In Adults with Chronic Hamstring Tendinopathy, Is Eccentric

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IN ADULTS WITH CHRONIC HAMSTRING TENDINOPATHY, IS ECCENTRIC

TRAINING COMPARED WITH OTHER THERAPEUTIC OPTIONS MORE EFFECTIVE

IN IMPROVING TREATMENT OUTCOMES?

A Research Project Presented to the Faculty of the

Department of Physical Therapy of Springfield College

In Partial Fulfillment

of the Requirements for the Degree

Doctor of Physical Therapy

Samantha Bastian

Meagan Kamens

Caitlin Semmelrock

May 2013

IN ADULTS WITH CHRONIC HAMSTRING TENDINOPATHY, IS ECCENTRIC

TRAINING COMPARED WITH OTHER THERAPEUTIC OPTIONS MORE EFFECTIVE

IN IMPROVING TREATMENT OUTCOMES?

A Research Project Presented

Samantha Bastian

Meagan Kamens

Caitlin Semmelrock

Approved as to style and content by:

Dawn Roberts, PT, PhD, Faculty Advisor

Amy Veres, PT, MS, OCS, Reader

______Jacqueline Shakar, DPT, MSPT, OCS, CMT, Reader

! 2013 Samantha Bastian, Meagan Kamens, and Caitlin Semmelrock

ABSTRACT

Background: The purpose of this manuscript is to determine the effectiveness of eccentric exercise (EE) in treating chronic hamstring tendinopathy in an adult female athlete. Tendinopathy in general is a common overuse injury among athletic populations without a definitive treatment option and thus further research is needed. EE has shown some promise in regards to treatment of tendinopathy resulting in improved outcomes such as decreased pain.

Method: A systematic review of the literature was performed by the authors collectively searching databases for relevant articles using various key words and search strings. The databases MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SPORTDiscus, and PubMed were searched.

Results: Inclusion and exclusion criteria were formulated and led to the final number of articles to be reviewed. A total of eight articles met the inclusion and exclusion criteria which were used to reach a clinical decision. The Visual Analogue Scale (VAS), Victorian Institute of Sport Assessment (VISA) and the Foot and Ankle Outcome Score (FAOS) were the outcome measures used to quantify pain and track changes over treatment time. Some positive results have been produced with EE, however a majority of these results have come from lower quality research studies.

Discussion/Conclusion: There were no studies that examined the use of EE in chronic hamstring tendinopathy specifically. This intervention’s effectiveness in improving outcomes of decreased pain was evident in both Achilles and patellar tendinopathy. The pathophysiology behind hamstring tendinopathy is similar to that of Achilles and patellar tendinopathy. Additionally, protocols used varied between studies indicating that the most ideal protocol for treatment is unknown. Although EE does not consistently demonstrate superior findings in comparison to other treatment options, it has shown overall positive results. Furthermore, EE is cost effective and the only adverse side effect reported was muscle soreness. Therefore, the authors suggest using EE to treat hamstring tendinopathy by following the protocol of three sets of 15 repetitions, twice daily for 12 weeks. EE coincides with the patient’s values and is a feasible intervention. 5

BACKGROUND

Tendinopathy is frequently referred to as a common overuse injury.1 The failed healing response of the tendon presents with no inflammation, leading to a chronic degenerative condition.1,2 Treatment of tendinopathy is often difficult and begins with conservative intervention, such as physical therapy. A specific protocol for the treatment of tendinopathy is unknown. Approximately 25% to 33% of lower extremity tendinopathies demonstrate poor outcomes with conservative treatment and will later require surgery, with only 46% to 64% successfully returning to pre-injury functional levels.3 Additionally, tendon injuries not only result in short-term decline in activity, but can lead to long-term changes resulting in decreased functional abilities.4

There are various factors that contribute to the severity and prevalence of hamstring tendinopathy. For one, it commonly occurs in athletes of various sport activities, especially running.5 Of these running injuries, 60% are overuse in nature.6 Gender may also be a factor which corresponds to a higher incidence of overuse injuries in males.6 Although tendon injuries are more commonly sustained by males, the incidence in women is rising due to increased involvement in high-risk physical activities.6 In addition to the aforementioned variables, research has suggested that age is another factor that affects the specific location of hamstring injury because of the changes of tendon structure that occur due to aging.7

However, specific age ranges have not yet been substantiated. In children, damage usually occurs at the apophyseal attachment of the muscle, in adolescents at the myotendinous junction, and in adults at the muscle-tendon-bone unit because it generally becomes weak due to degeneration.7 Furthermore, essential stiffness of the muscle-tendon junction has been 6 found to be decreased in dysfunctional tendons.8 This decrease in stiffness may also be a component of aging.8

The classification of tendinopathy is often used to describe a variety of tendon pathologies, which include paratendinitis, tendinitis, and tendinosis.6 Brody and Hall9 describe that tendinitis is the most commonly used term for tendon injury, however the suffix

‘-itis’ implies inflammation. Tendinosis has replaced tendinitis to describe tendon degeneration without the inflammatory component. Inflammation is not commonly found in histopathologic examination of the tendon in chronic tendinopathy. Histopathologic findings of tendinopathy include: tendon degeneration without inflammation, collagen disorientation, fiber separation, increased vascular spaces with or without neovascularization and focal necrosis or calcification.6 Hamstring tendinopathy is characterized by insidious onset of ill- defined pain during sporting activities or while sitting.5 The pain is often localized to the lower gluteal region in the absence of specific trauma or injury.1,5

