Page 136 - JSOM Spring 2020

many types of tendinopathies, but studies on their pain-re- average of 166 and 112 repetitions/day, respectively. Both
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ducing effectiveness for AT are at best conflicting, 60,62–65 and groups showed similar improvements on pain and function
if an analgesic effect is achieved it may allow patients to ig- scales (VISA-A and 0- to 100-point visual analog scale [VAS])
nore symptoms and do more damage to the tendon. Further, at the end of treatment. This suggests that the as-tolerated
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NSAIDs have been shown to have detrimental effects on the protocol results in similar improvements when compared to
normal healing processes associated with AT, specifically by the Alfredson protocol and thus the former may be preferable
preventing restoration of extracellular matrix components and since it is likely to increase patient compliance.
interfering with cellular control of inflammatory and wound
healing genes. Even in cases where paratenonitis appears to Another study addressed the question of whether or not ac-
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be contributing to AT and could perhaps provide an indication tive AT patients could continue their normal activity while do-
for use of NSAIDs, these concerns regarding effects of NSAIDs ing the eccentric exercise protocol. Patients with ultrasound
on normal healing processes for any coexisting tendon damage verified AT were randomized into two groups. Both groups
should be carefully considered before NSAIDs are prescribed. performed a progressive Achilles tendon loading and strength-
ening program for 3 to 6 months that included eccentric and
Eccentric Exercise Training concentric exercise (with increasing load and repetitions) and
Eccentric exercise training is one of the more effective and in later phases, plyometric training. However, one continued
apparently safe treatment options for AT. Systematic reviews with sport activities (e.g. running, jumping) while the other
involving various conservative treatments for AT have gener- group was restricted from these. The group that continued ac-
ally shown that eccentric muscle training reduces pain and im- tivity used a pain monitoring criterion such that if pain was
proves function 67,68 and is superior to concentric exercise for ≤5 (on a 10-point scale with 10 being the worst pain) they
pain reduction. The classic Alfredson eccentric exercise pro- could continue activity. The investigators found there were
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tocol is the one most often cited in the literature. The exercise no significant differences between groups on pain or symp-
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begins with the patient standing on their forefoot in full plan- toms (VISA-A test) or clinical evaluations (hop test), and both
tar flexion on the edge of a bench or stairs (Figure 6A). The pa- groups improved about equally over time. This suggests that
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tient lowers on the affected leg (eccentric muscle contraction) AT patients can continue activity as long as they monitor their
into full dorsiflexion, then returns to the starting position by pain. In a 5-year follow-up of these patients, 80% had fully
plantar flexing on the unaffected leg. No concentric exercise is recovered suggesting that for the large majority of patients, the
performed on the affected leg. Three sets of 15 repetitions are rehabilitation exercise regime alone is sufficient. 59
performed with the knee extended (Figure 6B), to recruit both
gastrocnemius and soleus muscles, and then with knee flexed In summary, the current evidence indicates that eccentric load-
(Figure 6C), to increase recruitment of the soleus muscle by ing or a combination of eccentric/concentric and plyometric
reducing the contribution of the gastrocnemius muscle to con- training can reduce pain and improve function in patients with
trolling the rate of dorsiflexion. This series is performed twice AT. Patients can continue their usual activities while perform-
a day for 12 weeks. At first, the patient uses only their body ing rehabilitation exercises as long as they monitor their pain
weight during the exercises, but once they can perform the and it does not exceed 5 on the 10-point pain scale. It should
exercises without pain or discomfort, weight is added using a also be noted that the above studies focus on patients with
backpack or Smith machine. Interestingly, one mechanism by midportion AT. It is not clear if eccentric exercise produces
which eccentric exercise appears to improve function in AT good clinical results in patients with insertional AT. 72,73
patients is by increasing type I collagen synthesis. 70
Stretching
FIGURE 6 Eccentric exercises used in the Alfredson protocol. Surprisingly few studies have examined the effects of stretch-
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Patient positioned on bench in full plantar flexion (A). Achilles tendon ing for treating AT. One study compared sustained Achilles
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eccentrically loaded going into full dorsiflexion with knee fully tendon stretches (3 minutes, 3 times per day) to intermittent
extended (B) and knee flexed (C) (from: https://www.semanticscholar
.org/paper/Heavy-load-eccentric-calf-muscle-training-for-the-Alfredson stretches (5 sets of 20 sec each twice a day) and found no
-Pietil%C3%A4/ab06c9e6df716793acdee96e060ea3f89a8d95c4 difference between groups in pain or function scores. Another
/figure/0). study compared eccentric exercise (slightly modified Alfred-
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son protocol) to sustained stretching of the Achilles tendon.
The latter involved maintaining a 30-sec stretch with 5 repe-
titions, twice a day, first with the leg straight (gastrocnemius
stretch) and then with knee bent (soleus stretch). Both groups
had reduced pain, stiffness, tenderness, and tendon thickness
at 3- and 12-month follow-ups, but there were no differences
between groups. In summary, both sustained stretching, inter-
mittent stretching, and eccentric exercise appear to improve
AT symptoms and reduce Achilles tendon thickness, but the
data for stretching are limited to a few studies. 74,75

Orthotics
The Alfredson eccentric exercise protocol involves 180 eccen- Foot orthotics are devices worn inside the shoe that presum-
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tric contractions per day. One study compared two groups of ably provide cushioning and assist in biomechanical align-
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AT patients, one performing the Alfredson protocol (standard ment. They are hypothesized to assist in the treatment of AT
group) and another group instructed to do as many eccentric by correcting excessive foot pronation or improving the ac-
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heel drops as tolerable (as-tolerated group). After 6 weeks of tivation of the quadriceps and gluteus medius to reduce strain
training the standard and as-tolerated groups performed an on the Achilles tendon. An early study that surveyed runners
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130 | JSOM Volume 20, Edition 1 / Spring 2020