.4)
Height (cm) 177.3 (10.7)
Duration (months) 22.7 (28.4)
VISA-A score 55.8 (15.1) 4.1. Primary outcomes
IPAQ score 4008.4 (4314.2)

(SD) standard deviation, (L) left, (R) right, (VISA-A Score) Victorian Institute of Sports According to the results, the isometric exercise protocol was
Assessment Achilles, (IPAQ) International physical activity questionnaire. feasible, and immediate changes in LS and RSI could be detected
during dynamic SM and M jump tasks. Pain levels reported during
study was 17 participants. This number is feasible for potential the assessment and intervention were low. This confirmed the
future studies. The estimated sample size for M hop task was 70 feasibility of the procedures used in this study. However, there is a
participants. twofold consideration when examining these results. Firstly, the
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L. Mantovani, L. Maestroni, F. Bettariga et al. Physical Therapy in Sport 46 (2020) 234e242

Table 3
Data from the force platform in the before-after sub-maximal (SM) and maximal (M) hop task (mean value and ±SD).

HOP TASK Sub-Maximal (SM) Maximal (M)

Before After Effect size Before After Effect size

Leg Stiffness (kN/m) 8725.04 (2139.93) 9825.63 (2208.46) ES ¼ 0.87 p  0.001 8153.93 (2845.18) 8624.55 (2500.11) p ¼ 0.15
RSI (m/s) 0.17 (0.12) 0.24 (0.16) p ¼ 0.17 0.67 (0.43) 0.73 (0.47) p ¼ 0.45
Pain (NPRS) 2.35 (2.67) 1.12 (1.53) ES ¼ 0.49 p ¼ 0.047 2.39 (2.26) 1.21 (1.57) ES ¼ 0.58 p ¼ 0.02

Leg Stiffness (kN/m), RSI: Reactive Strength Index (m/s), Pain level (NPRS), Effect size (ES).

Table 4
Intervention: Pain during intervention (NPRSiso), rate of perceived exertion (RPE), load applied (Kg), load normalized to bodyweight (% Kg/BW) were collected during the
intervention. Exercise tolerability scores and willingness to use the intervention were recorded at the end of the intervention (mean value and ±SD).

NPRSiso Pain change during the RPE Variation of RPE Load (kg) Load normalized Variation of load Exercise Willingness to adopt
intervention (D RPE) to bodyweight application tolerability the intervention
(DNPRSiso) (%bodyweight) (D % bodyweight) score

2.76 (2.63) 1.26 (2.21) 5.85 (1.87) 1.42 (1.98) 37.5 (8.2) 48.7 (6.4) 0.45 (19.0) 6.3 (2.2) 17/17 Yes
ES ¼ 0.57 p ¼ 0.02 ES ¼ 0.72 p ¼ 0.006 p ¼ 0.96

Pain during intervention (NPRSiso), rate of perceived exertion (RPE), load applied (Kg), load normalized to bodyweight (% Kg/BW) Pain during the intervention (Pain change
during the intervention (DNPRSiso), Variation of RPE (D RPE), Variation of load application (D % bodyweight).

Leg Stiffness in Sub Maximal Hop

16000

14000

12000

10000

8000

6000

4000

2000

0
Leg Stiffness Before Leg Stiffness After

01 LP 02 LP 03 MN 04 MS 05 FB 07 VS 08 FP
09 FS 11 AS 13 PO 14 NV 15 NR 16 FB 18 RD
19 RD 20 FL 22 SS MEAN 10 EG 12 GM

Fig. 2. Changes in Leg Stiffness (LS) in Sub-Maximal (SM) and Maximal (M) hop tasks.

