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A Proposed Return To Sport
A Proposed Return To Sport
KARIN GRVARE SILBERNAGEL, PT, ATC, PhD1 KAY M. CROSSLEY, BAppSc (Physio), PhD2
A Proposed Return-to-Sport
Downloaded from www.jospt.org at UNIVERSIDADE DE SO PAULO on November 2, 2015. For personal use only. No other uses without permission.
D
espite being the largest tendon in the body, the Achilles tary aims to describe a rationale
tendon is one of the most commonly injured tendons, for and the implementation of a
especially in athletes involved in running and jumping return-to-sport program for ath-
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
able to continue with regular activities in injured runners compared to uninjured ational and elite athletes, with which the
and sports, but as the injury progresses runners.26 Recurrence of Achilles tendi- first author (K.G.S.) has been affiliated for
the patients ability to be physically active nopathy symptoms was common, and 10 years. Successful return-to-sport plan-
is progressively impaired.44 Repetitive reinjury risk high, in elite soccer players ning also requires an understanding of the
overloading of the Achilles tendon and with short recovery periods.23 injury and knowledge of how to effectively
training errors, such as rapidly increas- Because return to sport is the goal manage the injury in the earlier stages of
ing training intensity or duration, are of rehabilitation, this clinical commen- treatment. This clinical commentary will
also include a brief description of the
TTSYNOPSIS: Achilles tendinopathy is a common sport all need to be considered when planning for injury and the evidence and recommen-
overuse injury in athletes involved in running and return to sport. This clinical commentary describes dations for the treatment preceding the
jumping activities and sports. The intervention with an approach to return to sport for patients with
initiation of the return-to-sport program.
the highest level of evidence is exercise therapy, midportion Achilles tendinopathy. The aim of
and it is recommended that all patients initially be the return-to-sport program is to facilitate the
treated with exercise for at least 3 months prior decision-making process in returning an athlete Achilles Tendinopathy
to considering other treatment options. Recovery with midportion Achilles tendinopathy back to full Achilles tendinopathy is an overuse injury
from Achilles tendinopathy can take up to a year, sport participation and to minimize the chances characterized by a combination of pain,
and there is a high propensity for recurrence, for recurrence of the injury. J Orthop Sports Phys
swelling (diffuse or localized), and im-
especially during the return-to-sport phase. The Ther 2015;45(11):876-886. Epub 21 Sep 2015.
doi:10.2519/jospt.2015.5885 paired performance.38,46 The diagnosis is
extent of the tendon injury, the age and sex of the
based on the patients history and the find-
athlete, the magnitude of pain/symptoms, the TTKEY WORDS: Achilles tendon, eccentric,
extent of impairments, and the demands of the exercise, jumping, running, tendinosis ings of the physical examination. Achilles
tendinopathy can be divided into midpor-
Department of Physical Therapy, University of Delaware, Newark, DE. 2School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne,
1
Australia. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or
materials discussed in the article. Address correspondence to Dr Karin Grvare Silbernagel, Department of Physical Therapy, University of Delaware, 540 South College Avenue,
Newark, DE 19713. E-mail: kgs@udel.edu t Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy
Heel drop: knee straight (FIGURE 2) 3 sets of 15 repetitions Do exercise even if painful (stop if pain
Standing on the edge of a step on the in- 2 times per day becomes disabling) and perform
volved side. Start with standing on the 7 days a week for 12 weeks until it becomes pain free
toes, then lower the heel as far down Once pain free, progressively add loads
as possible. Rise back on the toes with in either a backpack or in your hands
the assistance of the other foot until the exercise is again painful
Heel drop: knee bent (FIGURE 2) 3 sets of 15 repetitions Do exercise even if painful (stop if pain
Same as above, but keep the knee of the 2 times per day becomes disabling) and perform
A
involved side slightly bent 7 days a week for 12 weeks until it becomes pain free
Once pain free, progressively add loads
in either a backpack or in your hands
B until the exercise is again painful
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
Patient Status