The pathologic changes of hamstring tendinopathy are similar to other tendinopathies.5 The diagnosis of hamstring tendinopathy is concluded by structural changes visible on magnetic resonance imaging (MRI) or ultrasound (US).10 Ultrasonography findings display thickening of the tendon, irregular tendon structure with hypoechoic areas, and irregular fiber orientation.11 Additional factors contributing to the diagnosis include: patient- reported pain in the lower gluteal region during tendon loading, tenderness to palpation of the hamstring origin, positive straight leg raise testing, strong and painful or weak and painful strength testing of the affected hamstring, and neovascularization observed with colour

Doppler.12 The patient may also present with radiating pain to the popliteal fossa with prolonged sitting or during sport activities.5 7

Research has consented that tendinopathy is most likely a combination of anatomical and biomechanical factors, as well as persistent overuse.13 The risk factors that may contribute to hamstring tendinopathy consist of both intrinsic and extrinsic characteristics.

Intrinsic factors include malalignment such as excessive subtalar pronation, increased femoral neck anteversion, limb length discrepancies, muscular imbalance, and muscular insufficiency. Extrinsic factors include training errors (distance, intensity, hill work, technique, and fatigue), training surfaces, environmental conditions, footwear, equipment, and frequency.6 Physical therapy can address many of these intrinsic and extrinsic factors.

For one, the therapist can ensure proper positioning and form during therapeutic exercises to address body mechanics that may be contributing to subsequent training errors. Additionally, a specific treatment protocol can be implemented to restore ideal muscle balance, especially those that contribute to posture and hamstring length, which will require various strengthening and stretching exercises. Therapy can also assist in stimulating healing through the use of EE to promote positive histopathological tendon changes and decrease pain.9

Many authors have employed the use of EE in the treatment of chronic tendinopathy in various locations throughout the body.3,11-17 EE occurs when the muscle lengthens during activation because the external force on the muscle is greater than the muscle force.9 More tension per contractile unit is produced in eccentric loading with less energy expenditure in comparison to concentric exercise (CE).9 It is a fundamental movement produced in many functional activities.9 For example, eccentric activation of the hamstrings occurs during four different points in the gait cycle of running.18 The hamstrings act to decelerate knee extension at the end of the swing phase and are activated at heel strike to stabilize the leg eccentrically to prepare for weight acceptance. Additionally, the hamstrings also aid to begin 8 the transition from hip flexion to hip extension as well as provide assistance to the gastrocnemius with knee extension during the takeoff phase of running.7,18 During the late swing phase of running, the hamstrings are actively lengthened simultaneously with hip flexion and knee extension, creating extremely high tension on the muscle and potentially leading to injury.18,19

The use of EE has been suggested as a treatment option due to the assumption that it may promote remodeling of the degenerated tendon. This occurs by creating collagen fiber cross-linkage formation within the tendon during the specific mechanics of eccentric loading.20,21 Curwin and Stanish22 have proposed that poor neuromuscular control during eccentric muscle action may overload the tendon, and that EE works to retrain the neuromuscular system to be able to better accommodate these eccentric overloads.10,22

Additionally, EE has been found to decrease tendon volume and intratendinous signal on

MRI, both of which have been found to correlate with improved pain and participant performance.5 Furthermore, EE has been suggested to improve tendon stiffness and potentially help regain normal tendon structure.8

EE has been compared to various other possible treatments for tendinopathy such as concentric strengthening, flexibility, cross friction massage, shock-wave therapy (SWT), and endurance training.3,11-17 The outcome measure used in this research manuscript was pain using a variety of standardized measures, although additional outcomes, such as return to function and patient satisfaction, are also used in published research. Pain is described as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” by the International Association for the Study 9 of Pain.23 Pain was quantified using the VAS, VISA, or FAOS. The patient’s pain rating may have been measured during palpation, with movement, at rest, or in combination.

There is little evidence on the prognosis of hamstring tendinopathy in the literature.

Studies done on patellar and Achilles tendinopathy report a reduction in pain as early as six weeks, 12 weeks, or one-year follow up.3,11-17 Improvements made with EE, such as stimulated healing and biomechanical tendon changes, may lead to decreased pain and improved function.9

Description of the patient

The patient is a 39 year-old female who presents to an outpatient physical therapy clinic with at least a ten-year history of bilateral hamstring and buttock pain. She reports increased pain with prolonged sitting and after activity, and no specific mechanism of injury.

The etiology is hypothesized to be overuse. The patient reports pain as a two to three out of ten on the VAS at rest and seven to eight out of ten at worst during sitting. The patient is athletic, running an hour per day, cycling five or more hours per week, and exercising on average six to seven days per week. Manual muscle testing reveals strong and painful resisted hamstring strength both concentrically and eccentrically. Additionally, the right and left gluteus medius and maximus were found to be weak, ranging from three minus to three plus out of five. Upon palpation there is moderate fibrosis in the bilateral proximal hamstrings, medial plantarflexors, adductors, and iliotibial bands. A postural assessment reveals significant pronation at the subtalar joints bilaterally with the right greater than left, for which orthotics have been previously prescribed and are reportedly only worn during running. MRI shows significant bilateral hamstring tendinopathy with worse dysfunction and partial avulsion of the ischial tuberosity on the right. In addition to being employed as a 10 college professor, she is also a licensed physical therapist and has devised her own exercise program based on her extensive knowledge in the area of therapeutic exercise. Her self- designed program includes self-applied myofascial release as well as strengthening exercises of the core and gluteal muscles performed multiple times per week.

