Eccentric exercise in the treatment of Achilles Tendinopathy

Report By: Davina Flint, Stephanie Pugh and Michael Callaghan - Physiotherapist, Senior Specialist Physiotherapist and Clinical Specialist and Research Associate
Institution: MRI
Date Submitted: 9th April 2009
Date Completed: 4th November 2009
Last Modified: 4th November 2009
Status: Green (complete)

Three Part Question

In [adults with Achilles tendinopathy] is [eccentric exercise more beneficial than other non invasive treatments] at [decreasing pain and improving function].

Clinical Scenario

A 31 year old male presents with a 3 year history of Achilles tendinopathy. You are planning to use standard treatments of electrotherapy, ICE and strengthening exercises to improve his symptoms. You have heard from a colleague about an exercise regime based on eccentric muscle contractions and you wonder if there is any evidence of greater efficacy compared to the other treatments.

Search Strategy

MEDLINE 1966-10/08, Web of Science 1970-10/08, BIOSIS Previews 1926-10/08, Journal Citation Reports 1997-10/08, via ISI Web of knowledge database. SPORTDiscus 1830-10/08, EMBASE 1996-10/08, Cochrane Databases Nov 08 and PEDro database Nov 08.
MEDLINE, Web of Science, BIOSIS Previews, Journal Citation Reports, SPORTDiscus, EMBASE, Cochrane Databases [{(Achilles tendon or tendo-achilles or calacaneal tendon or TA) and (eccentric exercise) AND (pain)}]
PEDro [eccentric exercise]
LIMIT to human AND English language.

