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Can anybody please fill me in on the Anderson set of exercise for achilles tedinopthay? I really like the idea of use a set prescription as a starting point.
Can anybody please fill me in on the Anderson set of exercise for achilles tedinopthay? I really like the idea of use a set prescription as a starting point.
Patients performed the exercises twice a day, seven days a week for 12 weeks.
Initial phase: The patient performs the calf raise exercise as described above (Wallmann’s workout) but with the ball of the foot placed upon a step. The patient pushes up on the non-injured leg and lowers down on the injured leg, slowly and in control. Perform 3 sets x 15 repetitions of straight-leg calf raise and then bent-leg calf raise.
Progressions: Once this becomes comfortable, increase the eccentric load by adding weights to a back-pack. Loading is continually added – transferring from back-pack to a calf-raise resistance machine if necessary – throughout the 12-week programme.
Alfredson’s programme starts at the equivalent of level 4 of Wellmann’s programme, and involves more repetitions, as the patient performs straight-leg and bent-leg exercises in a single session and undertakes two sessions a day.
I believe Alfredson’s emph-asis on progressing through increased loading rather than through speed will be more effective in strengthening the tendon. And Alfredson’s use of the step enables the patient to perform the eccentric lowering through a full range of movement, which is a superior strengthening method and may even increase the length of the muscle-tendon unit. I would strongly recommend using the step for this exercise.
In summary, Alfredson’s programme is more aggressive than Wellmann’s, as it assumes the patients are capable of single-leg loading immediately. Wellmann assumes that by the end of his programme the patient will have sufficient strength using body weight only, whereas Alfredson’s programme is designed to develop as much strength as possible during the 12 weeks.
Alfredson et al reported this programme in a paper which compared two groups of patients, both with similar levels of tendonitis symptoms, following different treatment plans. One group had corrective surgery, while the other undertook the 12-week programme. Both groups enjoyed the same level of pain relief and both were able to return to normal activity afterwards. This proves that an eccentric loading programme can be a very effective alternative to surgery in reducing Achilles tendonitis symptoms.
Aim:
Prognosis and treatment of Achilles tendon pain (achillodynia) has been insufficiently studied. The purpose of the present study was to examine the long-term effect of eccentric exercises compared with stretching exercises on patients with achillodynia.
Methods:
Patients with achillodynia for at least 3 months were randomly allocated to one of two exercise regimens. Exercise was performed daily for a 3-month period. Symptom severity was evaluated by tendon tenderness, ultrasonography, a questionnaire on pain and other symptoms, and a global assessment of improvement. Follow-up was performed at time points 3, 6, 9, 12 weeks and 1 year.
Results:
Of 53 patients with achillodynia 45 patients were randomized to either eccentric exercises or stretching exercises. Symptoms gradually improved during the 1-year follow-up period and were significantly better assessed by pain and symptoms after 3 weeks and all later visits. However, no significant differences could be observed between the two groups. Women and patients with symptoms from the distal part of the tendon had significantly less improvement.
Conclusions:
Marked improvement in symptoms and findings could be gradually observed in both groups during the 1-year follow-up period. To that extent this is due to effect of both regimens or the spontaneous improvement is unsettled.
Background: Eccentric training has been shown to reduce pain and gain function in patients with chronic Achilles tendinopathy. However, currently no data are available regarding any potential adverse effects of an eccentric training intervention on Achilles tendon microcirculation.
Methods: 59 patients (49 (12) years; body mass index 27 (5); 49 mid-portion, 10 chronic insertional tendinopathy) with 64 symptomatic (54 mid-portion, 10 insertional) Achilles tendons were prospectively enrolled. Baseline tendon microcirculation at four distinct tendon positions from the insertion to the proximal mid-portion area was assessed using a laser Doppler system for capillary blood flow, tissue oxygen saturation and postcapillary venous filling pressure. A 12-week daily painful home-based eccentric training regimen was initiated (3x15 repetitions per tendon and day).