Clinical question

The clinical question the authors wanted to answer about this patient is “In adults with chronic hamstring tendinopathy, is eccentric training compared with other therapeutic options more effective in improving treatment outcomes?”

METHOD

Search description

The authors individually searched databases and found articles that supported the previously presented clinical question in MEDLINE, SPORTDiscus, PubMed, and CINAHL.

Titles of articles were primarily examined to see if they included EE and tendinopathy in the lower extremity. The abstracts of the relevant titles were then examined for the outcome measures VAS, VISA, and FAOS. The full-text articles that had at least one of the previously stated outcome measures were then obtained. The authors collectively compared articles and discarded any duplicates. The distribution of articles among the databases can be seen in

Table 1.

Keywords used in search

The primary keywords the authors used in the search included “chronic tendinopathy,” “tendin*,” “chronic tend*,” “Achilles tendinopathy improvement,” “patellar tendinosis,” “eccentric exercise,” and “systematic review”. The use of “tendin*” allowed the authors to gather results that included both tendinopathy and tendinosis, for the language has 11 changed in recent years and the authors did not want to exclude older articles for this reason.

The search terms that yielded the largest quantity of articles within a database were used, therefore different search strings were required for individual databases.

Final search strings

The authors used a total of seven search strings that yielded the articles chosen for review. These search strings span four databases; this information can be found in Table 1.

Article appraisal process

The authors individually searched for peer-reviewed, evidence-based articles pertaining to the clinical question. Articles were compared to determine those appropriate for inclusion. The articles were divided so that each article was read, appraised, and annotated by at least two authors. Authors then met to combine thoughts and submit a final appraisal and annotation for each of the eight articles. Consensus for final inclusion of each study was reached by discussion among the three authors.

RESULTS

Search results

The results of the search can be found in Table 2. Eight articles were chosen for this review and of those four were systematic reviews and four were randomized controlled trials

(RCTs).

Selection of articles for review

The articles were selected for review if the specified inclusion criteria were met and no exclusion criteria were present. The inclusion criteria consisted of participants with chronic tendinopathy of the lower extremity (Achilles, patellar, or hamstring tendinopathy), used EE, and used a standard outcome measure of VAS, VISA, or FAOS. Fredburg and 12

Stengaard-Pedersen24 reported that there is no defined time period to differentiate acute versus chronic symptoms, however they suggested that participants experiencing symptoms greater than six weeks were to be considered to have chronic tendinopathy. Therefore, six weeks was used as the standard in this research manuscript.24 Articles were excluded if they were written in a language other than English or were a commentary. These criteria were derived from the available literature, the generalizability to the patient case, and coincided with what other authors of existing research chose as inclusion and exclusion criteria in their studies. The following eight articles were used to make the clinical decision.

Jonsson P, Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: A prospective randomized study. Br J Sports Med. 2005;39(11):847-850.

This prospective randomized study looked at the comparison between painful eccentric and concentric quadriceps training on a decline board in athletes with patellar tendinosis. A total of 19 tendons, from 15 patients, were analyzed in this study. All of the participants came from the Sports Medicine Unit in Umea, Sweden and were diagnosed by the same orthopedic surgeon and instructed by the same physical therapist throughout the intervention. The intervention consisted of three sets of 15 repetitions performed twice daily for 12 weeks. The outcome measures were patient-reported pain measured on the VAS and VISA scales as well as patient satisfaction. Patients were told that the exercises were going to be painful and when it was no longer painful on the patellar tendon, the load was to be increased. The physical therapist followed up at 6 weeks and if the patients did not have severe pain, they were told to start sport specific training and gradually return to their pre- injury sporting activity. For the eccentric training group, the VAS score decreased and the VISA score increased, both reaching statistical significance. For the concentric training group, neither the VAS nor the VISA improved significantly, and none of the patients were satisfied with the treatment. Seven out of the eight patients in the eccentric group were satisfied with treatment, showing positive results.

Unfortunately, attrition among the concentric group left only five tendons to analyze and the sample size of the study was initially small. Although the sample size did not reach the projected number needed to treat, this article concluded that eccentric quadriceps training significantly reduces patellar tendon pain for a short duration; in this study, the duration was 32 months. It is imperative that more studies are performed on a large number of subjects as well as a long-term follow up period. This study may be of good use for the patient with hamstring tendinopathy because it shows that EE has a beneficial outcomes on both pain and satisfaction measures, however the time that outcome is sustained after 32 months is unknown. 13

Kingma JJ, Knikker R, Wittink HM, Takken T. Eccentric overload training in patients with chronic achilles tendinopathy: A systematic review. Br J Sports Med. 2007;41(6):e3.

This systematic review looked at the effectiveness of eccentric overload training in patients diagnosed with chronic Achilles tendinopathy. Articles were analyzed if they met the following five inclusion criteria: the study population consisted of male and female patients diagnosed with chronic Achilles tendinopathy, was an RCT or controlled trial, the intervention was within the scope of physical therapy practice and incorporated eccentric overload training, used at least one patient reported outcome such as pain, and the article was full text, peer-reviewed and was written in either English or Dutch. Nine articles met the inclusion criteria, three RCTs and six controlled trials. The intervention time frames of the included articles ranged from six to 12 weeks. The methodological quality of the articles was evaluated by the Delphi list and the classification system of the Dutch Institute for Healthcare Improvement. All but one of the articles had low methodological quality. The outcome measure was pain evaluated on either the VAS, FAOS, or an ordinal scale. A mean of a 60% decrease in pain was found in the eccentric group, and the control group saw a decrease in pain by 33%; there was no significant difference between groups.