low levels of pain found at baseline may have facilitated the multi-center trial.
execution, and thus, the tolerability of the jump tasks. Secondly,
they may have reduced the potential overall impact of the inter-
vention on pain changes (i.e. low mean pain change). No partici- 4.2. Secondary outcomes
pants withdrew from this study. All subjects judged the
intervention as “tolerable” and considered the strategy employed In our study the change in LS in SM jumps showed a statistically
feasible for rehabilitation. This may be mediated by the adoption of significant improvement and a moderate effect size after the
the GTS inclined at twenty-two degrees, which reduced AT loads, intervention. Since there is support from other studies that found
thus reducing symptom perception during dynamic tasks (NPRS reduced LS in the affected limb during SM jumps (Debenham et al.,
SM before ¼ 2.35 ± 2.6; SM after ¼ 1.1 ± 1.5; NPRS M 2017; Maquirriain, 2012; Otsuka et al., 2018; Sancho et al., 2019), we
before ¼ 2.3 ± 2.2; M after ¼ 1.2 ± 2.2). The sample size, estimated consider our results important for further investigations. Deben-
via pre-post variation in LS during SM jumps, was feasible for po- ham and colleagues (Debenham et al., 2017) described changes in
tential further studies. Instead, the sample size needed for the M the SSC behaviour (increase of lower limb stiffness from 5.9 to 6.8
task was much higher, thus appearing more feasible if included in a Nm-1) 7 days after a single eccentric loading intervention in 11
healthy subjects. Sancho and colleagues (Sancho et al., 2019)
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4.3. Strengths and limitations

LEG STIFFNESS (kN/m)
14000 The protocol used in this study has been selected for its simple
12000 implementation in rehabilitation settings and for its tightly
10000
controlled force application. Furthermore, subjects were allowed to
9825.63 manipulate loads according to their willingness to increase, main-
8000 8725.04 8624.55
8153.93 tain or decrease the load. We consider the latter to be a relevant
6000 feature transferable in an ordinary clinical practice, although the
4000 factors underpinning this decision need to be further investigated.
2000 Specific and tightly controlled isometric load regimes (70% of
their maximal voluntary isometric contraction MVIC) were applied
0
SM Before SM After M Before M After in other small studies (Holden et al., 2020; Rio et al., 2017) inves-
tigating acute effects of pain in subjects with patellar tendinopathy
Fig. 3. Leg Stiffness LS (kN/m) in Submaximal (SM) hop task: Individual Responses in with contrasting results. Despite more rigorous in their application,
the before assessment and after assessment, mean value in black.
these controlled load regimes may represent a limitation in their
applicability in clinical settings. Instead, a pragmatic protocol based
on each individual bodyweight may facilitate translation from
demonstrated significant increases (ES 0.54) in LS in SM jumps in research to clinical practice. It may be interesting to further explore
male recreational runners with mid-portion AT after a 12-week the correlation between RPE and MVIC. They may reveal the
rehabilitation programme including education, exercise and hop- presence of a cut-off value for RPE to elicit meaningful changes in
ping. This highlights the potential positive adaptations induced by pain and LS. In this study RPE was monitored together with pain
loading programmes on maladaptive mechanism affecting the SSC levels during the intervention because the relationship between
in AT. Cross-sectional studies revealed imbalances between excit- exercise induced hypoalgesia (EIH) and perceived effort was
atory and inhibitory motor pathways, which can influence muscle described previously (Koltyn et al., 2014). However, no study
activation, hence SSC function (McAuliffe et al., 2016; Wang et al., investigated RPE and EIH in symptomatic AT cohorts. Future studies
2011). These motor changes are likely to be influenced by both should aim to explore this thoroughly. Another strength of this
central and peripheral mechanisms (Wang et al., 2011). Contrary to study is the choice of the continuous jump as a task to assess the LS
our hypothesis, pain changes showed a significant improvement, and the isolated ankle movement, fixing the thigh with a belt on the
but they did not reach any minimally clinical important difference board of the GTS machine; this setting was never investigated
(MCID). Also, over the 5 sets employed during the intervention, a before. A limitation of this study is related to the heterogeneity in
statistically significant reduction in pain with a moderate effect size the sample, especially for the duration of the disorder, for the
was reported for both SM and M tasks. However, the magnitude of location of the symptoms (i.e. mid portion vs insertional) and for
change was around 1 point (0e11 NPRS), which arguably could be the physical activity level. These may underpin different stiffness
considered clinically significant. Moreover, the individual response characteristics and pain behaviours, thus altering the response to
was very varied (see Figs. 4a and b). This is in line with a recent the intervention. Therefore, these should be taken into account for
study by O’Neill and colleagues (O’Neill et al., 2018) where 18 future studies. As mentioned before, due to the main aim of this
participants with mid portion AT did not show consistent pain re- study being its feasibility, a relevant limitation is that the pair t-test
ductions following 5 sets of 45 s heavy seated isometric plantar- did not account for multiple variables which could impact the re-
flexor contractions. sults (e.g. baseline VISA-A, baseline physical activity levels, baseline

Fig. 4a. Assessment Before and after: Pain Level (NPRS) during Sub-Maximal (SM) Hop Task. Mean Values in black.