Results: Achilles tendon capillary blood flow was significantly reduced at the insertion (by 35%, p = 0.008) and the distal mid-portion area (by 45%, p = 0.015) at 2 mm and by 22% (p = 0.007) and 13% (p = 0.122) at 8 mm tissue depths, respectively. Achilles tendon oxygen saturation was not decreased after the 12-week eccentric training regimen throughout the insertion to the proximal mid-portion area (insertion 72 (13) vs 73 (10), proximal mid-portion 63 (13) vs 62 (11), both NS). Achilles tendon postcapillary venous filling pressures were significantly reduced at the insertion (51 (16) vs 41 (19), p = 0.001) and the distal mid-portion (36 (13) vs 32 (12), p = 0.037) at 2 mm and at the insertion at 8 mm (63 (19) vs 51 (13), p = 0.0001). Pain was reduced from 5.4 (2.1) to 3.6 (2.4; p = 0.001) in the mid-portion and from 6 (2.5) to 3.2 (2.7; p = 0.002) in the insertional tendinopathy group. No Achilles tendon rupture or any interruption during the eccentric training was noted among the 59 patients.
Conclusion: Daily eccentric training for Achilles tendinopathy is a safe and easy measure, with beneficial effects on the microcirculatory tendon levels without any evident adverse effects in both mid-portion and insertional Achilles tendinopathy
Re: Alfredson’s "prescription" for achilles tendinopathy
Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review
J J Kingma, R de Knikker, H M Wittink and T Takken British Journal of Sports Medicine 2007;41:e3
Quote:
Background: Eccentric overload training seems to be a promising conservative intervention in patients with chronic Achilles tendinopathy. The efficacy of eccentric overload training on the outcome measures of pain and physical functioning are not exactly clear.
Study design: Systematic review of the literature.
Methods: Electronic databases were searched for randomised clinical trials concerning eccentric overload training in patients with chronic Achilles tendinopathy. The Delphi list was used to assess the methodological quality of the studies.
Results: Nine clinical trials were included. Only one study had sufficient methodological quality. The included trials showed an improvement in pain after eccentric overload training. Because of the methodological shortcomings of the trials, no definite conclusion can be drawn concerning the effects of eccentric overload training in patients with chronic Achilles tendinopathy.
Conclusion: The effects of eccentric exercise training in patients with chronic Achilles tendinopathy on pain are promising; however, the magnitude of the effects cannot be determined. Large, methodologically sound studies from multiple sites in which functional outcome measures are included are warranted.
Re: Alfredson’s "prescription" for achilles tendinopathy
Chronic Achilles Tendinopathy: Prospective Randomized Study Comparing the Therapeutic Effect of Eccentric Training, the AirHeel Brace, and a Combination of Both
Wolf Petersen, Robert Welp, and Dieter Rosenbaum, The American Journal of Sports Medicine 35:1659-1667 (2007)
Quote:
Background: Previous studies have shown that eccentric training has a positive effect on chronic Achilles tendinopathy. A new strategy for the treatment of chronic Achilles tendinopathy is the AirHeel brace.
Hypothesis: AirHeel brace treatment improves the clinical outcome of patients with chronic Achilles tendinopathy. The combination of the AirHeel brace and an eccentric training program has a synergistic effect.
Study Design: Randomized controlled clinical trial; Level of evidence, 1.
Methods: One hundred patients were randomly assigned to 1 of 3 treatment groups: (1) eccentric training, (2) AirHeel brace, and (3) combination of eccentric training and AirHeel brace. Patients were evaluated at 6, 12, and 54 weeks after the beginning of the treatment protocol with ultrasonography, visual analog scale (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, and Short Form-36 (SF-36).