ing exercise therapy alone.2,68 Pain and difficulty with all activities, difficulty performing 10 one-legged heel rises
There is an urgent need to rigorously Goals
evaluate other treatment modalities that Start to exercise and understanding nature of the injury and how to use the pain-monitoring model
may serve as adjuncts or alternatives to Treatment Program
Perform exercises every day:
exercise therapy. Currently, patient-re-
Pain-monitoring model information and advice on exercise activity
ported outcomes (symptoms) are the pri- Circulation exercises (moving foot up/down)
mary outcome used in most studies, with Two-legged heel rises standing on the floor (3 10-15 repetitions)
only a few studies evaluating lower-leg One-legged heel rises standing on the floor (3 10 repetitions)
function and tendon structure.48 Further Sitting heel rises (3 10 repetitions)
Eccentric heel rises standing on the floor (3 10 repetitions)
research is needed to compare the effects
Phase 2: Weeks 2 to 5
of various interventions and dosages not If pain at the distal insertion of the tendon, continue standing on the floor
only on symptoms, but also on function Patient Status
and tendon structure, in patients with Pain with exercise, morning stiffness, pain when performing heel rises
Achilles tendinopathy. Goals
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
Start strengthening
Treatment Program
Exercise as Treatment Perform exercises every day:
The use of exercise as a treatment for Two-legged heel rises standing on edge of a step (3 15 repetitions)
Achilles tendinopathy involves 2 impor- One-legged heel rises standing on edge of a step (3 15 repetitions)
tant clinical questions: what is the most Sitting heel rises (3 15 repetitions)
Eccentric heel rises standing on edge of a step (3 15 repetitions)
effective type of exercise, and what is the
Quick rebounding heel rises (3 20 repetitions)
most appropriate dosage?50 Currently, the Phase 3: Weeks 3 to 12 (or Longer if Needed)
most commonly advocated therapeutic If pain at the distal insertion of the tendon, continue standing on the floor
approach consists of eccentric exercises, Patient Status
Journal of Orthopaedic & Sports Physical Therapy
using 3 sets of 15 repetitions done with Tolerates the phase 2 exercise program well, no pain at the distal tendon insertion, possibly decreased
or increased morning stiffness
the knee extended and slightly flexed,
Goals
performed twice daily (TABLE 1, FIGURE 2).4 Heavier strength training, increase or start running and/or jumping activity
While the initial research showed en- Treatment Program
couraging results for this program when Perform exercises every day and with heavier load 2 to 3 times per week:
used in the athletic population,4 it has One-legged heel rises standing on edge of step with added weight (3 15 repetitions)
Sitting heel rises (3 15 repetitions)
been less successful in patients who are
Eccentric heel rises standing on edge of step with added weight (3 15 repetitions)
not athletes.61 In addition, the results of Quick rebounding heel rises (3 20 repetitions)
more recent studies50,69 have brought into Plyometrics training
question this one-size-fits-all dosage for Phase 4: 3 to 6 months (or Longer if Needed)
exercise for Achilles tendinopathy. Stevens If pain at the distal insertion of the tendon, continue standing on the floor
Patient Status
and Tan69 compared the described eccen-
Minimal symptoms, not morning stiffness every day, can participate in sports without difficulty
tric program (TABLE 1), in which patients Goals
performed 180 repetitions per day, with Maintenance exercise, no symptoms
a do-as-tolerated protocol using the same Treatment Program
exercises. After 6 weeks of treatment, both Perform exercises 2 to 3 times per week:
One-legged heel rises standing on edge of step with added weight (3 15 repetitions)
groups had significantly improved, with
Eccentric heel rises standing on edge of step with added weight (3 15 repetitions)
no difference between groups. Quick rebounding heel rises (3 20 repetitions)
A different progressive Achilles ten-
donloading strengthening program64,66
promotes exercise once daily and uses term positive outcomes.62,64 With this The importance of the dosage of me-
concentric/eccentric exercises (TABLE 2, FIG- program, a pain-monitoring model (FIG- chanical loading, as treatment for Achil-
URES 3 through 9). This program has been URE 10) is used to assist with grading the les tendinopathy, has been addressed in
shown to result in both short- and long- dosage of exercise for each patient.64,66,71 a recent systematic review by Malliaras
FIGURE 3. Two-legged heel rise standing on the floor. FIGURE 7. Two-legged heel rise standing on a step.