Search Outcome

172 papers were retrieved, of which 14 were relevant to the three part question. Five were systematic reviews covering searches up to 2006. Nine were randomised controlled trials published since the latest systematic review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Herrington and McCulloch 2007 UK	N=25 Group 1 (n=13) received a 12 week eccentric loading programme plus Deep Frictional Massage (DFM), Ultrasound (US) and stretches. Group 2 (n=12) received DFM, Ultrasound and a stretching programme.	Level 1b RCT	1. VISA-A (Victorian Institute of Sports Assessment- Achilles) questionnaire	1. Group 1 demonstrated significantly higher (P=0.014) VISA-A scores than group 2.	Small sample size. No blinding. No Power calculation. Unclear randomisation process.
Knobloch et al 2007 Germany	N= 20 patients with chronic Achilles tendinopathy >3 months. Group 1 (n=15)performed 3 x 15 repetitions daily for 12 weeks. Group 2 (n=5) conventional repetitive cryotherapy and relative rest over 12 weeks.	Level 1b RCT	1. Visual Analogue Scale (VAS)	1. No between group statistical comparison.	No between group statistical comparison for VAS. Small sample size, particularly for the control group. No power calculation. No blinding of the participants or therapists. No concealed allocation. Not clear on randomisation process. Follow up results only recorded after 12 weeks.
			2. Paratendon Microcirculation	2. NSS between groups.
			3. Tendon and Paratendon Oxygen saturation	3. NSS between groups at 12 weeks.
			4. Tendon and Paratendon Postcapillary Venous Filling pressure	4. NSS between groups
Vos et al 2007 Netherlands	N= 58 >2 months symptoms (70 tendons, 46 unilateral, 12 bilateral.) Group 1 (n= 34 tendons) 180 repititions eccentric exercise daily for 12 weeks. Group 2 (n= 36 tendons) UFO night splint plus eccentric exercise.	Level 1b Single blinded RCT	1. VISA-A Questionnaire	1. NSS between groups.	Poor patient compliance- more than 25% of patients in both groups reported to performing the exercises at <50% of the prescribed intensity. No blinding of researcher. No power calculation included. No intention to treat analysis.
Vos et al 2007 Netherlands		Level 1b Single blinded RCT	2. Patient satisfaction	2. NSS between the groups at 12 weeks.
Norregaard et al 2007 Denmark	N= 45 with Achilles tendinopathy for at least 3 months. Group 1 Eccentric exercises versus Group 2 stretching exercises to be performed twice daily for 12 weeks.	Level 1b RCT	1. Manually assessed tenderness	1. NSS between groups.	Unclear randomisation process. No power calculation provided. No intention to treat analysis.
			2. Ultrasonography	2. NSS between groups.
			3. Questionnaire	3. NSS between groups.
			4. Patient's global assesment	4. NSS.
Stergioulas et al 2008 Norway	N= 52 with Achilles tendinopathy for 6 months+. Group 1 Eccentric Exercise (EE) and Low-Level Laser Treatment(LLLT). Group 2 EE and Placebo LLLT for 8 weeks treatment.	Level 1b RCT	1. Pain intensity during physical activity on a 100 mm VAS	1. VAS was significantly lower in Group 1 at 4 weeks (P=0.0003), at 8 weeks (P=0.0002) and at 12 weeks (P=0.007).	Unclear randomisation procedure. High number of dropouts (n=12)(23%). No power calculation.
			2. Morning stiffness measured on 100 mm VAS	2. Group 1 significantly lower VAS at 4 weeks (P< 0.05) and at 8 and 12 weeks (P<0.01).
			3. Crepitation severity measured on 100 mm VAS	3. Group 1 significantly lower VAS at 4, 8 and 12 weeks (P<0.05).
			4. Tenderness during palpation ,measure with a 40 mm VAS	4. Group 1 significantly lower VAS at 4, 8 and 12 weeks (P<0.05).
			5. Active dorsiflexion	5. Group 1 significantly increased active dorsiflexion at 4 weeks (P< 0.05) and at 8 and 12 weeks (P<0.01).
Petersen et al 2007 Germany	N= 100 with Achilles Tendinopathy for at least 3 months. Group 1: eccentric training (n=37), Group 2: Airheel brace (n=35), Group 3: Combination of Airheel Brace and eccentric training (n-28).	Level 1b RCT	1. American Orthopaedic Foot and Ankle Society (AOFAS) Score	1. NSS between the 3 treatment groups.	Large dropout rate (14%). No power calculation. No blinding of patient, assessor or therapist.
			2. VAS	2. NSS between the groups.
			3. Ultrasonography	3. NSS in tendon diameter in any of the treatment groups.
			4. Short Form- 36	4. NSS between the 3 treatment groups.
			5. Return to Sports	5. NSS between the groups.
Rompe et al 2008 Germany	N=50 with Chronic (6 months or more)insertional Achilles tendinopathy. Group 1- eccentric loading, Group 2- low-energy shock wave therapy.	Level 1b RCT	1. VISA-A Score	1. Group 2 significantly better at 4 months (p=0.005).	No blinding. Small sample size.
			2. General Assessment rated on a 6-point Likert scale	2. Group 2 significantly better at 4 months (p=0.043)
			3. Load-induced pain assessed on a numeric rating scale from 0-10	3. Group 2 significantly better at 4 months (p=0.004)
			4. Pain threshold (kg)	4. Group 2 were significantly better at 4 months (p=0.002)
			5. Tenderness	5. Group 2 were significantly better at 4 months (p=0.021)
