Purpose: Complete a review of tendon loading protocols for conservative treatment of chronic mid substance AT, and to investigate which training parameters are most effective for decreasing pain and improving function in recreational athletes with chronic midsubstance AT.

1. ResultsBackground
Analysis
Clinical Relevance
Purpose
Methods
Review of Most Effective Tendon Loading Regimen for Treatment
of Non-Insertional Chronic Midsubstance Achilles Tendinopathy
Department of Orthopedics & Sports Medicine
Lauren Jarmusz, PT, DPT
Conclusions
References
Complete a review of tendon loading protocols for
conservative treatment of chronic mid substance AT, and to
investigate which training parameters are most effective for
decreasing pain and improving function in recreational
athletes with chronic midsubstance AT.
§ Electronic databases MEDLINE, CINHAL
§ > 7000 studies were reviewed; 7 studies selected
§ Inclusion criteria: Studies investigating clinical outcomes of
loading programs in AT. Programs must include:
musculotendon loading including: eccentric, concentric,
isometric, combined loading programs, and/or stretching.
Study designs included were: RCTs, CCTs, case series.
Subjects must be considered recreational athletes with a
diagnosis of non-Insertional Achilles Tendinopathy with
symptoms greater than 3 months. Each study utilized the
VAS and/or VISA-A outcome measures.
§ Exclusion criteria: studies including patients with: diagnosis
of insertional AT, symptoms present less than 3 months,
studies comparing tendon loading programs to surgical
interventions or other non-operative treatments which did
not include tendon loading program, and participates which
were sedentary individuals or elite athletes.
§ Methodological Quality Assessment: 5 RCTs and 1 CCT à
PEDro score was used; 1 case series study à Quality
Assessment Tool for Case Series Studies (NIH)
1. Heavy slow resistance programs displayed a significant
increase in VISA-A scores and the largest drop in VAS scores
2. Tendon should be loaded at a minimum of 6 seconds - to
effectively remodel extra cellular matrix
3. Tendon should be loaded in a quick reactive manner - if
returning a patient to running/sports,
4. Protocols which allowed for controlled pain experienced
better VISA-A and VAS outcomes than protocols which did
not allow for controlled pain
The most effective tendon loading program for the treatment
of chronic midsubstance AT for recreational athletes by
improving VISA-A & VAS scores; taking into account:
compliance, pain management, and return to activity training
is: Progressive heavy slow resistance tendon loading program,
with quick tendon loading intervals, completed 3x/week,
allowing for controlled pain and avoiding use of NSAIDs.
AT is an extremely common ailment. AT injuries, may last for an
extended period of time, potentially years, and significantly
inhibit a recreational athletes ability to perform.
Achilles Tendinopathy (AT) is prevalent overuse injury of the
lower extremity commonly seen in recreational athletes.
Tendon injuries have been estimated to be as high as 30% to
50% of all sports injuries. For both acute and chronic phase
AT presentation, conservative treatment is the preferred
choice in treatment. The current gold standard for
conservative treatment of chronic AT is progressive tendon
loading. The Alfredson Eccentric Tendon Loading Program is
the current gold standard in tendon loading programs for
treating chronic AT. Within the last 5 years, new research has
begun to investigate the effectiveness of differing tendon
loading programs including not only the eccentric muscle
strengthening phase, but also the effects of concentric and
isometric muscular contraction, tendon loading speed, and
progressive addition of weight. The most recent literature has
shown promising results in respect to combined tendon
loading programs which rival - and may be superior to -
Alfredson’s Eccentric Loading Program.
Tendon Loading Time Under TensionPain
Beyer et al. 2015
The Alfredson Protocol
Heavy Slow Resistance
Stasinopoulos et al. 2013
Stanish Protocol
Alfredson Protocol
Silbernagel et al. 2001
Low Intensity Combined
High Intensity Combined
Mafi et al. 2001
Alfredson Protocol
Combined
Beyer et al. 2015
The Alfredson Protocol
Heavy Slow Resistance
Stasinopoulos et al. 2013
Stanish Protocol
Alfredson Protocol
Mafi et al. 2001
Alfredson Protocol
Combined
Stevens et al. 2014
Alfredson Protocol
Alfredson Do-As-Tolerated
Beyer et al. 2015
The Alfredson Protocol
Heavy Slow Resistance
Silbernagel et al. 2001
Low Intensity Combined
High Intensity Combined
Maffulli et al. 2008
Progressive Eccentric Loading
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