Abstract
BackgroundMidportion Achilles tendinopathy (AT) is a common overuse injury, usually requiring several months of rehabilitation. Exercise therapy of the ankle plantar flexors (i.e. tendon loading) is considered crucial during conservative rehabilitation. Alfredson’s isolated eccentric and Silbernagel’s combined concentric-eccentric exercise programs have both shown beneficial results, but it is unknown whether any of these programs is superior for use in clinical practice. Therefore, the primary objective of this study is to compare the effectiveness of both programs on clinical symptoms. Secondary objectives are to compare the effectiveness of both programs on quality of life and functional outcome measures, to investigate the prognostic value of baseline characteristics, to investigate differences in cost-effectiveness.Methods/DesignEighty-six recreational athletes (21–60 years of age) with unilateral chronic midportion AT (i.e. ≥ 3 months) will be included in this multicenter assessor blinded randomized controlled trial. They will be randomly allocated to either a group performing the Alfredson isolated eccentric training program (n = 43), or a group performing the Silbernagel combined concentric-eccentric program (n = 43). In the Alfredson group, participants will perform eccentric heel-drops on their injured side, twice daily for 12 weeks, whereas in the Silbernagel group, participants perform various concentric-eccentric heel-raise exercises, once daily for 12 weeks. Primary outcome measure will be the Victorian Institute of Sport Assessment – Achilles (VISA-A) questionnaire. Secondary outcomes will be a visual analogue scale (VAS) for pain during daily activities and sports, duration of morning stiffness, global perceived effect, the 12-item Short Form Health Survey and the Euroqol instrument, and functional performance measured with the heel-raise test and the countermovement jump. Additionally, alongside the RCT, a cost-effectiveness analysis will be performed. Assessments will be performed at baseline and after 12, 26, and 52 weeks.DiscussionThis study is the first to directly compare the Alfredson and the Silbernagel exercise program in a randomized trial. The results can further enlarge the evidence base for choosing the most appropriate exercise program for patients with midportion AT.Trial registrationDutch Trial register: NTR5638. Date of registration: 7 January 2016.
Highlights
Midportion Achilles tendinopathy (AT) is a common overuse injury, usually requiring several months of rehabilitation
Midportion Achilles tendinopathy (AT) is a common overuse injury of the lower extremity, [1, 2] most prevalent in male athletes who participate in sports that involve running and/or jumping. [2,3,4] When not adequately managed, the injury may cause long term absenteeism of sports and daily activities
AT is considered as an inflammatory condition, but more recently it has been regarded as a failed healing response of the tendon, with minimal inflammatory influence. [8, 9] In 2009, Cook and Purdam proposed a model that considers tendinopathy as a continuum, in which three somewhat interchangeable stages can be distinguished: 1) reactive tendinopathy, 2) tendon dysrepair, and 3) degenerative tendinopathy
Summary
Midportion Achilles tendinopathy (AT) is a common overuse injury, usually requiring several months of rehabilitation. Exercise therapy of the ankle plantar flexors (i.e. tendon loading) is considered crucial during conservative rehabilitation. The model was recently revisited, [11] but it is still generally agreed that exercise therapy (i.e. tendon loading) is crucial to promote improvement of symptoms and function. [13] In the Alfredson program, the plantar flexor muscle-tendon unit is loaded eccentrically by performing heel drops on the injured side, while using the non-injured limb to (concentrically) return to the start position. [18, 19] a recent study of Stevens & Tan (2014) showed that a less stringent “do-as-tolerated” eccentric protocol can lead to equal improvements in pain and function compared to the Alfredson protocol, [20] which may be advantageous from a patient perspective. As exercises were performed only for a period of 6 weeks, and mid- and long-term follow-up measurements (i.e. > 6 weeks) were lacking, conclusions should be interpreted with caution
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