Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis
Mid-portion Achilles tendinopathy is prevalent within both the athletic and non-athletic populations and loading protocols for Achilles tendinopathy are effective over time, though the rate of symptom change throughout rehabilitation is unknown.
The objective of this study was to determine the rate of change in pain and function over time in patients while completing a loading protocol for mid-portion Achilles tendinopathy.
A systematic review and longitudinal meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The databases PubMed, CINAHL (Ovid) and CINAHL (EBSCO) were searched for articles published from inception until 31 July, 2017. Our search focused on clinical trials and cohort studies examining changes in pain and function when completing a loading protocol for mid-portion Achilles tendinopathy. The primary outcome measure assessing pain and function was the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire.
A total of 31 separate cohorts (24 studies) were eligible, with follow-up ranging from 2 weeks to 6 months. The data were pooled to create the mean (standard deviation) of change from baseline at each time point. The data demonstrated an improvement in pain and function as early as 2 weeks that appeared to peak at 12 weeks with a mean (standard deviation) of 21.11 (6.61) points of change on the VISA-A.
The improvement in pain and function during rehabilitation suggests future research should be directed toward investigating contributing mechanisms as tendon structure on imaging does not change within 2 weeks and muscular hypertrophy is not seen for at least 4 weeks following the inception of a loading protocol. Systematic Review Registry: PROSPERO registration number: CRD42017062737 (https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=62737)
Myles Murphy acknowledges the support from the Australian Governments Research Training Program Scholarship. Ebonie Rio acknowledges the support from the National Health and Medical Research Councils Early Career Fellowship Scheme. All authors acknowledge the contributions of Dr. Clare Ardern (Linköping University, Linköping, Sweden) and Prof. Max Bulsara (Institute of Health Research, The University of Notre Dame, Fremantle, WA, Australia) for their assistance in developing the protocol for this systematic review.
MM, WG and ER conceptualised the study. MM, MT, WG, JD, SD, PC and ER developed the study design and protocol. All authors contributed and approved the final manuscript.
Compliance with Ethical Standards
No financial support was received for the conduct of this study or preparation of this article.
Conflict of Interest
Myles Murphy, Mervyn Travers, William Gibson, Paola Chivers, James Debenham, Sean Docking and Ebonie Rio have no conflicts of interest directly relevant to the content of this article.
- 6.Albers IS, Zwerver J, Diercks RL, Dekker JH, Van den Akker-Scheek I. Incidence and prevalence of lower extremity tendinopathy in a Dutch general practice population: a cross sectional study. BMC Musculoskelet Disord. 2016;17(1):16. https://doi.org/10.1186/s12891-016-0885-2.CrossRefPubMedPubMedCentralGoogle Scholar
- 9.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(1):42–7. https://doi.org/10.1007/s001670000148.CrossRefPubMedGoogle Scholar
- 10.Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35(6):897–906. https://doi.org/10.1177/0363546506298279.CrossRefPubMedGoogle Scholar
- 12.Beyer R, Kongsgaard M, Hougs Kjaer B, Ohlenschlaeger T, Kjaer M, Magnusson SP. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2015;43(7):1704–11. https://doi.org/10.1177/0363546515584760.CrossRefPubMedGoogle Scholar
- 16.Shalabi A, Kristoffersen-Wilberg M, Svensson L, Aspelin P, Movin T. 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(5):1286–96. https://doi.org/10.1177/0363546504263148.CrossRefPubMedGoogle Scholar
- 23.de Jonge S, Tol JL, Weir A, Waarsing JH, Verhaar JA, de Vos RJ. The tendon structure returns to asymptomatic values in nonoperatively treated achilles tendinopathy but is not associated with symptoms: a prospective study. Am J Sports Med. 2015;43(12):2950–8. https://doi.org/10.1177/0363546515605077.CrossRefPubMedGoogle Scholar
- 27.van Ark M, Cook JL, Docking SI, Zwerver J, Gaida JE, van den Akker-Scheek I, et al. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. J Sci Med Sport. 2016;19(9):702–6. https://doi.org/10.1016/j.jsams.2015.11.006.CrossRefPubMedGoogle Scholar
- 28.Murphy M, Travers MJ, Gibson W, Chivers P, Debenham J, Docking S, et al. The rate of improvement of pain and function in mid-portion Achilles tendinopathy with loading protocols: a systematic review and longitudinal meta-analysis. In: Figshare.2018. Available from: https://figshare.com/articles/The_rate_of_improvement_of_pain_and_function_in_mid-portion_Achilles_tendinopathy_with_loading_protocols_A_Systematic_Review_and_Longitudinal_Meta-Analysis_/6143210. Accessed 5 May 2018.
