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Evaluation of lower leg function in patients with Achilles tendinopathy

  • Sports Medicine
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

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.

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References

  1. 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

    PubMed  CAS  Google Scholar 

  2. Alfredson H, Lorentzon R (2000) Chronic Achilles tendinosis: recommendations for treatment and prevention. Sports Med 29:135–146

    Article  PubMed  CAS  Google Scholar 

  3. Alfredson H (2003) Chronic midportion Achilles tendinopathy: an update on research and treatment. Clin Sports Med 22:727–741

    Article  PubMed  Google Scholar 

  4. 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

    Article  PubMed  Google Scholar 

  5. Angermann P, Hovgaard D (1999) Chronic Achilles tendinopathy in athletic individuals: results of nonsurgical treatment. Foot Ankle Int 20:304–306

    PubMed  CAS  Google Scholar 

  6. 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

    Article  PubMed  CAS  Google Scholar 

  7. Clement DB, Taunton JE, Smart GW (1984) Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med 12:179–184

    PubMed  CAS  Google Scholar 

  8. Cook JL, Purdam CR (2003) Rehabilitation of lower limb tendinopathies. Clin Sports Med 22:777–789

    Article  PubMed  Google Scholar 

  9. 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

    PubMed  CAS  Google Scholar 

  10. Fleiss JL (1986) The design and analysis of clinical experiments. Wiley, New York

    Google Scholar 

  11. 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

    Article  PubMed  CAS  Google Scholar 

  12. 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

    Article  PubMed  CAS  Google Scholar 

  13. Grimby G (1986) Physical activity and muscle training in the elderly. Acta Med Scand Suppl 711:233–237

    PubMed  CAS  Google Scholar 

  14. 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

    Article  PubMed  Google Scholar 

  15. Hess GP, Cappiello WL, Poole RM, Hunter SC (1989) Prevention and treatment of overuse tendon injuries. Sports Med 8:371–384

    PubMed  CAS  Google Scholar 

  16. 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

    Article  PubMed  Google Scholar 

  17. Jones GM, Watt DG (1971) Observations on the control of stepping and hopping movements in man. J Physiol 219:709–727

    PubMed  CAS  Google Scholar 

  18. Józsa L, Kannus P (1997) Human tendons. Anatomy, physiology and pathology. Human Kinetics, Champaign

    Google Scholar 

  19. 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

    Article  PubMed  CAS  Google Scholar 

  20. Komi PV, Bosco C (1978) Utilization of stored elastic energy in leg extensor muscles by men and women. Med Sci Sports 10:261–265

    PubMed  CAS  Google Scholar 

  21. Komi PV, Fukashiro S, Jarvinen M (1992) Biomechanical loading of Achilles tendon during normal locomotion. Clin Sports Med 11:521–531

    PubMed  CAS  Google Scholar 

  22. Komi PV (2000) Stretch-shortening cycle: a powerful model to study normal and fatigued muscle. J Biomech 33:1197–1206

    Article  PubMed  CAS  Google Scholar 

  23. 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

    Article  PubMed  Google Scholar 

  24. Kvist M (1991) Achilles tendon injuries in athletes. Ann Chir Gynaecol 80:188–201

    PubMed  CAS  Google Scholar 

  25. Kvist M (1994) Achilles tendon injuries in athletes. Sports Med 18:173–201

    PubMed  CAS  Google Scholar 

  26. 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

    PubMed  CAS  Google Scholar 

  27. Lunsford BR, Perry J (1995) The standing heel-rise test for ankle plantar flexion: criterion for normal. Phys Ther 75:694–698

    PubMed  CAS  Google Scholar 

  28. 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

    Article  PubMed  Google Scholar 

  29. Maffulli N, Wong J, Almekinders LC (2003) Types and epidemiology of tendinopathy. Clin Sports Med 22:675–692

    Article  PubMed  Google Scholar 

  30. 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

    Article  PubMed  CAS  Google Scholar 

  31. 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

    Article  PubMed  CAS  Google Scholar 

  32. 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

    Article  PubMed  Google Scholar 

  33. 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

    Article  PubMed  CAS  Google Scholar 

  34. Nelen G, Martens M, Burssens A (1989) Surgical treatment of chronic Achilles tendinitis. Am J Sports Med 17:754–759

    PubMed  CAS  Google Scholar 

  35. 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

    Google Scholar 

  36. 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

    PubMed  CAS  Google Scholar 

  37. Paavola M, Kannus P, Järvinen TA, Khan K, Jozsa L, Järvinen M (2002) Achilles tendinopathy. J Bone Joint Surg Am 84-A:2062–2076

    PubMed  Google Scholar 

  38. 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

    Article  PubMed  Google Scholar 

  39. 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

    PubMed  Google Scholar 

  40. Peers K (2003) Extracorporeal shock wave therapy in chronic achilles and patellar tendinopathy, Leuven University Press, Leuven University, Leuven

  41. 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

    Article  PubMed  CAS  Google Scholar 

  42. 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

    PubMed  CAS  Google Scholar 

  43. 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

    Article  PubMed  Google Scholar 

  44. 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

    Article  PubMed  CAS  Google Scholar 

  45. 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

    Article  PubMed  Google Scholar 

  46. Stanish WD, Curwin S, Mandell S (2000) Tendinitis: its etiology and treatment. Oxford University Press, New York

    Google Scholar 

  47. Stokes M, Young A (1984) The contribution of reflex inhibition to arthrogenous muscle weakness. Clin Sci (Lond) 67:7–14

    CAS  Google Scholar 

  48. 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

    PubMed  CAS  Google Scholar 

  49. Svantesson U, Osterberg U, Thomee R, Grimby G (1998) Muscle fatigue in a standing heel-rise test. Scand J Rehabil Med 30:67–72

    Article  PubMed  CAS  Google Scholar 

  50. 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

    Article  Google Scholar 

  51. 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

    CAS  Google Scholar 

  52. 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

    Article  PubMed  CAS  Google Scholar 

  53. 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

    Article  PubMed  Google Scholar 

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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.

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Authors and Affiliations

  1. Lundberg Laboratory of Orthopaedic Research, Department of Orthopaedics, Göteborg University, Sahlgrenska University Hospital, Göteborg, Sweden

    Karin Grävare Silbernagel, Alexander Gustavsson, Roland Thomeé & Jon Karlsson

  2. Sportrehab—Physical Therapy & Sports Medicine Clinic, Göteborg, Sweden

    Karin Grävare Silbernagel, Alexander Gustavsson & Roland Thomeé

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  1. Karin Grävare Silbernagel
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Correspondence to Karin Grävare Silbernagel.

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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

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  • DOI: https://doi.org/10.1007/s00167-006-0150-6

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