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy
0 2 5 10
ported a return to sport ranged from 10% the one most often addressed in the lit- a more focal Achilles tendon thickening
to 86%.13,47,60 At 1-year follow-up, 55% to erature, is the level of pain with physical and pain, more often seen in the middle-
90% of the participants were reportedly activity.48 Other important factors that aged recreational athlete. As pointed out
back to sport participation.13,66 However, need to be included in the decision-mak- by the authors, this model is a simplifica-
the symptomatic state of the participants ing process are the healing and recovery tion of the complexity of tendinopathy but
who returned to sport in the above-men- of the tendon tissue18,30,43; the recovery of provides some guidelines for the clinician.
tioned study was not reported. strength, range of motion, and function; Mechanical loading of injured ten-
In the literature, resumption of ac- as well as the demands of the specific dons is of major importance for pro-
tivities such as running and jumping is sport.19,65 The objective with this return- moting healing and recovery of tendon
Journal of Orthopaedic & Sports Physical Therapy
generally recommended when the symp- to-sport program15 was to design a pro- tissue.36,37 At the same time, overloading
toms have subsided.4,67 Often, studies in- gram that would achieve optimal loading of the tendon with insufficient recov-
clude an intervention for a minimum of for the Achilles tendon in preparation for ery may result in tendon damage.43 The
12 weeks, and then describe that return full return to sports. tendons structural remodeling, which is
to sport is allowed.30,56 However, resting considered an integral part of the healing,
from sporting activities during the early Factors to Consider When is affected by the duration, magnitude,
phase of treatment may not be necessary. Planning Return to Sports and timing of loading.21 During recovery
The only known study to allow monitored Tendon InjuryThe pathology of tendi- from tendinopathy, it is therefore impor-
sporting activity early in the rehabilita- nopathy is described as either failed heal- tant to ensure that the dosage of loading
tion64 observed no negative impact of ing or degeneration due to continuous is appropriate to the capacity of the indi-
this approach, which might also have the overloading.18 Chronic tendinopathy has vidual and the stage of tendon pathology,
benefits of improving compliance and also been found not to be an inflamma- with appropriate monitoring of response
helping to maintain the athletes overall tory condition.10,34,58 Clinically, patients to loading. The above-mentioned pain-
health status. Gradual progression into with Achilles tendinopathy are diverse monitoring model (FIGURE 10) helps guide
the specific sport activity is generally and show a symptom duration ranging appropriate loading for the pathology
recommended.25,28 from a week to intermittent symptoms for and the individual. The continuous use
What we have learned from research many years. Cook and Purdam18 proposed of valid and reliable outcome measures
and clinical practice is that the return-to- a pathology model to explain the various to evaluate patient-reported symptoms,
sport phase is a balancing act between a clinical presentations of load-induced such as the Victorian Institute of Sport
swift return to full activity and avoiding tendinopathy. In their model, the reactive Assessment-Achilles59 (VISA-A) ques-
overloading and reinjury of the tendon. tendinopathy/early tendon disrepair stage tionnaire, and recovery of impairments63
There are various factors that need to be is the acutely overloaded tendon more of- (eg, strength, endurance, and jumping
considered when planning the return to ten seen in younger individuals. The ten- ability) can assist in evaluating the indi-
sport after Achilles tendinopathy (TABLE don disrepair/degeneration stage presents vidual athletes response.
Tendon healing Consider what stage of tendon healing the patient is in pain-monitoring model (FIGURE 10) can
Full tendon healing can take up to 12 months32 guide patients on how to cope with and
Mechanical loading of the tendon is important for promoting tendon healing36,37 respond to pain during rehabilitation64,66
Age, hormonal levels, medication, and genetics affect healing9,44,52
by facilitating patients understanding of
Tendon recovery The tendon seems to take up to 3 days to recover from heavy loading, so plan the amount of pain allowed during and
for appropriate recovery days37,41,42,51
after exercise. A study64 that used the
Pain and symptoms It is acceptable to exercise and load the Achilles tendon even if it is painful; pain-monitoring model to determine
use the pain-monitoring model (FIGURE 10) as a guide64,66
the level of continued sports activity (in-
It is important to also evaluate pain and symptoms the day after tendon-loading
activity, especially in the latter stages of the return-to-sport phase
cluding running and jumping) allowed
during rehabilitation found no negative
Impairments Patients with Achilles tendinopathy have been found to have deficits in
strength, endurance, range of motion, and jumping ability, and these should
effects from continuing such activities
be addressed5,49,63 and incorporating recovery days between
The impairments might not automatically be resolved even if symptoms are activities. This indicates that an athlete
no longer present65 may not have to completely stop athletic
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
Load on the Achilles tendon It is important to remember that speed and the specific task affect Achilles activity and that graded return-to-sport
tendon load6,14,38 activity may be started prior to complete
Perceived rate of exertion11 Because individual patients have different baseline abilities, using their perceived absence of symptoms. This approach
exertion will assist in determining how to progress the specific sport activities may also minimize deconditioning of the
athlete.
