Mid-portion Achilles tendinopathy is prevalent within both the athletic and non-athletic populations and loading protocols for Achilles tendinopathy are effective over time, though the rate of symptom change throughout rehabilitation is unknown.
The objective of this study was to determine the rate of change in pain and function over time in patients while completing a loading protocol for mid-portion Achilles tendinopathy.
A systematic review and longitudinal meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The databases PubMed, CINAHL (Ovid) and CINAHL (EBSCO) were searched for articles published from inception until 31 July, 2017. Our search focused on clinical trials and cohort studies examining changes in pain and function when completing a loading protocol for mid-portion Achilles tendinopathy. The primary outcome measure assessing pain and function was the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire.
A total of 31 separate cohorts (24 studies) were eligible, with follow-up ranging from 2 weeks to 6 months. The data were pooled to create the mean (standard deviation) of change from baseline at each time point. The data demonstrated an improvement in pain and function as early as 2 weeks that appeared to peak at 12 weeks with a mean (standard deviation) of 21.11 (6.61) points of change on the VISA-A.
The improvement in pain and function during rehabilitation suggests future research should be directed toward investigating contributing mechanisms as tendon structure on imaging does not change within 2 weeks and muscular hypertrophy is not seen for at least 4 weeks following the inception of a loading protocol. Systematic Review Registry: PROSPERO registration number: CRD42017062737 (https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=62737)
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409–16. https://doi.org/10.1136/bjsm.2008.051193.
Habets B, van Cingel RE. Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols. Scand J Med Sci Sports. 2015;25(1):3–15. https://doi.org/10.1111/sms.12208.
van Dijk CN, van Sterkenburg MN, Wiegerinck JI, Karlsson J, Maffulli N. Terminology for Achilles tendon related disorders. Knee Surg Sports Traumatol Arthrosc. 2011;19(5):835–41. https://doi.org/10.1007/s00167-010-1374-z.
Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? Br J Sports Med. 2016;50(19):1187–91. https://doi.org/10.1136/bjsports-2015-095422.
Lopes AD, Hespanhol LC, Yeung SS, Costa LOP. What are the main running-related musculoskeletal injuries? Sports Med. 2012;42(10):891–905. https://doi.org/10.1007/bf03262301.
Albers IS, Zwerver J, Diercks RL, Dekker JH, Van den Akker-Scheek I. Incidence and prevalence of lower extremity tendinopathy in a Dutch general practice population: a cross sectional study. BMC Musculoskelet Disord. 2016;17(1):16. https://doi.org/10.1186/s12891-016-0885-2.
Couppe C, Svensson RB, Silbernagel KG, Langberg H, Magnusson SP. Eccentric or concentric exercises for the treatment of tendinopathies? J Orthop Sports Phys Ther. 2015;45(11):853–63. https://doi.org/10.2519/jospt.2015.5910.
Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360–6.
Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2001;9(1):42–7. https://doi.org/10.1007/s001670000148.
Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35(6):897–906. https://doi.org/10.1177/0363546506298279.
Silbernagel KG, Thomee R, Thomee P, Karlsson J. Eccentric overload training for patients with chronic Achilles tendon pain: a randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports. 2001;11(4):197–206.
Beyer R, Kongsgaard M, Hougs Kjaer B, Ohlenschlaeger T, Kjaer M, Magnusson SP. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2015;43(7):1704–11. https://doi.org/10.1177/0363546515584760.
Meyer A, Tumilty S, Baxter GD. Eccentric exercise protocols for chronic non-insertional Achilles tendinopathy: how much is enough? Scand J Med Sci Sports. 2009;19(5):609–15. https://doi.org/10.1111/j.1600-0838.2009.00981.x.
Allison GT, Purdam C. Eccentric loading for Achilles tendinopathy: strengthening or stretching? Br J Sports Med. 2009;43(4):276–9. https://doi.org/10.1136/bjsm.2008.053546.
Arnoczky SP, Lavagnino M, Egerbacher M. The mechanobiological aetiopathogenesis of tendinopathy: is it the over-stimulation or the under-stimulation of tendon cells? Int J Exp Pathol. 2007;88(4):217–26. https://doi.org/10.1111/j.1365-2613.2007.00548.x.
Shalabi A, Kristoffersen-Wilberg M, Svensson L, Aspelin P, Movin T. Eccentric training of the gastrocnemius-soleus complex in chronic Achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by MRI. Am J Sports Med. 2004;32(5):1286–96. https://doi.org/10.1177/0363546504263148.