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L. Mantovani, L. Maestroni, F. Bettariga et al. Physical Therapy in Sport 46 (2020) 234e242

Fig. 4b. Assessment Before and After: Pain Level (NPRS) during Maximal (M) Hop Task. Mean Value in black.

symptom duration or baseline BMI). mixed model to evaluate their influence on stiffness characteristics
and response to exercise.

4.4. Implications for future studies

5. Conclusion
This exercise protocol appears feasible for being adopted in a
This study confirmed our primary hypothesis that the protocol
fully powered study and it may be compared to different loading
was feasible in a heterogeneous cohort presenting with persistent
programmes (e.g. isotonic) or type of exercise (e.g. aerobic) in RCTs
AT. The isometric exercise protocol produced immediate significant
aimed to explore acute LS changes in AT populations and other
changes in LS and pain for SM jumps, but not for RSI, demonstrating
predictive factors. Considering that most patients report AT
its potential to be clinically useful. Studies with larger sample sizes,
symptoms with SSC activities, similar specific tasks, such as single-
control/placebo/sham intervention arms, or larger studies powered
legged continuous jumps, should be used to reassess immediate
for analysis of multiple covariates (e.g. baseline VISA-A, baseline
clinical changes.
physical activity levels, baseline symptom duration or baseline
It would also be important to understand if the differences
BMI) are required in order to test the effectiveness of this isometric
found in the two tasks (SM and M) are related to specific underlying
exercise protocol and to detect whether these effects are statisti-
factors. Indeed, relevant aspects such as beliefs, fear of jumping,
cally and clinically meaningful.
confidence with the task, physical activity levels and athleticism,
may affect maximal strength capability and neural drive (Abate
et al., 2013; Edwards et al., 2016; Kozlovskaia et al., 2017; Linton Informed consent
& Shaw, 2011; Mallows et al., 2018; Scott et al., 2015; Yue et al.,
2014). Therefore, we recommend a multidimensional assessment Informed consent has been obtained from all individuals
to account for the multiple variables that may influence the out- included in this study.
comes. In particular, the correlation between pain and load
manipulation needs to be further investigated. In this study the Ethical approval
isometric exercise was performed in a standing position to maxi-
mize the whole calf muscle complex involvement during the iso- The research related to human use complies with the Helsinki
metric contractions. In a previous study O’Neill et al. (O’Neill et al., Declaration, and has been approved from local Ethical committee
2018, 2019) used a similar protocol, albeit in a seated position, to (Comitato Etico di Bergamo, REG. SPERIM N 205/19) and from
specifically increase the recruitment of the soleus muscle. The Sheffield Hallam University Ethics Committee.
selected position may play a role for AT population in terms of
specific provocative activity and/or targeted muscles deficits. This Research funding
should be further investigated. Furthermore, bilateral symptoms
and previous lower limb injuries should be entered into a linear Authors state no funding involved.
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L. Mantovani, L. Maestroni, F. Bettariga et al. Physical Therapy in Sport 46 (2020) 234e242

Declaration of competing interest Maestroni, L., Read, P., Bishop, C., & Turner, A. (2019). Strength and power training in
rehabilitation: Underpinning principles and practical strategies to return ath-
letes to high performance. Sports Medicine. https://doi.org/10.1007/s40279-019-
Authors state no conflict of interest. 01195-6
Malliaras, P., & O’Neill, S. (2017). Potential risk factors leading to tendinopathy.
Apunts. Medicina de l’Esport, 52(194), 71e77. https://doi.org/10.1016/
Appendix A. Supplementary data j.apunts.2017.06.001
Mallows, A. J., Debenham, J. R., Malliaras, P., Stace, R., & Littlewood, C. (2018).
Cognitive and contextual factors to optimise clinical outcomes in tendinopathy.
Supplementary data to this article can be found online at
BMJ Publishing Group Ltd and British Association of Sport and Exercise
https://doi.org/10.1016/j.ptsp.2020.09.005. Medicine.
Maquirriain, J. (2012). Leg stiffness changes in athletes with Achilles tendinopathy.
International Journal of Sports Medicine, 33, 567e571. https://doi.org/10.1055/s-
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