Due to the insufficient methodological quality of all but one of the articles, a conclusion could not be drawn. Therefore, this may create bias and produce an overestimate of beneficial treatment effect. Specific eccentric protocols were not discussed, making it difficult to apply the intervention to a patient. Blinding was not achieved in the included studies allowing diffusion of treatment and decreased validity of the data. Demographic information, attrition rates, and collected data were not recorded in this article. Although decreases in pain were seen in both groups from baseline to the end of treatment, further research is necessary to draw conclusions regarding specific patient treatment.

Petersen W, Welp R, Rosenbaum D. Chronic Achilles tendinopathy: A prospective randomized study comparing the therapeutic effect of eccentric training, the airheel brace, and a combination of both. Am J Sports Med. 2007;35(10):1659-1667.

The purpose of this prospective randomized trial was to evaluate the effectiveness of EE, AirHeel brace, or a combination of both for treatment of chronic Achilles tendinopathy. A total of 100 patients comprised the sample population with most of these patients being recreational athletes. After randomization by number selection, the three groups had similar demographic data. A power analysis revealed a sample of 30 individuals per group would be necessary to detect a difference between groups, which was reached in the eccentric training and AirHeel brace group. The combination group only had 23 participants, which was one limitation of the study. The outcome measures were VAS score, American Orthopedic Foot and Ankle Society (AOFAS) score, and Short Form-36 (SF-36) score. The protocol for the eccentric group was two different exercises each performed for three sets of 15 repetitions, three times a day, seven days a week for 12 weeks. When pain became minor, a load was added to increase the level of eccentric loading on the calf muscles. All of the outcome 14 measures improved significantly for each of the three groups from baseline to the last follow up at 12 weeks, but there was no significant difference between groups.

Attrition rates were not detrimental to the study. Only 14 subjects dropped out prior to the twelfth week of the study and 12 patients dropped out prior to the one year follow up. Due to the lack of blinding, diffusion of treatment may have occurred. Additionally, the authors did not state if the participants were allowed to receive treatment or continued activity participation outside of the intervention. The lack of a control group inhibited the ability to see the improvements that may have been due just to chance or the passage of time. Even with significant results and a sound methodology and study design, a definite result is still unclear as to which intervention is more effective, EE or AirHeel brace.

Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo achillis: A randomized controlled trial. Am J Sports Med. 2007;35(3):374-383.

This RCT compared the effectiveness of three management strategies for Achilles tendinopathy: EE into mild or moderate pain, repetitive low-energy SWT, and a wait-and-see method. Seventy-five patients with chronic tendinopathy with a diagnosis of greater than six months were used in the study. Participants were excluded if they received an anesthesia or corticosteroid injection four weeks prior, bilateral tendinopathy, symptoms beginning less than 6 months prior, or had other conditions that could contribute to posterior ankle pain. Patients with congenital or acquired deformities of the ankle or knee, surgery to the ankle or tendon, prior tendon tear or previous dislocations or fractures in the region within a year were also excluded. All patients had previously been treated with a local anaesthetic or corticosteroid injection, a trial of anti-inflammatory medications, use orthotics and/or a heel lift, and physical therapy. The outcome measure used was the VISA for pain. Results showed significant positive results in the EE and SWT groups compared to the wait-and-see group, with no differences between the EE and SWT groups. Results were based on an intention-to- treat basis. It is important to note that this study cited another study looking at the effectiveness of EE on tendinopathy which showed positive results for EE after a 12-week exercise program and satisfactory outcomes in 90 out of the 101 cases. Mean pain score on the VAS in this study decreased significantly from 6.7 to 1.0.

There are several threats to the internal validity of this RCT. Unbiased assessment of the outcomes was not implemented. A low number of participants was used in the study and should be increased in future studies. The authors calculated that to reach a power of 80%, 140 patients in total would need to be used, and they doubted that this number is feasible due to logistical and practical reasons. This study is applicable to a patient with hamstring tendinopathy because of the similarities that may be perceived by a therapist across different types of lower extremity tendinopathy, regardless of the joint. Therefore this study showing good results with EE for Achilles tendinopathy may be translated to a patient with hamstring tendinopathy and lead to possible similar positive results.

Van Usen C, Pumberger B. Effectiveness of eccentric exercises in the management of chronic Achilles tendinosis. Internet J Allied Health Sci Pract. 2007;5(2):1-14. 15

This systematic review reports the effectiveness of EE compared with other types of interventions for chronic Achilles tendinosis. After review of seven databases, 25 studies were included that reflected a variety of designs. Eight RCTs, six randomized non-control trials, and 11 other experimental designs were used. The studies were divided into four groups based on intervention type; EE, surgery, medication, and electrotherapy. The most frequently used objective measure was pain intensity using a VAS scale, however strength, function, and patient satisfaction were also used. Studies were categorized as ‘good,’ ‘fair,’ or ‘equivocal,’ based on their results. If both the primary and secondary outcome measures showed significant results, the study was classified as ‘good.’ If only primary outcome measures showed significant results, or no significant results were found, the study was deemed ‘fair’ or ‘equivocal’ respectively. The EE group followed the Alfredson protocol of three sets of 15 repetitions, twice daily for 12 weeks which may be completed at home. This systematic review shows equally beneficial results for EE and medication for the treatment of Achilles tendinosis, however the authors rank EE to be a better treatment intervention due to its ease for accessibility, simple to perform, patient choice, clinical application performance at home, and low cost in comparison to pharmacological treatment.