Tendon Recovery During running and recovery days can be decreased. It must Visnes et al72 also allowed continued
jumping, the Achilles tendon is sub- also be considered that in addition to the physical activity during treatment of elite
jected to tensile loads as high as 6 to tendon needing to recover from the in- volleyball players with patellar tendi
12 times body weight.22,38 If the recov- jury, the forced decrease in activity may nopathy but found no positive effect of
Journal of Orthopaedic & Sports Physical Therapy
ery time between heavy-loading exer- also affect the tendons loading capacity, eccentric training combined with normal
cise sessions is inadequate, cumulative which needs to be regained during the in-season training. These contrasting
trauma may lead to major injury such as latter stages of rehabilitation. results may reflect not using a physical
Achilles tendinopathy.1,43,56 It is proposed Factors that can influence the rate of activitymonitoring model, such as the
that tendinopathy is a result of collagen tendon tissue recovery need to be consid- pain-monitoring model, or not incorpo-
degradation occurring at a greater rate ered when planning for return to sports. rating recovery days. The VISA-A ques-
than collagen synthesis.7 Exercise in hu- These factors include age, hormonal lev- tionnaire59 should also be used to evaluate
mans has been shown to result in a net els, medications, and genetics.9,44,52 It has the patient-reported symptoms over time.
decrease of collagen during the first 24 been suggested that patients less than 35 During the latter stage of recovery
to 36 hours following the exercises, but years of age tend to develop load-related from tendon injury, symptoms might
a net increase after 36 to 78 hours.37,41,42,51 degenerative tendinopathy and older in- be absent during activity; however, the
This indicates that the tendons response dividuals tend to develop more of an age- athlete may notice increased pain and/or
to loading might take up to 3 days to oc- related disease.73 Because the turnover stiffness on the following day.1,43 There-
cur, suggesting that athletes should plan rate of collagen may decrease with ad- fore, monitoring the athlete over the 2 to
for 2 to 3 days of recovery between heavy vancing age,36 it may take longer for older 48 hours following the activity is critical
Achilles tendonloading activities. Our athletes to recover from tendinopathy. to determine whether the intensity level
return-to-sport program therefore in- Pain and Symptoms The most common was appropriate. In the clinic, the use of a
corporates 3 recovery days between heavy symptoms of Achilles tendinopathy are training diary in which the athlete docu-
tendon-loading activities to ensure that pain and stiffness.30 Allowing the patient ments the pain level during the activity,
the tendon has adequate time to repair it- to experience pain during rehabilitation as well as the next day (especially morn-
self. In the clinic, we recommend 3 recov- appears to have no negative effect on re- ing stiffness), is of great use both for the
ery days between heavy tendon-loading covery.4,66 In fact, allowing for pain may athlete and the clinician.
activities while increasing the training be necessary to ensure that the Achilles Impairments Achilles tendinopathy is
level. At the latter stages, the amount of tendon load is sufficient to create mean- not only associated with pain and symp-
program for that specific athlete. Pain level after activity (next day), NPRS (0-10) 1-2 3-4 5-6
A battery of tests of lower-limb The athlete's RPE (with regard to the Achilles 0-1 2-4 5-10
strength, endurance, and jumping abil- tendon) (0-10)
ity has also been developed for patients Recovery days needed between activities 0 (can be per- 2 3
with Achilles tendinopathy.63 This test formed daily)
battery has been found to be reliable and Examples of activities for a runner Walking for 70 Jogging on flat Running 85% of
valid and can be used to evaluate changes minutes surface for 30 preinjury speed
minutes for 20 minutes
in function over time. Functional deficits
Abbreviations: NPRS, numeric pain-rating scale; RPE, rate of perceived exertion.