Results: The VAS score for pain, AOFAS score, and SF-36 improved significantly in all 3 groups at all 3 follow-up examinations. At the 3 time points (6 weeks, 12 weeks, and 54 weeks) of follow-up, there was no significant difference between all 3 treatment groups. In all 3 groups, there was no significant difference in tendon thickness after treatment.
Conclusions: The AirHeel brace is as effective as eccentric training in the treatment of chronic Achilles tendinopathy. There is no synergistic effect when both treatment strategies are combined.
Purpose. To evaluate the effects of eccentric strengthening exercises (ESE) in athletic patients with Achilles tendinopathy.
Methods. Forty-five athletic patients (29 men, average age 26 years +/- 12.8, range 18 - 42; 16 women, average age 28 years +/- 13.1, range 20 - 46; average height: 173 +/- 16.8, range 158 - 191; average weight 70.8 kg +/- 15.3, range 51.4 - 100.5) with a clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks.
Results. The mean pre-management VISA-A scores of 36 (SD 23.8; 95% CI: 29 - 46) improved to 52 (SD 27.5; 95% CI: 41.3 - 59.8) at the latest follow up (p = 0.001). Twenty seven of the 45 patients responded to the eccentric exercises. Of the 18 patients who did not improve with eccentric exercises, 5 (mean age: 33 years) improved with two peritendinous aprotinin and local anaesthetic injections. 10 of the 18 patients (9 men, mean age 35 years; 1 woman aged 40 years) who did not improve with eccentric exercises and aprotinin injections proceeded to have surgery. The remaining three patients (3 women, mean age 59.6 years) of the 18 non-responders to eccentric exercises and aprotinin injections declined surgical intervention.
Conclusions. ESE in athletic patients provide comparable clinical outcome compared to our previous results in non-athletic patients. ESE are a viable option for the management of AT in athletes, but, in our hands, only around 60% of our athletic patients benefited from an intensive, heavy load eccentric heel drop exercise regimen alone. If ESE fail to improve the symptoms, aprotinin and local anaesthetic injections should be considered. Surgery is indicated in recalcitrant cases after 3 to 6 months of non operative management.
Re: Alfredson’s "prescription" for achilles tendinopathy
New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study
P Jonsson, H Alfredson, K Sunding, M Fahlström, J Cook British Journal of Sports Medicine 2008;42:746-749
Quote:
Background: Chronic painful insertional Achilles tendinopathy is seen in both physically active and non-active individuals. Painful eccentric training, where the patients load the Achilles tendon into full dorsiflexion, has shown good results in patients with mid-portion Achilles tendinosis. However, only 32% of patients with insertional Achilles tendinopathy had good clinical results with that type of eccentric training regimen.
Aim: To investigate whether a new model of painful eccentric training had an effect on chronic painful insertional Achilles tendinopathy.
Patients and methods: 27 patients (12 men, 15 women, mean age 53 years) with a total of 34 painful Achilles tendons with a long duration of pain (mean 26 months), diagnosed as insertional Achilles tendinopathy, were included. The patients performed a new model of painful eccentric training regimen without loading into dorsiflexion. This was done as 3x15 reps, twice a day, 7 days/week, for 12 weeks. Pain during Achilles-tendon-loading activity (VAS) and patient’s satisfaction (back to previous activity) were evaluated.
Results: At follow-up (mean 4 months) 18 patients (67%, 23/34 tendons) were satisfied and back to their previous tendon-loading activity. Their mean VAS had decreased from 69.9 (SD 18.9) to 21 (SD 20.6) (p<0.001). Nine patients (11 tendons) were not satisfied with the treatment, although their VAS was significantly reduced from 77.5 (8.6) to 58.1 (14.8) (p<0.01).
Conclusion: In this short-term pilot study this new model of painful eccentric calf-muscle training showed promising clinical results in 67% of the patients.
