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Letter to the Editor |
Hannover, Germany
Dear Editor:
I read with great interest the recent excellent work from Silbernagel et al examining the effect of continued sports activity based on a pain-monitoring model in Achilles tendinopathy ("Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy: A Randomized Controlled Study"), which was published electronically on February 16, 2007 as DOI: 10.1177/0363546506298279. Based on a hypothesized continuum from the healthy Achilles tendon via the tendinopathic state to the tendon rupture, this paper can be interpreted as an equivalent to the recent published randomized trial following Achilles tendon repair. It was suggested that Achilles tendon elongation was somewhat less in the early motion group following surgery.3
However, I would like to comment on some of the issues raised by the authors. The authors stated that they found no significant difference among 38 patients randomized in either early adjunct physical exercise up to visual analog scale (VAS) 5 of 10 or active rest for 6 weeks regarding the improvement based on the score from the Swedish version of the Victorian Institute of Sports Medicine Assessment–Achilles questionnaire. This is of special interest because based on this conclusion, early adjunct physical activity such as running or jumping might be allowed or even recommended during rehabilitation for Achilles tendinopathy when a pain level of 5 of 10 on the VAS is not passed by the athlete.
Inclusion was performed based only on clinical findings such as Achilles tendon pain, swelling, and impaired performance. There is no doubt that clinical parameters are important, as presented by Silbernagel et al, but morphological (color Doppler sonography, MRI) or, even better, functional data (capillary blood flow, tendon oxygenation, postcapillary venous pressure) regarding the response of the Achilles tendon to both treatment regimens are reported to broadly implement the conclusion of the authors into clinical practice.
Ultrasound in a conventional gray scale technique was performed. Unfortunately, we do not know anything about the presence or absence of neovascularization in the painful Achilles tendons depicted, such as by color Doppler sonography. The authors did not comment on the distribution of pathological sonographic changes in both groups. It would be interesting to speculate whether both groups demonstrate the same response to the rehabilitation program or not in morphological and/or functional aspects. Semiquantitative assessment of neovascularization by power Doppler or direct capillary blood flow measurement based on laser Doppler flowmetry5 might support the mere clinical finding of equal results in early motion and active rest in the randomized controlled study presented by Silbernagel et al. Eccentric training leads to a significant decrease of Achilles tendon capillary blood flow and postcapillary venous filling pressures with stable tendon oxygenation.4
Magnetic resonance imaging might be supportive, as an immediate increment of Achilles tendon diameter to a single eccentric training has been reported.6 Interestingly, MRI signal rather than tendon volume correlates to pain and functional impairment in chronic Achilles tendinopathy, as demonstrated superbly by Gärdin et al in 2006.2 Therefore, color Doppler, laser Doppler flowmetry, and/or MRI could further support the mere clinical finding of suggested equal subjective results in the small randomized controlled trial with 38 patients included in 2 groups, before one could recommend early adjunct physical activity in Achilles tendinopathy.
Another important issue is the compliance in eccentric training: Silbernagel reported a 100% compliance rate among 38 patients with Achilles tendinopathy over 12 months. All patients were in contact with the physical therapists on average once a week for the first 6 weeks and then as often as the physical therapist and the patient deemed necessary. de Vos et al1 reported in a randomized trial that more than a quarter of the patients undergoing eccentric training for midportion Achilles tendinopathy reported performing less than 50% of the prescribed intensity. It would be interesting to know how often between the weeks 7 and 52 and by which means the physical therapists had to contact the patients to achieve such a convincing compliance rate over 12 months in the 20- to 60-year-old patients. I think we will learn much more about motivating our patients undergoing eccentric training with sustained results if the authors will further comment on this important issue. I would like to thank the authors for their stimulating work.
REFERENCES
Göteborg, Sweden
We thank Dr Knobloch for his interest and comments regarding our study on "Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy."
We do not believe that treatment and/or recovery following chronic Achilles tendinopathy and acute Achilles tendon ruptures can easily be compared, as these of course are 2 separate injuries. There are vast differences in the amount of tendon damage, the symptoms present, and the functional limitations when tendinopathy is compared with a complete tear with full interruption of the tendon tissue.
Achilles tendinopathy is a clinical diagnosis in patients with a clinical syndrome characterized by a combination of pain, swelling (diffuse or localized) in the Achilles tendon, and impaired performance.2 The clinical examination, along with the patient’s history, form the basis of the diagnosis. Evaluation with imaging is not necessary to establish the clinical diagnosis. Imaging can, however, be useful when the diagnosis is questionable or the patient fails to respond to treatment.1,3 Magnetic resonance imaging has been shown to be reliable and valid as an evaluation tool in terms of tendon tissue changes with treatment.4–8 In our study, we have chosen to perform ultrasonography measures to describe the tendons; however, ultrasonography was not used as an outcome measure. The purpose of our study was to prospectively evaluate if continued running and jumping during treatment with an Achilles tendon-loading strengthening program would have an effect on the outcome. There was no attempt in this study to evaluate tissue changes but instead to focus on the patients’ symptoms and function. We believe it is of utmost importance to address the clinically relevant questions with a research design that can allow the results to be generalized and used in the clinic. The study was prospective, the patients were randomized to the 2 treatment groups, and the evaluations were blinded and performed by a single physical therapist not involved in the rehabilitation. Further studies are, however, needed on this issue, and hopefully this study can generate hypotheses for further basic research studies as well as further clinical studies.
In terms of compliance, we first would like to clarify some issues that might have been misunderstood. The treatment was performed for 6 months following the specific rehabilitation protocol published with the paper. The last follow-up evaluation was performed after 12 months. We believe the important aspects for achieving compliance are informing the patient regarding the injury and what to expect in terms of treatment. The treating physical therapists had a thorough knowledge regarding the injury and the treatment protocol. The patients also filled out training diaries daily, which were reviewed by the physical therapist together with the patient at all follow-up visits. The patients were also evaluated with questionnaires and functional tests after 6 weeks and 3, 6, and 12 months. Most patients described that being continuously evaluated encouraged compliance. The patients exercised once a day and not 3 times per day as recommended in other studies. Finally, we also believe that improvement is a good motivator, and with thorough continuous evaluations, the patients can better follow the improvement in symptoms and function.
REFERENCES
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