There are several threats to the usefulness of this review. Many of the studies were completed in Scandinavia (Sweden, Norway, Finland and Denmark), while others were completed in the UK, Australia and Belgium, so generalizability in the US could be low. However the authors argue that geographical bias may not be important for patient outcomes as the need for patient compliance is of more importance. This systematic review is beneficial in the patient case because two treatment options with positive results have been shown here. The values of the patient may lead to a desire to attempt exercise as a first option. However, this review links positive results to pharmacological treatments as well. An alternate treatment other than exercise could be useful if it does not produce satisfactory results to the patient.

Wasielewski NJ, Kotsko KM. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review. J Athl Train. 2007;42(3):409-421.

This systematic review aimed to critically review evidence for the effectiveness of EE to treat lower extremity tendinosis (patellar and Achilles). The authors selected 11 studies that had an average methodologic score of 5.3 out of 10 based on PEDro criteria. EE was compared to no treatment, CE, stretching, night splinting and physical agents. Outcome measures included VAS, VISA, and FAOS. Studies comparing EE to CE mostly found that EE groups showed slightly less pain at the end of the treatment session. Both EE groups and stretching groups had modest but significant decreases in pain when comparing these two interventions. When comparing EE to US, there were significant improvements in pain for the EE group compared to the US group. In the end, authors acknowledge that there is evidence to support the use of EE for the treatment of tendinosis, however more evidence is needed to determine if EE is superior in comparison to other treatment methods. An important consideration to take from this review is that when a study did not allow the 16 participants to participate in sports activity, EE was found to have a greater effect on pain reduction than if they were allowed to continue their normal activities.

There may be some threats to the usefulness of this systematic review. None of the studies included blinding, concealed allocation, or intention-to-treat analysis. Also, low sample sizes were used, and other outcome measures that have higher reliability and validity could have been used. These studies showed that EE may be superior when compared to other treatments; however further studies need to be conducted to determine the effect of EE compared to other modes of treatment options for treatment of tendinosis.

Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med. 2007;41(4):188-189.

This systematic review was completed to determine the effectiveness of EE in the treatment of common tendinopathies. Only randomized control trials were used, and 11 were selected from a variety of databases that met the inclusion criteria. These 11 studies looked at patients clinically diagnosed with tendinopathies of the Achilles tendon, patellar tendon, and the common wrist extensor tendon. Each article was assessed using the PEDro scale and the van Tulder scale; high quality articles were rated for the PEDro scale as meeting six of the 10 criteria and the van Tulder scale as reaching six of the 11 criteria. The clinical outcome measures of interest in this review were pain, function and patient satisfaction/return to activity. Two of the 11 studies showed statistically significant results using a validated outcome measure of pain, however both of these studies were of low quality. The results of these two studies show that EE produced a greater decrease in pain than CE at the 12-week measure. Similar results were found in the outcome measure of patient satisfaction with three studies showing statistical significance, however those studies were of low quality or used outcome measures that were not validated. It is important to note that EE also led to more significant positive results than CE for function and patient satisfaction.

There are several threats to the value of this review. Due to lack of high-quality studies with significant results, no strong conclusions can be made of the effectiveness of EE for tendinopathy. Lack of homogeneity between the studies, low sample numbers, large confidence intervals, lack of blinding, and a lack of adequate follow-up all lead to further inconclusive results of this systematic review. However, overall positive results from these studies suggest the use of EE for the treatment of tendinopathy. Further adequately powered studies with long-term follow-ups and appropriate randomization procedures are needed to continue research on this topic. The results of this study can be applied to patients with hamstring tendinopathy because of similar tendon histopathologic findings.

Yu JH, Park DS, Lee GC. Effect of eccentric strengthening on pain, muscle strength, endurance, and functional fitness factors in male patients with Achilles tendinopathy. Am J Phys Med Rehabil. 2013;92(1):68-76.

This RCT was designed to compare the effects of EE to CE in males with chronic Achilles tendinopathy. The dependent variables measured were pain, muscle strength, muscle endurance, and functional fitness including balance, dexterity and agility. The 32 participants 17 were randomly assigned to either an experimental group performing EE or a control group performing CE. The subjects and researchers were blinded to the group assignments. Each group participated in their respective exercise programs for 50 minutes, three times a week for eight weeks. Measures were taken at baseline and after the eight week intervention. Both treatment groups made gains regarding the outcomes of interest and the EE group demonstrated significant improvements in pain, ankle strength, endurance, total balance index and agility after the eight week intervention. Additionally, the EE group demonstrated greater improvements in pain, ankle plantarflexion endurance, ankle dorsiflexion endurance, total balance index, and agility compared to the CE group.

The validity of this study is threatened by a variety of factors. The sample size was small, only males were included, and took place in Seoul, Korea, making the results difficult to generalize to a female patient within the United States. Although there were statistically significant results, additional studies should be conducted that compare EE to other therapeutic interventions with a higher level of methodology. A long-term follow up would also be beneficial to determine the possible lasting effects of EE on chronic tendinopathy.

DISCUSSION AND CONCLUSION

Clinical decision

A variety of treatment options have been presented in the research related to chronic tendinopathy producing a multitude of outcomes. Using the information gathered from the cited research for evidence-based review, the authors were able to determine that EE is effective in treating chronic lower extremity tendinopathy.3,11-17 Even with no studies using

EE specifically for hamstring tendinopathy, it appears that this treatment is still applicable to this diagnosis. It has been suggested that the pathophysiologies of patellar and Achilles tendinopathies are similar to hamstring tendinopathy and therefore it is plausible that this treatment would produce similar results in lower extremity tendons since they perform similar weight-bearing functions.10

In a systematic review conducted by Van Usen et al.,13 25 studies were compared which investigated EE, surgery, medication or electrotherapy for the treatment of chronic

Achilles tendinopathy. EE and medications, such as topical glyceryl trinitrate, both demonstrated positive results. However, EE is believed to be a more prudent choice because 18 of its ability to be conveniently performed at home without extensive equipment or training, as well as its application to functionality with closed chain performances.13 Additionally, the only side effects of EE discussed in the literature is muscle soreness8, where as medications may produce adverse systemic reactions.