O’Neill S, Watson PJ, Barry S. Why are eccentric exercises effective for achilles tendinopathy? Int J Sports Phys Ther. 2015;10(4):552–62.
Rio E, Kidgell D, Moseley GL, Gaida J, Docking S, Purdam C, et al. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med. 2016;50(4):209–15. https://doi.org/10.1136/bjsports-2015-095215.
Maquirriain J. Leg stiffness changes in athletes with Achilles tendinopathy. Int J Sports Med. 2012;33(7):567–71. https://doi.org/10.1055/s-0032-1304644.
Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277–83. https://doi.org/10.1136/bjsports-2014-094386.
Gabriel DA, Kamen G, Frost G. Neural adaptations to resistive exercise: mechanisms and recommendations for training practices. Sports Med. 2006;36(2):133–49.
DeFreitas JM, Beck TW, Stock MS, Dillon MA, Kasishke PR 2nd. An examination of the time course of training-induced skeletal muscle hypertrophy. Eur J Appl Physiol. 2011;111(11):2785–90. https://doi.org/10.1007/s00421-011-1905-4.
de Jonge S, Tol JL, Weir A, Waarsing JH, Verhaar JA, de Vos RJ. The tendon structure returns to asymptomatic values in nonoperatively treated achilles tendinopathy but is not associated with symptoms: a prospective study. Am J Sports Med. 2015;43(12):2950–8. https://doi.org/10.1177/0363546515605077.
de Vos RJ, Heijboer MP, Weinans H, Verhaar JA, van Schie JT. Tendon structure’s lack of relation to clinical outcome after eccentric exercises in chronic midportion Achilles tendinopathy. J Sport Rehabil. 2012;21(1):34–43.
de Vos RJ, Weir A, Tol JL, Verhaar JA, Weinans H, van Schie HT. No effects of PRP on ultrasonographic tendon structure and neovascularisation in chronic midportion Achilles tendinopathy. Br J Sports Med. 2011;45(5):387–92. https://doi.org/10.1136/bjsm.2010.076398.
Gardin A, Movin T, Svensson L, Shalabi A. The long-term clinical and MRI results following eccentric calf muscle training in chronic Achilles tendinosis. Skeletal Radiol. 2010;39(5):435–42. https://doi.org/10.1007/s00256-009-0798-3.
van Ark M, Cook JL, Docking SI, Zwerver J, Gaida JE, van den Akker-Scheek I, et al. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. J Sci Med Sport. 2016;19(9):702–6. https://doi.org/10.1016/j.jsams.2015.11.006.
Murphy M, Travers MJ, Gibson W, Chivers P, Debenham J, Docking S, et al. The rate of improvement of pain and function in mid-portion Achilles tendinopathy with loading protocols: a systematic review and longitudinal meta-analysis. In: Figshare.2018. Available from: https://figshare.com/articles/The_rate_of_improvement_of_pain_and_function_in_mid-portion_Achilles_tendinopathy_with_loading_protocols_A_Systematic_Review_and_Longitudinal_Meta-Analysis_/6143210. Accessed 5 May 2018.
Robinson JM, Cook JL, Purdam C, Visentini PJ, Ross J, Maffulli N, et al. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med. 2001;35(5):335–41.
Scott A, Docking S, Vicenzino B, Alfredson H, Murphy RJ, Carr AJ, et al. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. Br J Sports Med. 2013;47(9):536–44. https://doi.org/10.1136/bjsports-2013-092329.
Murphy M, Rio E, Debenham J, Docking S, Travers MJ, Gibson W. Evaluating the progress of mid-portion Achilles tendinopathy during rehabilitation: a review of outcome measures for self-reported pain and function. Int J Sports Ther. 2018;13(2):283–92. https://doi.org/10.26603/ijspt20180283.
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700. https://doi.org/10.1136/bmj.b2700.
Higgins JPT, Sterne JAC, Savović J, Page MJ, Hróbjartsson A, Boutron I, Reeves B, Eldridge S. A revised tool for assessing risk of bias in randomized trials. Cochrane Database Syst Rev. 2016. https://doi.org/10.1002/14651858.cd201601.
Sterne JA, Hernan MA, Reeves BC, Savovic J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919. https://doi.org/10.1136/bmj.i4919.
Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.1.0 [updated March 2011]. http://www.handbook.cochrane.org. Accessed 5 May 2018.
Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60.
Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ. 2004;328(7454):1490. https://doi.org/10.1136/bmj.328.7454.1490.
