Arthritis

02 December 2010

Exercise to heal Achilles injury

Inflammation of the Achilles tendon often resolves with exercise therapy alone, a small study suggests.

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Inflammation of the Achilles tendon often resolves with exercise therapy alone, a small study suggests.

A full recovery might take time, as tendons are often slow to heal, researchers say, but sticking with exercise could help some patients avoid more invasive treatments.

Among 34 patients with Achilles tendinopathy who received exercise therapy for three to six months, 80% recovered completely with no further treatment, although some developed new symptoms over the next several years.

Another seven patients (20%) continued to have pain or other symptoms, but for three, the symptoms were minimal, and only one sought a different form of treatment.

Exercise therapy is known to be effective for Achilles tendinopathy, particularly so-called eccentric exercises where the calf muscles contract while being lengthened. (An example would be rising onto the balls of the feet, then slowly lowering the heels back to the ground.)

But it is not clear how long patients can, or should, stick with exercise before moving on to more invasive treatments.

Recommendations for patients

A common recommendation is for people with Achilles tendinopathy to try exercise therapy for three months, and if they have not recovered at that point, to consider other options.

That is a fairly arbitrary recommendation, however, based on studies that have chosen that window of treatment time. In real life, three months may be too short a time for a full recovery, said Dr Karin Gravare Silbernagel, a physical therapist and the lead researcher on the new study.

Injured tendons need mechanical loading i.e., exercise to heal, said Dr Silbernagel, of the University of Gothenburg in Sweden and the University of Delaware in Newark.

"But we also know that a tendon can take a year to heal," she said.

If exercise therapy is given time, she said, many people with Achilles tendinopathy will do well, while continuing with their daily activities during a potentially lengthy recovery.

The study

The patients in the current study were originally part of a clinical trial looking at the effects of three to six months of exercise therapy for Achilles tendinopathy.

In that trial, half were told that they could continue their usual physical activities during their rehab, while the other half were told to rest for the first six weeks of therapy.

One year later, both groups were showing similar improvements in pain and functional ability, suggesting that people with Achilles tendinopathy can stay active in their day-to-day lives during therapy, as long as they monitor their symptoms and cut back on exercise if necessary.

The current study, published in the American Journal of Sports Medicine, was a five-year follow-up of that original patient group. At the five-year mark, 65% had no symptoms from their initial injury, while 15% (five patients) had fully recovered but eventually developed new Achilles symptoms. Only one person in that latter group sought treatment, in the form of further exercise therapy.

"I think the bottom line is that exercise is a treatment that can provide a full recovery," Dr. Silbernagel said.

Exercise at home

And longer duration exercise therapy need not mean six months of sessions with a physical therapist, she said. Instead, people can learn exercises to perform on their own at home, and if needed, see their physical therapist for follow-ups.

Dr Silbernagel and her colleagues also found that patients' "fear of movement" was related to their long-term recovery of functional ability as measured by a heel-rise test. Those with a greater level of anxiety about exercising causing pain or raising the risk of an Achilles tendon rupture tended to show less recovery of their muscular endurance.

Dr Silbernagel says reassuring patients that exercise is a key part of recovery might ultimately lead to better treatment outcomes.

Short of surgery, other treatment options for Achilles tendinopathy include standard painkillers, injections of medications like aprotinin (which inhibits an enzyme that breaks down collagen), and injections of platelet-rich plasma into the injured joint.

But whether any of those therapies are truly effective remains unclear. A clinical trial published earlier this year found that platelet-rich plasma, used in addition to eccentric exercises, offered no additional benefit to patients with Achilles tendinopathy.

(Reuters Health, Amy Norton, December 2010)

 

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Professor Asgar Ali Kalla completed his MBChB (Bachelor of Medicine and Bachelor of Surgery) degree in 1975 at the University of Cape Town and his FRCP in 2003 in London. Professor Ali Kalla is the Isaac Albow Chair of Rheumatology at the University of Cape Town and also the Head of Division of Rheumatology at Groote Schuur Hospital. He has participated in a number of clinical trials for rheumatology and is active in community outreach. Prof Ali Kalla is an expert in Arthritis for Health24.

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