may not only increase the risk of reinjury
but also put the athlete at risk for other in-
juries.54 Rehabilitation for the injury and low rates of loading, tendons are more ning, with the actual load being related
addressing impairments as well as func- viscous or ductile and, consequently, can to running speed. Their work38 also in-
tional deficits and possible risk factors absorb more energy compared to high dicated that when walking, the force was
are important during the return-to-sport loading rates.14 At high rates of loading, approximately 3.5 times body weight,
phase. Following full return to sports, a tendons become more brittle and absorb whereas during cycling the load was close
maintenance program is recommended to less energy, but they are more effective at to body weight. The authors38 also mea-
be continued for at least a whole season.67 transferring loads.14 Therefore, tendon sured the Achilles tendon load during
The Load of the Activity In the literature, load can be increased in 2 ways when hopping (a submaximal jump similar to
there appears to be a consensus that re- prescribing exercise: by the external load jumping rope), and the force was approx-
turn to full sports activity should involve or by the speed of movement.31 imately 5 times body weight. It is impor-
a gradual loading progression. It is there- In vivo measurements of the Achilles tant to remember that this invasive study
fore of great importance to have knowl- tendon performed by Komi et al38 indi- was conducted on a few participants and
edge of the rate and magnitude of Achilles cated that the Achilles tendon was loaded that the tendon forces are likely to vary
tendon loads during various activities. At up to 12 times body weight during run- considerably between individuals. But, in
Day Activity Documented by the Athlete exercise intensity since it was developed
1 Jogging 30 minutes plus rehabilitation exercises in the 1960s.12 In the return-to-sport pro-
2 Walking 70 minutes plus rehabilitation exercises gram, the Borg category-ratio scale (TABLE
3 Walking 70 minutes plus rehabilitation exercises
4) is used as a tool for the patient/athlete
to grade how heavy they perceive various
4 Running 85% for 20 minutes plus rehabilitation exercises
activities are for their Achilles tendon.
5 Walking 70 minutes plus rehabilitation exercises
The RPE scale is also a familiar measure-
6 Walking 70 minutes plus rehabilitation exercises ment for coaches and athletes and pro-
7 Walking 70 minutes plus rehabilitation exercises vides an additional measure to assist in
8 Running 85% for 20 minutes plus rehabilitation exercises designing the individual athletes return-
9 Walking 70 minutes plus rehabilitation exercises to-sport progression. This is especially
useful when working with elite athletes
10 Walking 70 minutes plus rehabilitation exercises
in a variety of sports, where the clinician
11 Walking 70 minutes plus rehabilitation exercises
might not have an in-depth knowledge of
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
12 Jogging 30 minutes plus rehabilitation exercises the various components of the athletes
13 Walking 70 minutes plus rehabilitation exercises training program.
14 Walking 70 minutes plus rehabilitation exercises
15 Running 85% for 20 minutes plus rehabilitation exercises Principles of the Return-to-Sport
16 Walking 70 minutes plus rehabilitation exercises
Program
The guiding principle of the return-to-
17 Walking 70 minutes plus rehabilitation exercises
sport program (TABLE 5) is to progressively
18 Walking 70 minutes plus rehabilitation exercises increase the demand on the tendon by
19 Running 85% for 20 minutes plus rehabilitation exercises controlling the intensity, duration, and
Journal of Orthopaedic & Sports Physical Therapy
F
tivity, and in the evening). The clinician ple, if the athlete is a runner, the initial or athletes with Achilles tendi-
consistently reviews this information and running activity can be of a slow speed on nopathy, the extent of tendon injury,
discusses progress with the patient. a flat surface and possibly utilizing more the age of the athlete, the amount
Step 2 is the initiation of the program of a rearfoot-strike pattern to lower the of pain/symptoms, the extent of impair-
when the athlete meets the requirement Achilles tendon loading. ments, and the demands of the sport all
of performing activities of daily living In TABLE 5, the criteria for each activity need to be considered when planning for
with pain no higher than 2/10. At this level are provided. An activity is consid- return to sports. In general, athletes with
step, an important task is to determine ered light if the pain is no more than 2/10, Achilles tendinopathy can be expected to
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