No Rest Necessary for Achilles Tendinopathy

Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Am J Sports Med. 2007 Jun;35(6):897-906.

Abstract
BACKGROUND: Achilles tendinopathy is a common overuse injury, especially among athletes involved in activities that include running and jumping. Often an initial period of rest from the pain-provoking activity is recommended.
 
PURPOSE: To prospectively evaluate if continued running and jumping during treatment with an Achilles tendon-loading strengthening program has an effect on the outcome.
 
STUDY DESIGN: Randomized clinical control trial; Level of evidence, 1.
 
METHODS: Thirty-eight patients with Achilles tendinopathy were randomly allocated to 2 different treatment groups. The exercise training group (n = 19) was allowed, with the use of a pain-monitoring model, to continue Achilles tendon-loading activity, such as running and jumping, whereas the active rest group (n = 19) had to stop such activities during the first 6 weeks. All patients were rehabilitated according to an identical rehabilitation program. The primary outcome measures were the Swedish version of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A-S) and the pain level during tendon-loading activity.
 
RESULTS: No significant differences in the rate of improvements were found between the groups. Both groups showed, however, significant (P < .01) improvements, compared with baseline, on the primary outcome measure at all the evaluations. The exercise training group had a mean (standard deviation) VISA-A-S score of 57 (15.8) at baseline and 85 (12.7) at the 12-month follow-up (P < .01). The active rest group had a mean (standard deviation) VISA-A-S score of 57 (15.7) at baseline and 91 (8.2) at the 12-month follow-up (P < .01).
 
CONCLUSIONS: No negative effects could be demonstrated from continuing Achilles tendon-loading activity, such as running and jumping, with the use of a pain-monitoring model, during treatment. Our treatment protocol for patients with Achilles tendinopathy, which gradually increases the load on the Achilles tendon and calf muscle, demonstrated significant improvements. A training regimen of continued, pain-monitored, tendon-loading physical activity might therefore represent a valuable option for patients with Achilles tendinopathy.

Diagnosis: Achilles Tendinopathy

Outcome: VISA-A, VAS, and a variety of functional tests.

When Assessed: 6 weeks, 3 months, 6 months, and 1 year

Subjects: 19 subjects per group, ~half men and women, average age 46

Protocol: Both groups did same rehab exercise protocol including concentric, eccentric, and plyometric calf muscle exercises 12 to 15 total sets of 10-15 reps increasing intensity over 12 weeks, then at 12 weeks reducing exercise frequency to 2-3x per week. The “exercise group” was instructed to continue normal running and jumping activities keeping pain <5/10, while the “active rest group” was instructed to stop all running and jumping type exercises for 6 weeks.

Other Activity: Active rest group only did exercise program as per protocol for the first 6 week, while the exercise group was instructed to continue running and jumping activities over the course of treatment so long as pain did not rise above 5/10 on VAS and pain did not rise from week to week.

Chad’s Comments:  There is a lot to be learned from this study. Both groups had an rapid increase in function in first 6 weeks and more steady improvements thereafter. Both groups improved statistically equal in regard to both pain and function, but absolute gains in the resting group were a little higher with VISA-A score increasing from 57 to 75 at 6 weeks and 91 at 1 year. The exercise group improved from 57 to 70 at 6 weeks and 85 at 1 year. One could ague the rest helped a little but the continued exercise group improved nearly as much in spite of continued exercise and would otherwise be better able to maintain and or further improve fitness/sports performance rather than a decline in health/function from lesser activity. Downside of this study is it did not state how active either group was before or after the 6 week differential period, so it is hard to say how this adapts to various activity levels. In light of the in season elite level volleyball players it does seem improvements can be seen in pain and function even with intense and prolonged additional exercise. Also this study used both concentric, eccentric, and plyometric types of exercises in their program indicating that the combination of contractions types is effective in treating Achilles tendinopathy.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

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