A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. (2011)

Abstract
BACKGROUND: Eccentric exercises have the most evidence in conservative treatment of midportion Achilles tendinopathy. Although short-term studies show significant improvement, little is known of the long-term (>3 years) results.
AIM: To evaluate the 5-year outcome of patients with chronic midportion Achilles tendinopathy treated with the classical Alfredson’s heel-drop exercise programme.
STUDY DESIGN: Part of a 5-year follow-up of a previously conducted randomised controlled trial. Methods 58 patients (70 tendons) were approached 5 years after the start of the heel-drop exercise programme according to Alfredson. At baseline and at 5-year follow-up, the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire score, pain status, alternative treatments received and ultrasonographic neovascularisation score were recorded.
RESULTS: In 46 patients (58 tendons), the VISA-A score significantly increased from 49.2 at baseline to 83.6 after 5 years (p<0.001) and from the 1-year to 5-year follow-up from 75.0 to 83.4 (p<0.01). 39.7% of the patients were completely pain-free at follow-up and 48.3% had received one or more alternative treatments. The sagittal tendon thickness decreased from 8.05 mm (SD 2.1) at baseline to 7.50 mm (SD 1.6) at the 5-year follow-up (p=0.051).
CONCLUSION: At 5-year follow-up, a significant increase of VISA-A score can be expected. After the 3-month Alfredson’s heel-drop exercise programme, almost half of the patients had received other therapies. Although improvement of symptoms can be expected at long term, mild pain may remain.

Diagnosis: Mid-portion Achilles tendinitis (2-6 cm above insertion)

Outcome: VISA-A at 1 year and 5 year. Average score improved from 49.2 to 65 following 12 week trial, increased to 75 at one year and 83.4 at 5 years. 39.7% were completely pain free at 5 years, rest have some degree of residual symptoms.

When Assessed: 1 year and 5 years

Subjects: 46 subjects at follow up, ave age 51, 35 of whom were recreational athletes.

Protocol: After completing Alfredson’s 12 week protocol, 67% never performed eccentric exercise again, but no correlation in pain status was found between patients who continued the exercises and those who did not.

Other Activity: No mention of other activity during or after protocol. Perhaps in their earlier short term study with the same subjects this is mentioned, older study on order.

Chad’s Comments:  Interesting to me was that most did not continue with the exercise after the 12-week trial and that there was no correlation towards further improvement in those that did and didn’t. I suspect this might be a limitation of Alfredson’s protocol as there is no work to increase concentric strength at any point, perhaps holding them back with regards to further functional gains. Also eccentric exercises do become unwieldy and perhaps needlessly complex and that might decrease compliance compared to continuing with a more conventional progressive resistance exercise program.