Dechartres A, Trinquart L, Boutron I, Ravaud P. Influence of trial sample size on treatment effect estimates: meta-epidemiological study. BMJ. 2013;346:f2304. https://doi.org/10.1136/bmj.f2304.
Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–34.
Ishak KJ, Platt RW, Joseph L, Hanley JA, Caro JJ. Meta-analysis of longitudinal studies. Clin Trials. 2007;4(5):525–39. https://doi.org/10.1177/1740774507083567.
Balius R, Álvarez G, Baró F, Jiménez F, Pedret C, Costa E, et al. A 3-arm randomized trial for Achilles tendinopathy: eccentric training, eccentric training plus a dietary supplement containing mucopolysaccharides, or passive stretching plus a dietary supplement containing mucopolysaccharides. Curr Ther Res Clin Exp. 2016;78:1–7. https://doi.org/10.1016/j.curtheres.2016.11.001.
Bell KJ, Fulcher ML, Rowlands DS, Kerse N. Impact of autologous blood injections in treatment of mid-portion Achilles tendinopathy: double blind randomised controlled trial. BMJ. 2013;346:f2310. https://doi.org/10.1136/bmj.f2310.
Boesen AP, Hansen R, Boesen MI, Malliaras P, Langberg H. Effect of high-volume injection, platelet-rich plasma, and sham treatment in chronic midportion Achilles tendinopathy: a randomized double-blinded prospective study. Am J Sports Med. 2017;45(9):2034–43. https://doi.org/10.1177/0363546517702862.
Brown R, Orchard J, Kinchington M, Hooper A, Nalder G. Aprotinin in the management of Achilles tendinopathy: a randomised controlled trial. Br J Sports Med. 2006;40(3):275–9. https://doi.org/10.1136/bjsm.2005.021931.
de Vos RJ, Weir A, Visser RJ, de Winter T, Tol JL. The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. Br J Sports Med. 2007;41(7):e5. https://doi.org/10.1136/bjsm.2006.032532.
Kearney RS, Parsons N, Costa ML. Achilles tendinopathy management: a pilot randomised controlled trial comparing platelet-richplasma injection with an eccentric loading programme. Bone Joint Res. 2013;2(10):227–32. https://doi.org/10.1302/2046-3758.210.2000200.
Knobloch K, Schreibmueller L, Kraemer R, Jagodzinski M, Vogt PM, Redeker J. Gender and eccentric training in Achilles mid-portion tendinopathy. Knee Surg Sports Traumatol Arthrosc. 2010;18(5):648–55. https://doi.org/10.1007/s00167-009-1006-7.
Maffulli N, Walley G, Sayana MK, Longo UG, Denaro V. Eccentric calf muscle training in athletic patients with Achilles tendinopathy. Disabil Rehabil. 2008;30(20–22):1677–84. https://doi.org/10.1080/09638280701786427.
McAleenan M, McVeigh JG, Cullen M, Sayers F, McCrea K, Baxter D. The effectiveness of night splints in achilles tendinopathy: a pilot study. Physiother Pract Res. 2010;31(1):28–33.
Munteanu SE, Scott LA, Bonanno DR, Landorf KB, Pizzari T, Cook JL, et al. Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial. Br J Sports Med. 2015;49(15):989–94. https://doi.org/10.1136/bjsports-2014-093845.
Pearson J, Rowlands D, Highet R. Autologous blood injection to treat achilles tendinopathy? A randomized controlled trial. J Sport Rehabil. 2012;21(3):218–24.
Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2009;37(3):463–70. https://doi.org/10.1177/0363546508326983.
Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med. 2007;35(3):374–83. https://doi.org/10.1177/0363546506295940.
Sayana MK, Maffulli N. Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. J Sci Med Sport. 2007;10(1):52–8. https://doi.org/10.1016/j.jsams.2006.05.008.
Stasinopoulos D, Manias P. Comparing two eccentric exercise programmes for the management of Achilles tendinopathy: a pilot trial. J Bodyw Move Ther. 2013;17(3):309–15. https://doi.org/10.1016/j.jbmt.2012.11.003.
Stevens M, Tan CW. Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. J Orthopaed Sports Phys Ther. 2014;44(2):59–67. https://doi.org/10.2519/jospt.2014.4720.
Tumilty S, Mani R, Baxter GD. Photobiomodulation and eccentric exercise for Achilles tendinopathy: a randomized controlled trial. Lasers Med Sci. 2016;31(1):127–35. https://doi.org/10.1007/s10103-015-1840-4.