Re: Alfredson’s "prescription" for achilles tendinopathy
Eccentric calf muscle exercise produces a greater acute reduction in Achilles tendon thickness than concentric exercise
Nicole L Grigg, Scott C Wearing, and James E Smeathers BJSM Published Online First: 19 November 2008
Quote:
Objective: To investigate the acute effects of isolated eccentric and concentric calf muscle exercise on Achilles tendon sagittal thickness.
Design: Within subject, counter balanced, mixed design.
Setting: Institutional.
Participants: Eleven healthy, recreationally-active male adults.
Interventions: Participants performed an exercise protocol, which involved isolated eccentric loading of the Achilles tendon of a single limb and isolated concentric loading of the contra-lateral, both with the addition of 20% bodyweight.
Main Outcome Measurements: Sagittal sonograms were acquired prior to, immediately following and 3, 6, 12 and 24 hours post-exercise. Tendon thickness was measured 2 cm proximal to the superior aspect of the calcaneus.
Results: Both loading conditions resulted in an immediate decrease in normalised Achilles tendon thickness. Eccentric loading induced a significantly greater decrease than concentric loading despite a similar impulse (-0.21 vs -0.05, P < 0.05). Post-exercise, eccentrically loaded tendons recovered exponentially, with a recovery time constant of 2.5 hours. The same exponential function did not adequately model changes in tendon thickness resulting from concentric loading. Even so, recovery pathways subsequent to the three hour time point were comparable. Regardless of the exercise protocol full tendon thickness recovery was not observed until 24 hours.
Conclusions: Eccentric loading invokes a greater reduction in Achilles tendon thickness immediately after exercise but appears to recover fully in a similar time frame to concentric loading.
Re: Alfredson’s "prescription" for achilles tendinopathy
Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation.Knobloch K, Schreibmueller L, Longo UG, Vogt PM. Disabil Rehabil. 2008;30(20-22):1685-91.
Quote:
PURPOSE: To compare eccentric training and the combination of eccentric training with the AirHeel Brace for the management of tendinopathy of the main body of the Achilles tendon.
METHODS: We recruited 116 subjects with unilateral tendinopathy of the main body of the Achilles tendon, who were randomized in two groups. Group A performed a regimen of daily eccentric training associated with the AirHeel Brace (Donjoy Orthopedics, Vista, CA, USA). Group B performed the same eccentric training without the AirHeel Brace. Tendon microcirculatory mapping was performed using combined Laser-Doppler and spectrophotometry. Pre- and post-operative FAOS score and VAS score were used to evaluate the patients.
RESULTS: The FAOS score and the VAS score showed significant improvements from pre-operative to post-operative values in both groups (A 5.1 +/- 2 vs. 2.9 +/- 2.4, 43% reduction and B: 5.4 +/- 2.1 vs. 3.6 +/- 2.4, 33% reduction, both p = 0.0001). There were no statistically significant differences in FAOS score and VAS score when comparing the two groups after the end of the intervention. In Group A, tendon oxygen saturation in the main body of the Achilles tendon showed significant increase from pre- to post-management values (68 +/- 12 vs.74 +/- 8%, p = 0.003). Post-capillary venous filling pressures showed significant reduction from pre- to post-intervention values.
CONCLUSION: Eccentric training, associated or not with the AirHeel Brace, produces the same effect in patients with tendinopathy of the main body of the Achilles tendon. The combination of eccentric training with the AirHeel Brace can optimize tendon microcirculation, but these micro-circulator advantages do not translate into superior clinical performance when compared with eccentric training alone.
Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without an AirHeel Brace. A randomized controlled trial. B: Effects of compliance.Knobloch K, Schreibmueller L, Longo UG, Vogt PM. Disabil Rehabil. 2008;30(20-22):1692-6
Quote:
PURPOSE: To evaluate microcirculatory variables in and around the Achilles tendon (AT) in patients undergoing a programme of daily eccentric training for the management of tendinopathy of the main body of the AT in non-compliant in contrast to compliant patients.
