Abstract
Achilles tendinopathy is considered to be one of the most common overuse injuries in elite and recreational athletes. However, the effect that the Achilles tendinopathy has on patients’ physical performance is still unclear. The purpose of this study was to evaluate if Achilles tendinopathy caused functional deficits on the injured side compared with the non-injured side in patients. A test battery comprised of tests for different aspects of muscle-tendon function of the gastrocnemius, soleus and Achilles tendon complex was developed to evaluate lower leg function. The test battery’s test–retest reliability and sensitivity (the percent probability that the tests would demonstrate abnormal lower limb symmetry index in patients) were also evaluated. The test battery consisted of three jump tests, a counter movements jump (CMJ), a drop counter movement jump (drop CMJ) and hopping, and two strength tests, concentric toe-raises, eccentric–concentric toe-raises and toe-raises for endurance. The reliability was evaluated through a test–retest design on 15 healthy subjects. The test battery’s sensitivity and possible functional deficits in patients with Achilles tendinopathy were evaluated on 42 patients (19 women and 23 men). An excellent reliability was found between test days 1–2 and 2–3 for all tests (ICC = 0.76–0.94) except for concentric toe-raise, test 2–3, which had fair reliability (ICC = 0.73). The methodological error ranged from 8 to 17%. There were significant differences (P = 0.001–0.049) between the non-injured (or least symptomatic) side and injured (most symptomatic) side for hopping, drop CMJ, concentric and eccentric–concentric toe-raises, and significant differences (P = 0.000–0.012) in the level of pain during CMJ, hopping, and drop CMJ. The sensitivity of the test battery at a 90% capacity was 88. Achilles tendinopathy causes not only pain and symptoms in patients but also apparent impairments in various aspects of lower leg muscle-tendon function as measured with the test battery. This test battery is reliable and able to detect differences in lower leg function between the injured or “most symptomatic” and non-injured or “least symptomatic” side in patients with Achilles tendinopathy. The test battery has higher demand on patients’ function compared with each individual test.
Similar content being viewed by others
References
Alfredson H, Pietila T, Jonsson P, Lorentzon R (1998) Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 26:360–366
Alfredson H, Lorentzon R (2000) Chronic Achilles tendinosis: recommendations for treatment and prevention. Sports Med 29:135–146
Alfredson H (2003) Chronic midportion Achilles tendinopathy: an update on research and treatment. Clin Sports Med 22:727–741
Alfredson H, Ohberg L (2005) Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial. Knee Surg Sports Traumatol Arthrosc 13:338–344
Angermann P, Hovgaard D (1999) Chronic Achilles tendinopathy in athletic individuals: results of nonsurgical treatment. Foot Ankle Int 20:304–306
Bosco C, Tarkka I, Komi PV (1982) Effect of elastic energy and myoelectrical potentiation of triceps surae during stretch-shortening cycle exercise. Int J Sports Med 3:137–140
Clement DB, Taunton JE, Smart GW (1984) Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med 12:179–184
Cook JL, Purdam CR (2003) Rehabilitation of lower limb tendinopathies. Clin Sports Med 22:777–789
Farley CT, Blickhan R, Saito J, Taylor CR (1991) Hopping frequency in humans: a test of how springs set stride frequency in bouncing gaits. J Appl Physiol 71:2127–2132
Fleiss JL (1986) The design and analysis of clinical experiments. Wiley, New York
Fukashiro S, Komi PV, Jarvinen M, Miyashita M (1995) In vivo Achilles tendon loading during jumping in humans. Eur J Appl Physiol Occup Physiol 71:453–458
Funase K, Higashi T, Sakakibara A, Imanaka K, Nishihira Y, Miles TS (2001) Patterns of muscle activation in human hopping. Eur J Appl Physiol 84:503–509
Grimby G (1986) Physical activity and muscle training in the elderly. Acta Med Scand Suppl 711:233–237
Haglund-Åkerlind Y, Eriksson E (1993) Range of motion, muscle torque and training habits in runners with and without Achilles tendon problems. Knee Surg Sports Traumatol Arthrosc 1:195–199
Hess GP, Cappiello WL, Poole RM, Hunter SC (1989) Prevention and treatment of overuse tendon injuries. Sports Med 8:371–384
Ishikawa M, Komi PV (2004) Effects of different dropping intensities on fascicle and tendinous tissue behavior during stretch-shortening cycle exercise. J Appl Physiol 96:848–852
Jones GM, Watt DG (1971) Observations on the control of stepping and hopping movements in man. J Physiol 219:709–727
Józsa L, Kannus P (1997) Human tendons. Anatomy, physiology and pathology. Human Kinetics, Champaign
Kader D, Saxena A, Movin T, Maffulli N (2002) Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med 36:239–249
Komi PV, Bosco C (1978) Utilization of stored elastic energy in leg extensor muscles by men and women. Med Sci Sports 10:261–265
Komi PV, Fukashiro S, Jarvinen M (1992) Biomechanical loading of Achilles tendon during normal locomotion. Clin Sports Med 11:521–531
Komi PV (2000) Stretch-shortening cycle: a powerful model to study normal and fatigued muscle. J Biomech 33:1197–1206
