Insertional Achilles tendinopathy is a disabling injury that is common in running athletes. Exercise therapy is considered the best treatment option, but there is still no agreement on the modalities. For example, it is thought that compression overload may be a major cause of tendinopathy and should therefore be restricted during rehabilitation. However, this recommendation is based on expert opinion and not on hard scientific evidence. Therefore, this randomised controlled trial (RCT) will investigate whether a therapy that limits the amount of compression of the tendon during a progressive tendon-loading rehabilitation protocol actually has better outcomes in athletes with insertional Achilles tendinopathy. Athletes with insertional Achilles tendinopathy will be randomised into two treatment groups; (1) an experimental rehabilitation protocol in which the amount of tendon compression is limited and (2) a control rehabilitation protocol in which the amount of tendon compression is not limited and is rather high. Both treatments consist of supervised progressive tendon-loading exercise therapy and patient education. In addition, the experimental group will also receive heel inserts to limit the amount of dorsiflexion during sports or daily activities. At baseline, at 12 weeks (end of intervention) and at 24 weeks (follow-up), pain, functionality, structure and intratendinous pressure will be determined.
Achilles tendinopathy is a debilitating injury that is common among athletes, especially those involved in running sports. Around 30% of all runners exhibit Achilles tendinopathy with an annual incidence of 7-9%. Of these patients, roughly one-third will have insertional Achilles tendinopathy (IAT). Several mechanisms are considered to play a role in the aetiology of Achilles tendinopathy, yet a prominent role seems present for excessive overload. Traditionally, the nature of this overload is thought to be purely tensile. However, the Achilles tendon can also be exposed to compressive loads at the insertion when the tendon wraps around the posterior prominence of the calcaneus during dorsiflexion of the ankle. The formation of fibrocartilage-like tissue, which is typically found in histological examination of tendinopathy, can be considered as an adaptation to this compressive load, driven by the tenocyte's mechanotransduction process. Therefore, it is recommended to reduce the amount of compressive load on the tendon during rehabilitation while exerting sufficient tensile load. However, these recommendations are mainly based on a pilot study and expert opinion. Therefore, this RCT investigates whether a therapy in which the amount of tendon compression is restricted during a progressive tendon-loading rehabilitation protocol actually has better outcomes in terms of pain scores, functionality and structure of the Achilles tendon in athletes with insertional Achilles tendinopathy. Limiting the amount of tendon compression on the Achilles tendon insertion will be achieved by (1) patient education, (2) heel inserts and (3) an adapted exercise regimen.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
DOUBLE
Enrollment
42
The intervention treatment consists of a progressive 4-stage, criteria-based exercise protocol, in which the amount of tendon compression is limited. This includes: 1. Education: Specific information on the importance of limiting tendon compression during rehabilitation, as well as general information on load management, the importance of active exercise therapy and setting expectations. 2. Orthotic treatment: heel inserts to reduce ankle dorsiflexion during daily activities and sports 3. Physiotherapy: Progressive tendon-loading exercise therapy (4 phases) restricting the amount of tendon compression by limiting dorsiflexion of the ankle and prohibiting stretching
The control treatment consists of a progressive 4-phase, criteria-based exercise protocol, in which the amount of tendon compression is not limited. This includes: 1. Education: general information on load management, the importance of active exercise therapy and setting expectations. 2. No orthotic treatment. 3. Physiotherapy: Progressive tendon-loading exercise therapy (4 phases) without any restriction around tendon compression and encouraging stretching
Department of rehabilitation sciences
Ghent, Belgium
The change of the Victorian Institute of Sports Assessment-Achilles Questionnaire (VISA-A) score over 12 weeks
The VISA-A score is a measure of pain and lower limb function (disability) associated with Achilles tendinopathy. A higher score indicates a better outcome and a 10 point increase is accepted as being clinically meaningful.
Time frame: 12 weeks (at the end of intervention)
The change of the Victorian Institute of Sports Assessment-Achilles Questionnaire (VISA-A) score over 24 weeks
The VISA-A score is a measure of pain and lower limb function (disability) associated with Achilles tendinopathy. A higher score indicates a better outcome and a 10 point increase is accepted as being clinically meaningful.
Time frame: 24 weeks (at follow-up)
Subjective patient satisfaction
Patient overall rating: excellent / good / fair / poor
Time frame: This will be assessed at the end of the intervention (week 12) and at follow-up (week 24).
Return to sports rate
Participation: return to desired sport on pre-injury level / return to desired sport but on a lower level / return to sports but not desired sport / no return to sports
Time frame: This will be assessed at the end of the intervention (week 12) and at follow-up (week 24).
Hop test
Self-reported pain rating on a Visual Analogue Scale (VAS) during a single leg hop test
Time frame: This will be assessed at the start (week 0), at the end of the intervention (week 12) and at follow-up (week 24).
Lower Extremity Functional Scale
The lower extremity functional scale (LEFS) is a valid patient-rated outcome measure for the measurement of lower extremity function.
Time frame: This will be assessed at the start (week 0), at the end of the intervention (week 12) and at follow-up (week 24).
Tampa scale for kinesiophobia (TSK)
The TSK is a 17-item self report checklist using a 4-point Likert scale that was developed as a measure of fear of movement or (re)injury.
Time frame: This will be assessed at the start (week 0), at the end of the intervention (week 12) and at follow-up (week 24).
Heel-raise test
Participants will have to perform heel raises in standing position until thay are fatigued.
Time frame: This will be assessed at the start (week 0), at the end of the intervention (week 12) and at follow-up (week 24).
Health status using the EuroQol 5 Dimension 5 Level (EQ-5D-5L) questionnaire
The EQ-5D-5L is a self-assessed, health related, quality of life questionnaire.
Time frame: This will be assessed at the start (week 0), at the end of the intervention (week 12) and at follow-up (week 24).
Pain rating (VAS) during activities of daily living
Self-reported pain (VAS, 0-100 mm) during activities of daily living over the last seven days. A higher score indicates more pain.
Time frame: This will be assessed at the start (week 0), at the end of the intervention (week 12) and at follow-up (week 24).
Ultrasound examination to assess the structure of the Achilles tendon insertion
Anteroposterior thickness (5 mm distal from the posterosuperior calcaneal border) - Neovascularisation (modified-Öhberg scale)
Time frame: This will be assessed at the start (week 0), at the end of the intervention (week 12) and at follow-up (week 24).
Compliance
Compliance to the exercise programme and orthotics (total percentage of prescription) will be assessed using a short online questionnaire.
Time frame: This will be assessed weekly until the end of the intervention.
Pain monitoring
Numeric Pain Rating Scale (NRS, 0-10) during exercises, after exercises and in the morning will be assessed. A higher score indicates more pain.
Time frame: This will be assessed weekly until the end of the intervention.
Adverse effects
Adverse effects resulting from the intervention
Time frame: This will be assessed weekly until the end of the intervention.
Credibility/Expectations Questionnaire
As participants are not blinded about their assigned intervention, it is important to determine their beliefs about the treatment. With this in mind, participants will complete the Credibility/Expectations Questionnaire (CEQ) after being assigned to an intervention group.
Time frame: This wel be assessed at the start of the intervention (week 0)
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