Several articles used the Alfredson protocol which allows tolerable pain during the exercises as a measure in order to gradually increase resistance.26 The parameters for this protocol consist of three sets of 15 repetitions performed twice daily for 12 weeks.26 This protocol was derived from Håkan Alfredson’s clinical experience, who is the original author of the protocol, rather than data collection or previous research.16 Studies, such as one by

Fahlstrom et al.25, have shown this 12-week EE protocol at a high pain threshold may be effective in the treatment of tendinopathies.25,27,28 Fahlstrom et al.25 demonstrated an 89% patient satisfaction rate after use of the Alfredson protocol and these patients’ pain level during activity was significantly decreased from an average of 6.7 to 1.0 on the VAS.25 In a study conducted by Kingma et al.14, the mean reduction of pain in the eccentric overload training group was 60%, while the control group mean was only 33%.14 Pain was reduced by

60% in the EE group of the study by Petersen et al.11 according to VAS scores from baseline to 12 weeks and remained 30% lower than baseline levels at the one-year follow up when performing activities of daily living.11 Significant improvements in pain during walking and sports activities were also found in the EE group.11 There was also a 71% decrease in pain while walking in the EE group at 12 weeks and a continued 45% decrease at the one-year follow up.11 Those in the EE group saw a 51% reduction in pain at the one-year follow up when performing sports activities that typically provoke the highest pain level.11 Niesen-

Vertommen et al.29 reported pain measured over the average of four evaluation times of 19 before treatment and at four, eight, and 12 weeks of an EE intervention program which produced results of significant pain reduction. Norregaard et al.30 found that both stretching and EE generated significant decreases in pain over time measured at six, nine, 12, and 52 weeks, with no significant differences found between EE and stretching. It is because of this repeated result of decreased pain across multiple sources that led the authors of this manuscript to recommend painful EE for the treatment of hamstring tendinopathy as a primary or adjunctive therapy.

Tenotomy surgery demonstrates beneficial results, however, it is difficult to determine if these results are due to the surgical intervention itself, or the rest period required after surgery.13 However, even if surgical interventions do provide significant results for the treatment of tendinopathy, the rehabilitation time, cost, and inconvenience of this method should not designate this as a primary treatment option for tendinopathy.13

A possible adjunctive therapy to EE includes SWT, with a study by Rompe et al.15 showing significant decreased pain in both the EE only and SWT only group. SWT is a treatment that utilizes a device that generates energy through pressurized air to apply shock waves at a frequency of eight pulses per second.15 Each treatment session consisted of a total of 2,000 pulses in the area of maximal tenderness.15 Rompe et al.15 describe that this therapy may help to progress patients who have plateaued with EE treatments and to further treatment progression. Although the primary effects of this therapeutic modality is not well understood, it is thought to stimulate the healing process in soft tissues, enhance angiogenesis, as well as block pain receptors.15

Isokinetic EE strengthening, using a Cybex Norm dynamometer, is another adjunctive therapy for tendinopathy and has been studied by Croisier et al.10 Isokinetic training allows 20 for controlled resistance throughout the range, gradual progression, and fixed speed and joint motion.10 This isokinetic strengthening is similar to activities of functional contraction and may be safer for injured tendons due to the increased control of movements.10 This shows positive results especially with tendons that have been rebellious to other forms of treatment.10 Following 20-30 sessions of eccentric isokinetic training, a significant reduction in pain was noted, as well as 74% of patients reporting complete relief from symptoms when returning to pre-injury activities.10 However, isokinetic movements lack the functionality of closed chain exercises that utilize both the targeted and stabilizing muscles. The speed and movement are both controlled in isokinetic movements, and therefore the practice of coordination and motor control input is excluded from this treatment option, which is known to be essential for gait as well as sports related activity.13 In addition, the study by Croisier et al.10 fails to show results in comparison to a control group, thus the power of this study to support the clinical question is negated. Further research on the application of isokinetic EE for the treatment of tendinopathy is needed.

When the patient is performing exercises independently in a home exercise program, they have significant influence over their treatment and thus their recovery. This ownership may have potential positive outcomes with an athletic patient such as this patient case.

Additionally, this possession of a patient’s recovery process may empower them, provide motivation to engage in therapy, and increase overall participation, which is an invaluable enhancement of any therapeutic program.13 Although EE is an inexpensive and useful choice, it is somewhat technique-dependent and the psychological ownership patients feel may help with motivation to achieve proper technique.15 21

EE is an easy, feasible, and cost-effective treatment strategy.13 It does not require a great deal of equipment and is convenient to perform in nearly every setting.13 Furthermore, the lack of a serious adverse side effect also contributed to the decision to use EE with this patient. The only side effect discussed was the risk of delayed onset muscle soreness

(DOMS).3,8,10,12,13,15 DOMS was present during the first and second week after the onset of the exercise program.3,11,12 To help remediate DOMS, Rompe et al.15 described the use of a gradual increase in the number of sets the participant performed. It has also been suggested that slow progression of the number of repetitions in the first week of exercise may help to decrease the presence of DOMS.8 Therefore, the patient may begin with a low weight and number of repetitions, then gradually increase to a therapeutic level within the first week.