Tumilty S, McDonough S, Hurley DA, Baxter GD. Clinical effectiveness of low-level laser therapy as an adjunct to eccentric exercise for the treatment of Achilles’ tendinopathy: a randomized controlled trial. Arch Phys Med Rehabil. 2012;93(5):733–9. https://doi.org/10.1016/j.apmr.2011.08.049.
Tumilty S, Munn J, Abbott JH, McDonough S, Hurley DA, Baxter GD. Laser therapy in the treatment of achilles tendinopathy: a pilot study. Photomed Laser Surg. 2008;26(1):25–30. https://doi.org/10.1089/pho.2007.2126.
Yelland MJ, Sweeting KR, Lyftogt JA, Ng SK, Scuffham PA, Evans KA. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med. 2011;45(5):421–8. https://doi.org/10.1136/bjsm.2009.057968.
Zhang BM, Zhong LW, Xu SW, Jiang HR, Shen J. Acupuncture for chronic Achilles tendnopathy: a randomized controlled study. Chin J Integr Med. 2013;19(12):900–4. https://doi.org/10.1007/s11655-012-1218-4.
Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin Orthop Relat Res. 1986;208:65–8.
Herrington L, McCulloch R. The role of eccentric training in the management of Achilles tendinopathy: a pilot study. Phys Ther Sport. 2007;8(4):191–6. https://doi.org/10.1016/j.ptsp.2007.07.001.
Drew BT, Smith TO, Littlewood C, Sturrock B. Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. Br J Sports Med. 2014;48(12):966–72. https://doi.org/10.1136/bjsports-2012-091285.
Rio E, Moseley L, Purdam C, Samiric T, Kidgell D, Pearce AJ, et al. The pain of tendinopathy: physiological or pathophysiological? Sports Med. 2014;44(1):9–23. https://doi.org/10.1007/s40279-013-0096-z.
Tompra N, van Dieen JH, Coppieters MW. Central pain processing is altered in people with Achilles tendinopathy. Br J Sports Med. 2016;50(16):1004–7. https://doi.org/10.1136/bjsports-2015-095476.
McAuliffe S, Synott A, Casey H, Mc Creesh K, Purtill H, O’Sullivan K. Beyond the tendon: Experiences and perceptions of people with persistent Achilles tendinopathy. Musculoskelet Sci Pract. 2017;29:108–14. https://doi.org/10.1016/j.msksp.2017.03.009.
Travaline JM, Ruchinskas R, D’Alonzo GE Jr. Patient-physician communication: why and how. J Am Osteopath Assoc. 2005;105(1):13–8. https://doi.org/10.7556/jaoa.2005.105.1.13.
Cook CE. Clinimetrics corner: the minimal clinically important change score (MCID): a necessary pretense. J Man Manip Ther. 2008;16(4):E82–3. https://doi.org/10.1179/jmt.2008.16.4.82E.
Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. Am J Sports Med. 2011;39(3):607–13. https://doi.org/10.1177/0363546510384789.
van der Plas A, de Jonge S, de Vos RJ, van der Heide HJ, Verhaar JA, Weir A, et al. A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012;46(3):214–8. https://doi.org/10.1136/bjsports-2011-090035.
Murphy M, Travers MJ, Gibson W. Is heavy eccentric calf training superior to wait-and-see, sham rehabilitation, traditional physiotherapy and other exercise interventions for pain and function in mid-portion Achilles tendinopathy. Syst Rev. 2018;7(58):1–7. https://doi.org/10.1186/s13643-018-0725-6.
Myles Murphy acknowledges the support from the Australian Governments Research Training Program Scholarship. Ebonie Rio acknowledges the support from the National Health and Medical Research Councils Early Career Fellowship Scheme. All authors acknowledge the contributions of Dr. Clare Ardern (Linköping University, Linköping, Sweden) and Prof. Max Bulsara (Institute of Health Research, The University of Notre Dame, Fremantle, WA, Australia) for their assistance in developing the protocol for this systematic review.
No financial support was received for the conduct of this study or preparation of this article.
Conflict of Interest
Myles Murphy, Mervyn Travers, William Gibson, Paola Chivers, James Debenham, Sean Docking and Ebonie Rio have no conflicts of interest directly relevant to the content of this article.
The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. The data sheet used for the meta-analysis was also registered and stored on Figshare (https://doi.org/10.6084/m9.figshare.6143210.v1) .
Electronic supplementary material
Below is the link to the electronic supplementary material.
About this article
Cite this article
Murphy, M., Travers, M., Gibson, W. et al. Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis. Sports Med 48, 1875–1891 (2018). https://doi.org/10.1007/s40279-018-0932-2