METHODS: A total of 116 patients with tendinopathy of the AT were enrolled for prospective eccentric training. Non-compliant patients were defined following drop-out due to less than 80% participation in the daily eccentric training regimen.
RESULTS: Overall 12-week-compliance was 79% (92/116). The reasons for non-compliance were moving out of town (21%, 5/24), overwhelming pain (25%, 6/24), limited discipline (29%, 7/24), and surgery (17%, 4/24). Capillary blood flow, tendon and paratendon oxygen saturation as well as postcapillary venous filling pressures were not significantly different between compliant and non-compliant patients. Gender, age, BMI, non steroidal anti inflammatory drugs, corticosteroid medication and smoking habits were not significantly different. Only the use of oral contraceptives (non- vs. compliant: 54% vs. 10%, p = 0.0001) and walking/swimming (46% vs. 70%, p = 0.041) were significantly different. Pain level was reduced (5.6 +/- 1.9 to 2.9 +/- 1.2, p < 0.05) following eccentric training.
CONCLUSIONS: In patients undergoing eccentric training for tendinopathy of the main body of the AT, there is no difference in microcirculatory variables regardless of compliance with the eccentric exercises programme. With the exception of the more frequent use of oral contraceptive medication and less often walking/swimming, no predictive factors could be identified in non-compliant patients.
Re: Alfredson’s "prescription" for achilles tendinopathy
I started to thank each posting but found it would be easier to just type thanks to Admin, Admin2 and Newsbot for all the info and to emoclew for starting the thread - very easy to incorporate into clinical practice.
Wendy
How do we increase the weights in the alfredson programme? Is there a specific incrimental weight increase? or is it just a matter of increasing enough so that the exercises cause pain and when its no longer painful with that weight......increase the weight until it causes pain again? Is there no systematic way of increasing the weight is my question?????
CHEERS TO ALL IN ADVANCE,
FD
Last edited by Admin2 : 28th May 2009 at 10:02 PM.
Reason: threads merged
The use of eccentric resistance training as management of Achilles tendinopathy is widespread. The investigators have recently demonstrated that heavy slow resistance training was superior in the management of patellar tendinopathy. Hypothesis: heavy slow resistance training is more effective than eccentric resistance training in the clinical management of Achilles tendinopathy.
The role of gender in Achilles tendinopathy is yet to be determined. We hypothesized that female patients respond the same as males to 12 weeks of painful eccentric training. A total number of 75 consecutive mid-portion patients with Achilles tendinopathy (25 females, 38 males) were enrolled in a cohort study with 63 being analyzed after 12 weeks according to their gender for tendon and paratendon microcirculatory mapping. Outcome was determined by pain on visual analogue scale, VISA-A score, Foot Ankle Outcome Score (FAOS), tendon and paratendon capillary blood flow, oxygen saturation, and postcapillary venous filling pressures. Eccentric training resulted in a morning resting pain reduction by 44% in males (P = 0.001) and by 27% in females (P = 0.08). VISA-A score improved in males by 27% from 63 +/- 12 to 86 +/- 13 (P = 0.036) and by 20% in females from 60 +/- 14 to 75 +/- 11 (P = 0.043, P < 0.05 for gender difference). Among females, only one out of five FAOS items was increased (sport 72 +/- 21 to 82 +/- 15, P = 0.045), while in males, four out of five items were increased (symptoms, pain, all-day-life, and sport, all P < 0.01). The microcirculatory gender-specific response to eccentric training revealed a greater postcapillary venous filling pressure reduction among symptomatic females and inconclusive capillary blood flow changes. No change in tendon oxygenation was noted in both genders. Symptomatic females suffering Achilles tendinopathy do not benefit as much as symptomatic males from 12 weeks of eccentric training. The pain reduction is significantly lower among symptomatic females in contrast to males, and the improvement in the FAOS and VISA-A scores is significantly lower among females in contrast to males. Additional treatment options warrant scrutiny to symptomatic females suffering Achilles tendinopathy beyond eccentric training.