Rompe et al 2007 Germany	N= 75 patients with Chronic noninsertional Achilles tendinopathy. Group 1 eccentric loading exercise programme (n=25). Group 2 shock wave therapy (n=25). Group 3 wait-and-see policy (n=25).	Level 1b RCT	1. VISA-A	1. At 4 months, group 1 and group 2 significantly better group 3 (P<0.01). Group 1 and group 2 significantly better than group 3 at 4 months follow up (P<0.001). NSS between the group 1 and group 2 (P=0.259).	No blinding of patients or therapists.
			2. General Assessment	2. Four months group 1 and group 2 significantly better than group 3 (P<0.001; P=0.001). NSS between group 1 and group 2 (P=0.557).
			3. Pain (Load-induced)	3. Groups 1 and 2 significantly better than group 3 (P<0.001). NSS between group 1 and 2 (P=.0494).
			4. Pain Threshold	4. Groups 1 and 2 significantly better than group 3 (P<0.001; P=0.008). NSS between group 1 and 2 (P=0.181).
			5. Tenderness	5. NSS between groups.
			6. Tendon diameter	6. NSS at 4 months.
Rompe et al. 2009. Germany.	N=68 patients with Chronic (>6 months) noninsertional Achilles tendinopathy. Group 1- eccentric training regimen (n=34). Group 2- eccentric training regimen plus Shock-Wave treatment (SWT) (n=34).	Level 1b RCT	1. VISA-A	1. At 4 months group 2 significantly better than group 1 (P=0.0016).	No patient or therapist blinding.
			2. General Assessment (Likert scale)	2. At 4 months group 2 significantly better than group 1 (P=0.001).
			3. Load Induced Pain	3. At 4 months, group 2 significantly better than group 1 (P=0.0045).
Kingma et al 2006 Netherlands	9 Studies (3RCT’s, 6 CCT’s) N= 484 subjects.	Level 1a Systematic review	1. Pain: VAS (6 studies)	1. No pooled data.	Hetrogenous study population, interventions and outcome measures prevented statistical pooling of results. Small number of small scale, poor quality studies.
			2. Foot and Ankle outcome score (FAOS) (1 study)	2. 37% reduction in eccentric training group. 23% reduction in eccentric training with night splint. 13% reduction in night splint only.
			3. Ordinal scale (2 studies)	3. No pooled data.
				Mean reduction in pain for eccentric overload training group was 60% (CI 29% to 94%. Control group 33% (CI 13% to 86%). 8 studies using a control group reported greater reductions in pain in the treatment group.
Van Usen and Pumberger 2007 Australia	25 Studies (8 RCT’s, 6 RNCT’s, 11 experimental. N = no details of patient numbers given 11 Studies (eccentric training)	Level 1a Systematic review	VAS (5 studies)	No pooled data.	Hetrogenous data. No meta analysis. Pedro modified to exclude blinding.
			US (4 studies)	No pooled data.
			Patient satisfaction (1 study)	No data available.
			Functional Strength (1 study)	No data available. Treatment effect size was 0.44 for isokinetic strength PF eccentric 90 degrees at 52/52 for 1 study & 0.6 for strength in PF after 6/12 in 1 study.
				All 11 studies were found to be significant at p<0.05 for one or more outcome measures.
Woodley et al. 2007 New Zealand	11 RCTs, 4 of which investigated subjects diagnosed with Achilles Tendinopathy (n= 145 subjects).	Level 1a Systematic review	1. Pain VAS (1 study)	NSS at 12 weeks.	Heterogeneous data in patient populations, ages gender ratio, duration of symptoms, interventions, controls and outcome measures. Low sample size for most outcome measures therefore unable to pool data. Two out of 4 studies were rated as high quality (6/10) using Pedro and van Tulder.
			2. FAOS Pain Score (1 study)	NSS at 12 weeks.
			3. FAOS subscale of sport and recreation (1 study)	NSS at 12 weeks.
			4. Plantarflexion ROM (1 study)	NSS at 12 weeks.
			5. Jumping test (1 study)	NSS at 12 weeks.
			6. Toe raise test (1 study)	NSS at 12 weeks.
			7. Patient satisfaction/Return to activity (3 studies)	Pooled data from 2 studies showed significant difference in favour of eccentric exercise after 12 weeks (p= 0.003) (RR 2.38’ 95% CI 1.36 to 4.18). A significant risk ratio in favour of eccentric was not found in a study measuring satisfaction after 12 months (p=0.25) (RR 1.56; 95% CI 0.73 to 3.32).
Wasielewski and Kotsko 2007 US	11 Studies 5 Achilles (All RCT’s) N=165 subjects.	Level 1a Systematic review	1. FAOS (1 study)	1. NSS for Eccentric Exercise (EE) +/- night splint v night splint only.	No summary statistics or pooled data or meta analysis due to hetrogenity.
			2. Modified knee injury and OA outcome score (1 study)	2. NSS between EE v stretching.
			3. Concentric (CE) and eccentric PF average torque at 30 & 50 degrees (1 study).	3. NSS between EE v CE. Significantly less pain reported in EE group.
			4. Pain (2 studies)	4. No pooled data. NSS between EE v CE.
			5. Vertical jump (2nd outcome measure 1 study)	5. NSS between EE v CE.
			6. Toe-raise test (3rd outcome measure 1 study)	6. NSS between EE v CE.
Satyendra and Byl 2006 USA.	2 RCTs and 5 CCTs/prospective cohort studies.	Level 1a Systematic review	1. Pain VAS (5 study)	1. No pooled data.	Unable to pool data due to heterogeneity. No summary statistics calculated for outcomes.
			2. 2. Concentric plantar flexion 90 degrees/sec (1 study)	2. Absolute benefit 29.2 of EE. Relative difference in change from baseline 19.6%.
			3. Toe raise test (1 study)	3. Absolute benefit -2 of EE. Relative difference in change from baseline -9.5%.
			4. Tendon thickness with US (1 study)	4. No summary statistics.
			5. Tendon vol cm3 by MRI (1 study)	5. No summary statistics.
			6. Pain Ordinal (1 Study).	6. No summary statistics.