Kraemer WJ, Adams K, Cafarelli E, Dudley GA, Dooly C, Feigenbaum MS, Fleck SJ, Franklin B, Fry AC, Hoffman JR, Newton RU, Potteiger J, Stone MH, Ratamess NA, Triplett-McBride T (2002) American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc 34:364–380
Kvist M (1991) Achilles tendon injuries in athletes. Ann Chir Gynaecol 80:188–201
Kvist M (1994) Achilles tendon injuries in athletes. Sports Med 18:173–201
Lowdon A, Bader DL, Mowat AG (1984) The effect of heel pads on the treatment of Achilles tendinitis: a double blind trial. Am J Sports Med 12:431–435
Lunsford BR, Perry J (1995) The standing heel-rise test for ankle plantar flexion: criterion for normal. Phys Ther 75:694–698
Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB (2003) Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med 13:11–15
Maffulli N, Wong J, Almekinders LC (2003) Types and epidemiology of tendinopathy. Clin Sports Med 22:675–692
Mafi N, Lorentzon R, Alfredson H (2001) 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 9:42–47
Moller M, Movin T, Granhed H, Lind K, Faxen E, Karlsson J (2001) Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br 83:843–848
Möller M, Lind K, Styf J, Karlsson J (2005) The reliability of isokinetic testing of the ankle joint and a heel-raise test for endurance. Knee Surg Sports Traumatol Arthrosc 13:60–71
Neeter C, Thomeé R, Silbernagel KG, Thomeé P, Karlsson J (2003) Iontophoresis with or without dexamethazone in the treatment of acute Achilles tendon pain. Scand J Med Sci Sports 13:376–382
Nelen G, Martens M, Burssens A (1989) Surgical treatment of chronic Achilles tendinitis. Am J Sports Med 17:754–759
Niesen-Vertommen S, Taunton J, Clement D, Mosher R (1992) The effect of eccentric versus concentric exercise in the management of Achilles tendonitis. Clin J Sport Med 2:109–113
Paavola M, Kannus P, Paakkala T, Pasanen M, Järvinen M (2000) Long-term prognosis of patients with achilles tendinopathy. An observational 8-year follow-up study. Am J Sports Med 28:634–642
Paavola M, Kannus P, Järvinen TA, Khan K, Jozsa L, Järvinen M (2002) Achilles tendinopathy. J Bone Joint Surg Am 84-A:2062–2076
Paavola M, Kannus P, Orava S, Pasanen M, Järvinen M (2002) Surgical treatment for chronic Achilles tendinopathy: a prospective seven month follow up study. Br J Sports Med 36:178–182
Paoloni JA, Appleyard RC, Nelson J, Murrell GA (2004) Topical glyceryl trinitrate treatment of chronic noninsertional achilles tendinopathy. A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am 86-A:916–922
Peers K (2003) Extracorporeal shock wave therapy in chronic achilles and patellar tendinopathy, Leuven University Press, Leuven University, Leuven
Robinson JM, Cook JL, Purdam C, Visentini PJ, Ross J, Maffulli N, Taunton JE, Khan KM (2001) The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 35:335–341
Roos EM, Brandsson S, Karlsson J (2001) Validation of the foot and ankle outcome score for ankle ligament reconstruction. Foot Ankle Int 22:788–794
Roos EM, Engström M, Lagerquist A, Söderberg B (2004) Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy—a randomized trial with 1-year follow-up. Scand J Med Sci Sports 14:286–295
Silbernagel KG, Thomeé R, Thomeé P, Karlsson J (2001) 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 11:197–206
Silbernagel KG, Thomee R, Karlsson J (2005) Cross-cultural adaptation of the VISA-A questionnaire, an index of clinical severity for patients with Achilles tendinopathy, with reliability, validity and structure evaluations. BMC Musculoskelet Disord 6:12
Stanish WD, Curwin S, Mandell S (2000) Tendinitis: its etiology and treatment. Oxford University Press, New York
Stokes M, Young A (1984) The contribution of reflex inhibition to arthrogenous muscle weakness. Clin Sci (Lond) 67:7–14
Svantesson U, Carlsson U, Takahashi H, Thomee R, Grimby G (1998) Comparison of muscle and tendon stiffness, jumping ability, muscle strength and fatigue in the plantar flexors. Scand J Med Sci Sports 8:252–256
Svantesson U, Osterberg U, Thomee R, Grimby G (1998) Muscle fatigue in a standing heel-rise test. Scand J Rehabil Med 30:67–72
Svantesson U, Osterberg U, Thomee R, Peeters M, Grimby G (1998) Fatigue during repeated eccentric-concentric and pure concentric muscle actions of the plantar flexors. Clin Biomech (Bristol, Avon) 13:336–343
Tallon C, Coleman BD, Khan KM, Maffulli N (2001) Outcome of surgery for chronic Achilles tendinopathy. A critical review. Am J Sports Med 29:315–320
Viitasalo JT, Salo A, Lahtinen J (1998) Neuromuscular functioning of athletes and non-athletes in the drop jump. Eur J Appl Physiol Occup Physiol 78:432–440
Öhberg L, Alfredson H (2004) Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis? Knee Surg Sports Traumatol Arthrosc 12:465–470
Acknowledgments
The authors thank physiotherapists Andreas Hansson and Patrik Jacobsson for their participation in the study. This study was supported by grants from the Swedish National Centre for Research in Sports and The local Research and Development Council of Gothenburg and Southern Bohuslän.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Silbernagel, K.G., Gustavsson, A., Thomeé, R. et al. Evaluation of lower leg function in patients with Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc 14, 1207–1217 (2006). https://doi.org/10.1007/s00167-006-0150-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00167-006-0150-6