Re: Alfredson’s "prescription" for achilles tendinopathy
Check out the article in the November issue of Lower Extremity Review on a four part approach to treating achilles tendinopathy. This clinical strategy for Achilles tendinopathy includes massage techniques that apply pressure along injured soft tissues to promote healing, as well as Mulligan taping for the control of pronation and management of symptoms. http://lowerextremityreview.com/arti...-part-approach
How do we increase the weights in the alfredson programme? Is there a specific incrimental weight increase? or is it just a matter of increasing enough so that the exercises cause pain and when its no longer painful with that weight......increase the weight until it causes pain again? Is there no systematic way of increasing the weight is my question?????
CHEERS TO ALL IN ADVANCE,
FD
I am not aware of any research that looked at a sytematic increase in resistance for the eccentric training program. Most physical therapists will use a back pack loaded with weights until pain is reproduced with th eccentric portion of the exercise.
Re: Alfredson’s "prescription" for achilles tendinopathy
One-year follow-up of a randomised controlled trial on added splinting to eccentric exercises in chronic midportion Achilles tendinopathy
S de Jonge, R J de Vos, H T M Van Schie, J A N Verhaar, A Weir, J L Tol Br J Sports Med doi:10.1136/bjsm.2008.052142
Quote:
Objective The study examined whether the addition of a night splint to eccentric exercises is beneficial for functional outcome in chronic midportion Achilles tendinopathy.
Design One-year follow-up of a randomised controlled single blinded clinical trial.
Setting Sports medicine department in a general hospital.
Patients 58 patients (70 tendons) were included.
Interventions All patients completed a 12-week heavy load eccentric training programme. One group received a night splint in addition to eccentric exercises.
Main outcome measurements Outcome scores were: Victorian Institute of Sport Assessment—Achilles (VISAA) score, subjective patient satisfaction and neovascularisation score measured with power Doppler ultrasonography (PDU).
Results For both groups the VISA-A score increased significantly (from 50 to 76 (p<0.01) in the eccentric group and from 49 to 78 (p<0.01) in the night splint group). No significant differences in the VISA-A score were found between the groups from baseline to one year (p = 0.32). The presence of neovessels at baseline did not predict a change in the VISA-A score after one year in the whole group (p = 0.71).
Conclusion Eccentric exercises with or without a night splint improved functional outcome at one year follow-up. At follow-up there was no significant difference in clinical outcome when a night splint was used in addition to an eccentric exercise programme. Between 3 months and one year follow-up, a continuing increase in the VISA-A score was found. Assessment of the neovascularisation score with PDU at baseline has no prognostic value on long-term clinical outcome.
Re: Alfredson’s "prescription" for achilles tendinopathy
Hi, I had a query regarding the number of sets and repetitions of the Alfreson prescription.
With weight lifting fewer reps at heavier weight are generally considered best for building muscle strength. It's also beneficial to train on alternate days for maximum strength gain.
I was wondering why the Alfredson recommends exercising every day instead of alternate days?
Is it because of differences in building muscle strength or tendon strength where tendons benefit from more regular training?
Re: Alfredson’s "prescription" for achilles tendinopathy
The point of the Alfredson program is not to strengthen the muscle, but more to stress the tendon so the body jumps in to beef it up. (jump-starting the repair process) That's why it doesn't follow the classic strengthening protocol.
If you want the patient's body to get to work you need to convince them that they are nagging their tissues like a parent nagging a child to clean their room. Telling the kid every other day to clean the room is less effective than nagging them every two hours...
Some patients like hearing the story of how Dr. Alfredson "discovered" the program named after him. They laugh, but it does seem to help them remember the purpose of the exercise protocol. (He was sharing a rural surgical coverage in Sweden. The other doctor didn't want to work on Dr. Alfredson's achilles because then he'd have to cover Dr. Alfredson's practice during the healing process, so Dr. Alfredson tried to stress his tendon enough to rupture it to force the other doctor to attend to him. Instead the increased stress convinced his body to repair it.)