This treatment also corresponds with the patient’s values and preferences. The patient of this particular case exercises frequently and may easily incorporate hamstring EE into her daily exercise routine.

The most common protocol used for EE training for a therapeutic program for tendinopathy has been established by Alfredson et al.,16 which consists of three sets of 15 repetitions performed twice a day for six to 12 weeks.3,8,12,14,16,25-27 This protocol has been used in multiple studies that have shown positive results for EE over other therapeutic programs.8,12,31 Factors that varied across studies include the velocity of the movements, amount of pain allowed during treatment, method used to return to the start position, other conjunctive activity allowed during the therapy program, as well as the method used to progress the exercise.3 While the amount of activity allowed outside of the studies varied, overall, there was a tendency for studies with more positive results to have allowed less extraneous activity. In general, outside activity such as hill workouts, variable training 22 surfaces, and other environmental conditions seem to be a major confounding factor in many studies looking at the effectiveness of EE for the treatment of tendinopathies, and should be addressed in future research.3

One exercise that produces eccentric activation of the hamstring muscles is the

Nordic hamstring EE.4 The Nordic hamstring exercise is described by Anastasi and

Hamzeh.32 This exercise is performed with the patient starting in tall kneeling with hips in neutral and upright trunk. Another individual is required to hold the patient’s lower legs in contact with the ground in order to recruit the use of the hamstrings. The patient will then be asked to slowly lower the upper body and thighs towards the ground while maintaining neutral trunk and hip alignment in a slow, controlled manner, ideally reaching a position parallel to the floor. At the point in which the patient is no longer able to resist the forward movement, hands may be placed on the ground to prevent a fall. The patient will then use upper extremities to push back to the starting position to prevent concentric activation of the hamstrings.32 Therefore, the primary focus of this exercise is on eccentric hamstring activation only. It is important to note that this exercise promotes the use of bilateral hamstrings which is indicated in this patient case because of the presence of bilateral tendinopathy. Another exercise that may be used for a patient with hamstring tendinopathy is backwards walking which could be progressed by utilizing inclines or a partner for increased resistance.4 An additional option for an eccentric hamstring exercise is the “good morning” exercise.4 This requires the patient to stand in a split stance and flex the trunk forward at the hips followed by return to start position.4 This exercise can be progressed by the patient holding a weighted object at chest level.4 A fourth option for an eccentric hamstring exercise is supine ball curl outs using a physioball.18 Each of these exercises should be performed for 23 three sets of 15 repetitions two times daily.3,8,11,12,15,26 The patient should be reassessed after four, eight, and 12 weeks in order to determine treatment effectiveness towards decreasing pain.29

Compiling a final recommendation regarding the use of EE over other therapeutic options for hamstring tendinopathy is difficult given the limited available literature.

Numerous reasons such as unknown etiology, as well as the physiology of EE towards improving tendinopathies further limit our understanding of treatment options. The application of the compiled research to the patient with hamstring tendinopathy is further complicated because this pathology has yet to be studied with the use of EE. However, some studies have shown definitive benefits of EE over other therapies for the treatment of similar tendinopathies, such as being more effective than splinting8, friction massage, physical agents, and CE.12,31 Cumulative research has not found universal significant positive results with EE over other therapeutic interventions nor a definitive exercise protocol.3,13 General trends show positive results with EE for the treatment of tendinopathies.16 It can be acknowledged that tendinopathies are multi-factorial in origin, thus therapeutic treatment may also need to be multi-factorial.8

Limitations

Most tendon injuries occur in males, with specifically 60% of overuse running injuries occurring in men, which directs the focus of research studies towards this gender.6

This research bias leaves the female gender less studied, and makes the research outcomes potentially less applicable to this particular patient. According to van der Plas33 much of the research, including several articles3,12,14,16 used in this research manuscript regarding EE for tendinopathy is performed in the Scandinavian population. Most studies incorporating this 24 population have demonstrated significant results, however differing results have been found in non-Scandinavian populations. Therefore, this could indicate that there may be a genetic component associated with the positive treatment outcomes found.33 These population differences could limit the generalizability to the patient case because there is no history of

Scandinavian heritage.

Another limitation of the study of tendinopathy is that the comparison of an experimental group to a control group is not frequently done as it is unethical to withhold treatment.3,16 The low numbers of participants in studies regarding tendinopathies also limit the power of research in this topic.15 Concealed allocation, intention-to-treat analyses, as well as blinding to the therapists, researches, and patients have also been lacking in research of tendinopathies;3,13 however, it must also be acknowledged that because of ethical guidelines, intervention studies of these kinds will never reach a perfect level of methodology.3 It is of interest to note that there is a trend among studies that increased positive results corresponds with low methodology due to the previously mentioned factors.8

Much of the research did not investigate the long-term outcome of the interventions.3,14,15,16 Researchers conducted final follow-up measurements between zero to

32 months post-intervention.3,8,11-16 The methodological quality of the studies was often jeopardized because of the lack of blinding and/or small sample sizes.3,11-17 Furthermore, it is difficult to determine the best protocol for EE because the protocols varied greatly among the studies.3,13 Because of these limitations, generalizability of results to individuals with chronic tendinopathy is decreased. Bias of the results can also be due to the focus of much of the research derived from Alfredson, a Scandinavian author who is a leading researcher in the study of EE.13,16 25

The possibility of EE causing aggravation and potentially negative effects on a dysfunctional tendon must be addressed. If the tensile forces of EE or any other type of exercise cause maladaptive changes in tendon structure or harmful results, the therapeutic methods should be reevaluated as well as the diagnosis. These maladaptive results should be avoided by continually evaluating the treatment to maintain a safe threshold between safe and unsafe EE, however this threshold has not been defined.3 Indicators for maladaptive changes in the tendon may include increased pain, changes in gait, and abnormal posturing.3

Most athletic patients who have presented with hamstring tendinopathy have been active in sprinting, hurdling, or jumping (50%), and soccer (22%).6 Although the patient from the patient case is a long-distance runner and cyclist, the actions of forced hip flexion and knee extension is shared with all of the aforementioned activities. These similarities between the participants included in the research and the patient case should be acknowledged. The shared mechanism of injury between these different activities may lead to congruent treatment options.