- 30.Scott A, Docking S, Vicenzino B, Alfredson H, Murphy RJ, Carr AJ, et al. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. Br J Sports Med. 2013;47(9):536–44. https://doi.org/10.1136/bjsports-2013-092329.CrossRefPubMedPubMedCentralGoogle Scholar
- 31.Murphy M, Rio E, Debenham J, Docking S, Travers MJ, Gibson W. Evaluating the progress of mid-portion Achilles tendinopathy during rehabilitation: a review of outcome measures for self-reported pain and function. Int J Sports Ther. 2018;13(2):283–92. https://doi.org/10.26603/ijspt20180283.CrossRefGoogle Scholar
- 32.Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700. https://doi.org/10.1136/bmj.b2700.CrossRefPubMedPubMedCentralGoogle Scholar
- 35.Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.1.0 [updated March 2011]. http://www.handbook.cochrane.org. Accessed 5 May 2018.
- 41.Balius R, Álvarez G, Baró F, Jiménez F, Pedret C, Costa E, et al. A 3-arm randomized trial for Achilles tendinopathy: eccentric training, eccentric training plus a dietary supplement containing mucopolysaccharides, or passive stretching plus a dietary supplement containing mucopolysaccharides. Curr Ther Res Clin Exp. 2016;78:1–7. https://doi.org/10.1016/j.curtheres.2016.11.001.CrossRefPubMedPubMedCentralGoogle Scholar
- 43.Boesen AP, Hansen R, Boesen MI, Malliaras P, Langberg H. Effect of high-volume injection, platelet-rich plasma, and sham treatment in chronic midportion Achilles tendinopathy: a randomized double-blinded prospective study. Am J Sports Med. 2017;45(9):2034–43. https://doi.org/10.1177/0363546517702862.CrossRefPubMedGoogle Scholar
- 46.Kearney RS, Parsons N, Costa ML. Achilles tendinopathy management: a pilot randomised controlled trial comparing platelet-richplasma injection with an eccentric loading programme. Bone Joint Res. 2013;2(10):227–32. https://doi.org/10.1302/2046-3758.210.2000200.CrossRefPubMedPubMedCentralGoogle Scholar
- 49.McAleenan M, McVeigh JG, Cullen M, Sayers F, McCrea K, Baxter D. The effectiveness of night splints in achilles tendinopathy: a pilot study. Physiother Pract Res. 2010;31(1):28–33.Google Scholar
- 58.Tumilty S, McDonough S, Hurley DA, Baxter GD. Clinical effectiveness of low-level laser therapy as an adjunct to eccentric exercise for the treatment of Achilles’ tendinopathy: a randomized controlled trial. Arch Phys Med Rehabil. 2012;93(5):733–9. https://doi.org/10.1016/j.apmr.2011.08.049.CrossRefPubMedGoogle Scholar
- 62.Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin Orthop Relat Res. 1986;208:65–8.Google Scholar
- 71.van der Plas A, de Jonge S, de Vos RJ, van der Heide HJ, Verhaar JA, Weir A, et al. A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012;46(3):214–8. https://doi.org/10.1136/bjsports-2011-090035.CrossRefPubMedGoogle Scholar
- 72.Murphy M, Travers MJ, Gibson W. Is heavy eccentric calf training superior to wait-and-see, sham rehabilitation, traditional physiotherapy and other exercise interventions for pain and function in mid-portion Achilles tendinopathy. Syst Rev. 2018;7(58):1–7. https://doi.org/10.1186/s13643-018-0725-6.CrossRefGoogle Scholar