You can find some good pictures in "Treat your own strains, sprains, and bruises" by Lindsay, Watson, Hickmott, Broadfoot, and Bruynel. Some patients like to borrow the book, so it's nice to have an extra copy or two around.
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Re: Alfredson’s "prescription" for achilles tendinopathy
Thanks for the reply and a great story!
I guess it's not overusing the tendon as it's done in a way that doesn't cause micro tears, eg in the way playing a strenuous sport every single day would?
In other words it's gradual stress rather than sudden trauma.
Background Eccentric exercises have the most evidence in conservative treatment of midportion Achilles tendinopathy. Although short-term studies show significant improvement, little is known of the long-term (>3 years) results.
Aim To evaluate the 5-year outcome of patients with chronic midportion Achilles tendinopathy treated with the classical Alfredson's heel-drop exercise programme.
Study design Part of a 5-year follow-up of a previously conducted randomised controlled trial.
Methods 58 patients (70 tendons) were approached 5 years after the start of the heel-drop exercise programme according to Alfredson. At baseline and at 5-year follow-up, the validated Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire score, pain status, alternative treatments received and ultrasonographic neovascularisation score were recorded.
Results In 46 patients (58 tendons), the VISA-A score significantly increased from 49.2 at baseline to 83.6 after 5 years (p<0.001) and from the 1-year to 5-year follow-up from 75.0 to 83.4 (p<0.01). 39.7% of the patients were completely pain-free at follow-up and 48.3% had received one or more alternative treatments. The sagittal tendon thickness decreased from 8.05 mm (SD 2.1) at baseline to 7.50 mm (SD 1.6) at the 5-year follow-up (p=0.051).
Conclusion At 5-year follow-up, a significant increase of VISA-A score can be expected. After the 3-month Alfredson's heel-drop exercise programme, almost half of the patients had received other therapies. Although improvement of symptoms can be expected at long term, mild pain may remain.
BACKGROUND:
This study assessed the efficacy of a modified eccentric heel-drop program (reduced time and increased duration of stretch) in treating chronic Achilles tendinopathy.
METHODS:
Athletes with at least 12 weeks of symptoms diagnosed clinically as chronic Achilles tendinopathy were enrolled in the study. The only treatment recommended was a 6-week eccentric stretching regimen, with each stretch being maintained for at least 15 seconds. Athletes were followed to assess the response to treatment using a Visual Analogue Scale (VAS) for pain and a patient effectiveness rating for treatment satisfaction as well as time to return to pre-injury activity level. Followup was successful in 156 (82%) of the athletes. A total of 190 athletes were seen with chronic Achilles tendinopathy.
RESULTS:
Mid-substance injuries were diagnosed in 168 (88%) with the remainder 22 (12%) having distal insertional injuries. Pain as assessed by VAS reduced from mean of 7.2 at commencement of the regimen to 2.9 (p<0.01) after 6 weeks of stretching. Six months post commencement of program mean pain was 1.1. Patient satisfaction was rated at 7 or above (excellent) in 124 (80%) of the athletes. For mid-substance injuries the satisfaction rating was excellent in 86%. Overall mean time to return to pre-morbid activity was 10 weeks.
CONCLUSION:
A modified 6-week eccentric heel-drop training regimen as the only treatment for chronic Achilles tendinopathy resulted in a high degree of patient satisfaction, reduced pain and a successful return to pre-morbid activity levels. These results were best for mid-substance rather than insertional tendinopathy.
