Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy: A Randomized Controlled Study
Karin Gravare Silbernagel, Roland Thomee, Bengt I. Eriksson and Jon Karlsson
American Journal of Sports Medicine 2007 35: 897 originally published online February 16, 2007
Achilles tendinopathy is an overuse injury affecting the Achilles tendon. This type of injury usually occurs in active people who participate in distance running, basketball, volleyball and other high impact sports that involve excessive running and jumping. Achilles tendinopathy is usually brought on by changes in running surface, foot-wear or significant increases in intensity of training. The typical treatment for patients diagnosed with an Achilles tendinopathy is physical therapy. A physical therapist can employ a variety of tactics to alleviate pain, increase strength and eventually allow the patient to return to full participation in their sport of choice.
Experimental Method and Results
The researchers wanted to compare two different rehabilitation protocols for patients suffering from Achilles tendinopathy. Both groups were given identical strengthening programs consisting of a progressive Achilles tendon-loading treatment that was based on previous research by the group. One group of patients, the Exercise Training Group, was allowed to continue Achilles tendon-loading activities (i.e. running and jumping) throughout the first 6 weeks of rehabilitation. A visual analog pain scale was used by the Exercise Training Group to determine the point when exercise became too painful. This group was asked not to exceed a level of 5 out of 10 pain during such running and jumping activities (0 is considered no pain at all and 10 is considered the worst pain imaginable). The other group of patients, the Active Rest Group, was not allowed to partake in such activities during the first 6 weeks of rehabilitation.
Both groups demonstrated significant improvements on a self report questionnaire (Victorian Institute of Sports Assessment-Achilles questionnaire VISA-A-S) and decreased pain during hopping at 6-weeks, 3-months, 6-months and 12-months after the initial evaluation. A functional evaluation was also performed at the same time increments listed above. This evaluation included a measurement of ankle dorsiflexion range of motion, 3 jumping tests, 2 strength tests and 1 endurance test. When comparing the two groups, the rate of improvement regarding functional outcomes was not significantly different during any stage of the recovery. Also, the VISA-A-S scores and the pain during hopping were not significantly different between groups at any of the follow-ups. The lack of differences between the groups provides evidence to suggest that Achilles tendon-loading activity performed early in rehabilitation does not inhibit long term functional recovery.
Applications to Clinical Practice
This study suggests that even during the early stages of rehabilitation for Achilles tendinopathy, it is okay to partake in Achilles tendon-loading activities such as running and jumping as long as the patient uses the pain monitoring model described above (no greater than 5/10 pain during these loading activities). This is exceedingly important clinically because many patients who suffer from Achilles tendinopathy are active people such as runners, basketball players, volleyball players and participants of other high impact sports. In general, these patients may not like to take time off and this study provides sound evidence that they can continue their activity as long as it does not cause them severe pain.
Strengths of the Study
1. This was a randomized controlled study which is considered the highest level of evidence.
2. The group followed patients up to a year after the beginning of their therapy.
3. The functional evaluations were performed by a physical therapist that was unaware of the treatment groups and not involved in the rehabilitation.
4. The functional tests and the VISA-A-S have been shown to have good validity in patients recovering from Achilles tendinopathy.
Weakness of the Study
1. There were no concrete objective measures that guided progression of the exercise program. The exercise program was progressed at set intervals of time.
2. The group could not draw definitive conclusions from the functional evaluations because the power calculation for these measures was not made.
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