Comment(s)

Two studies found eccentric exercises combined with electrotherapy, to be significantly better than eccentric exercise as a stand alone treatment. One study combining eccentric exercise with other standard non-invasive treatments had significantly better results than carrying out other non-invasive treatments without eccentric exercise. Another study reports that eccentric exercise is significantly better than a wait-and-see policy. The systematic reviews were unable to provide any significant evidence in favour of eccentric exercise due to heterogeneity of the data.

Clinical Bottom Line

Present evidence suggests that eccentric exercise is no better than other non-invasive treatments for Achilles tendinitis. There is however, moderate evidence to suggest that when eccentric exercise is combined with other non-invasive treatment modalities, there is significant improvements in outcome measures.

References

Herrington L and McCulloch R. The role of eccentric training in the management of Achilles tendinopathy: A pilot study. Physical Therapy in Sport. 2007 191-196
Knobloch K, Kraemer R, Jagodzinski M, Zeichen J, Meller R and Vogt P M. Eccentric Training Decreases Paratendon Capillary Blood Flow and Preserves Paratendon Oxygen Saturation in Chronic Achilles Tendinopathy. Journal of Orthopaedic and Sports Physical Therapy. May 2007, Volume 37 (5) 269-276
Vos R J, Weir A, Visser R J A, Winter T C and Tol J L. The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. British Journal of Sports Medicine 2007; 41;e5
Norregaard J, Larsen C C, Bieler T and Langberg H. Eccentric exercise in treatment of Achilles tendinopathy. Scandinavian Journal of Medicine & Science in Sports. 2007 (17) 133-138.
Stergioulas A, Stergioula M, Aarskog R, Lopes-Martins R A B and Bjordal J M. Effects of Low-level Laser Therapy and Eccentric Exercises in the Treatment of Recreational Atheletes with Chronic Achilles Tendinopathy. American Journal of Sports Medicine. 2008 (36) 881- 887
Petersen W, Welp R and Rosenbaum D A prospective Randomized Study Comparing the Therapeutic Effect of Eccentric Training, the AirHeel Brace, and a Combination of Both. American Journal of Sports Medicine 2007 (35) 1659-1667
Rompe J D, Furia J and Maffulli N. Eccentric Loading Compared with Shock Wave Treatment for Chronic Insertional Achilles Tendinopathy. The Journal of Bone and Joint Surgery. 2008 (90) 52-61.
Rompe J D, Nafe B and Furia J P. Eccentric Loading, Shock-Wave Treatment, or a Wait- and- See Policy for Tendinopathy of the Main Body of Tendo Achillis. American Journal of Sports Medicine. 2007 (35) 374-383.
Rompe J D, Furia J and Maffulli N. Eccentric Loading Versus Eccentric Loading Plus Shock-Wave Treatment for Midportion Achilles Tendinopathy. American Journal of Sports Medicine. 2009 (37) 463-470.
Kingma J J, de Knickker R, Wittink H M and Takken T. Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. British Journal of Sports Medicine. 2006, 1-5.
Van Usen C and Pumberger B. Effectiveness of Eccentric Exercises in the Management of Chronic Achilles Tendinosis. The Internet Journal of Allied Health Sciences and Practise. 2007, 1-5.
Woodley B L, Newsham- West R J and Baxter G D. Chronic tendinopathy: effectiveness of eccentric exercise. British Journal of Sports Medicine. 2007, 188-199.
Wasielewski N J and Kotsko K M Does Eccentric Exercise Reduce Pain and Improve Strength in Physically Active Adults with Sympotmatic Lower Extremity Tendinosis? Asystematic Review. Journal of Athletic Training. 2007 (42) 409-421.
Satyendra L and Byl N. Effectiveness of physical therapy for Achilles tendinopathy: An evidence based review of eccentric exercises. Isokinetics and Exercise Sciences. 2006 (14) 71-80.