Re: Alfredson’s "prescription" for achilles tendinopathy
Effect of Eccentric Strengthening on Pain, Muscle Strength, Endurance, and Functional Fitness Factors in Male Patients with Achilles Tendinopathy
Yu, JaeHo PhD, PT; Park, DaeSung PhD, PT; Lee, GyuChang PhD, PT American Journal of Physical Medicine & Rehabilitation; 5 October 2012
Quote:
Objective: The aim of this study was to investigate the effect of eccentric strengthening on pain, muscle strength, endurance, and functional fitness factors in Achilles tendinopathy patients.
Design: Thirty-two male patients with Achilles tendinopathy were assigned to either the experimental group that performed eccentric strengthening or the control group that performed concentric strengthening (n = 16, both groups) for 8 wks (50 mins per day, three times per week). A visual analog scale, an isokinetic muscle testing equipment, the side-step test, and the Sargent jump test were used to assess pain, muscle strength, endurance, and functional fitness factors before and after the intervention.
Results: In comparison with the control group, the experimental group showed significant improvement in pain, ankle dorsiflexion endurance, total balance index, and agility after the intervention (P < 0.05). However, there was no significant difference in dexterity between the two groups.
Conclusions: Eccentric strengthening was more effective than concentric strengthening in reducing pain and improving function in patients with Achilles tendinopathy; therefore, regular eccentric strengthening is important for patients in a clinical setting.
Re: Alfredson’s "prescription" for achilles tendinopathy
Effects of eccentric training on mechanical properties of the plantar flexor muscle-tendon complex
Alexandre FOURÉ, Antoine NORDEZ, and Christophe CORNU Journal of Applied Physiology December 13, 2012
Quote:
Eccentric training is a mechanical loading classically used in clinical environment to rehabilitate patients with tendinopathies. In this context, eccentric training is supposed to alter tendon mechanical properties but interaction with the other components of the muscle-tendon complex remains unclear. The aim of this study was to determine the specific effects of 14 weeks of eccentric training on muscle and tendon mechanical properties assessed in active and passive conditions in vivo. Twenty-four subjects were randomly divided into a trained group (n=11) and a control group (n=13). Stiffness of the active and passive parts of the series elastic component of plantar flexors were determined using a fast stretch during submaximal isometric contraction; Achilles tendon stiffness and dissipative properties were assessed during isometric plantar flexion; and passive stiffness of gastrocnemii muscles and Achilles tendon were determined using ultrasonography while ankle joint was passively moved. A significant decrease in the active part of the series elastic component stiffness was found (P < 0.05). In contrast, a significant increase in Achilles tendon stiffness determined under passive conditions was observed (P < 0.05). No significant change in triceps surae muscles and Achilles tendon geometrical parameters was shown (P > 0.05). Specific changes in muscle and tendon involved in plantar flexion are mainly due to changes in intrinsic mechanical properties of muscle and tendon tissues. Specific assessment of both Achilles tendon and plantar flexor muscles allowed a better understanding of the functional behavior of the muscle-tendon complex and its adaptation to eccentric training.
Objective
To compare eccentric and static exercises as proposed by Stanish with eccentric exercises as proposed by Alfredson in the management of Achilles tendinopathy.
Methods
Patients with midportion Achilles tendinopathy for at least 3 months were included in this trial. They were sequentially allocated to receive either Stanish's exercise programme or Alfredson's exercise programme. Outcome measures were pain and function using the VISA-A score. Patients were evaluated at baseline, at the end of treatment (week 12), and 6 months (week 36) after the end of treatment.
Results
41 patients met the inclusion criteria. At the end of treatment, there was a rise in VISA-A score in both groups compared with baseline (p < 0.05, paired t-test). There were significant differences in the VISA-A score between the groups at the end of treatment and at the 6-month follow up; Alfredson exercise programme group produced the largest effect (p < 0.0005, independent t-test).
Conclusion
An exercise programme based on Alfredson protocol was superior to Stanish model to reduce pain and improve function in patients with Achilles tendinopathy at the end of the treatment and at the follow-up. Further research is needed to confirm our results.
Alfredson’s "prescription" for achilles tendinopathy
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