In conclusion, more research needs to be completed in the specific investigation of hamstring tendinopathy treatment, specifically in the athletic population. A specific EE treatment protocol should be solidified through further high quality research. Patients may respond differently to the application of EE, and this intervention should be used in conjunction with other therapeutic treatment to address muscle imbalances and postural abnormalities.

Acknowledgements

We would like to acknowledge Professor Amy Veres for her efforts and guidance through the primary research process as well as Doctor Dawn Roberts for her advising in the 26 final stages of this manuscript. We would like to thank Doctor Jacqueline Shakar for providing the patient case. We are indebted to the patient who provided the inspiration for this research effort and hope that therapy has helped her towards recovery. We also would like to thank the Doctorate of Physical Therapy class of 2013 for their unyielding support and consistent understanding of this whole process.

References

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3. Wasielewski NJ, Kotsko KM. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review. J Athl Train. 2007;42(3):409-421.

4. Lorenz D, Reiman M. Clinical commentary: The role and implementation of eccentric training in athletic rehabilitation: Tendinopathy, hamstring strains, and ACL reconstruction. Int J Sports Phys Ther. 2011;6(1):27-44.

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9. Brody LT, Hall CM. Therapeutic Exercise: Moving Toward Function, 3rd ed. Philadelphia, PA: Wolters Kluwer Lippencott Williams & Wilkins, 2011.

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11. Petersen W, Welp R, Rosenbaum D. Chronic Achilles tendinopathy: A prospective randomized study comparing the therapeutic effect of eccentric training, the AirHeel brace, and a combination of both. Am J Sports Med. 2007;35(10):1659-1667.

12. Jonsson P, Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: A prospective randomized study. Br J Sports Med. 2005;39(11):847-850.

13. Van Usen C, Pumberger B. Effectiveness of eccentric exercises in the management of chronic Achilles tendinosis. Internet J Allied Health Sci Pract. 2007;5(2):1-14.

14. Kingma JJ, Knikker R, Wittink HM, Takken T. Eccentric overload training in patients with chronic Achilles tendinopathy: A systematic review. Br J Sports Med. 2007;41(6):e3.

15. Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo achillis: A randomized controlled trial. Am J Sports Med. 2007;35(3):374-383.

16. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med. 2007;41(4):188-189.

17. Yu JH, Park DS, Lee GC. Effect of eccentric strengthening on pain, muscle strength, endurance, and functional fitness factors in male patients with Achilles tendinopathy. Am J Phys Med Rehabil. 2013;92(1):68-76.

18. Fredericson M, Moore W, Guillet M, Beaulieu C. High hamstring tendinopathy in runners: Meeting the challenges of diagnosis, treatment, and rehabilitation. Phys Sportsmed. 2005;33(5):32-43.

19. Brughelli M, Nosaka K, Cronin J. Application of eccentric exercise on an Australian rules football player with recurrent hamstring injuries. Phys Ther Sport. 2009;10(2):75-80.

20. Peers KHE, Lysens RJJ. Patellar tendinopathy in athletes: Current diagnostic and therapeutic recommendations. Sports Med. 2005;35(1):71-87.

21. Jeffery R, Cronin J, Bressel E. Eccentric strengthening: Clinical applications to Achilles tendinopathy. New Zealand Journal of Sports Medicine. 2005;33:22-30.

22. Curwin S, Stanish W. Tendinitis: Its etiology and treatment. Lexington, MA: Colamore Press; 1984.

23. Merskey H, Bogduk N. Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle: IASP Press, 1994:210-211.

24. Fredburg U, Stengaard-Pedersen K. Chronic tendinopathy tissue pathology, pain mechanism, and etiology with a special focus on inflammation. Scand J Med Sci Sports. 2008;18(1):3-15.

25. Fahlstrom M, Jonsson P, Lorentzon R, Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc. 2003;11(5):327-333.

26. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360-366.

27. Alfredson H, Lorentzon R. Intratendinous glutamate levels and eccentric training in chronic Achilles tendinosis: A prospective study using microdialysis technique. Knee Surg Sports Traumatol Arthrosc. 2003;11(3):196-199.

28. Purdam CR, Johnsson P, Alfredson H, Lorentzon R, Cook JL, Khan KM. A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. Br J Sports Med. 2004;38(4):395-397.

29. Niesen-Vertommen SL, Taunton JE, Clement DB, Mosher RE. The effect of eccentric versus concentric exercise in the management of Achilles tendonitis. Clin J Sport Med. 1992;2(2):109-113.

30. Norregaard F, Larsen CC, Bieler T, Langberg H. Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports. 2007;17(2):133-138.

31. Stasinopoulos D, Stasinopoulos I. Comparison of effects of exercise programme, pulsed ultrasound and transverse friction in the treatment of chronic patellar tendinopathy. Clin Rehabil. 2004;18(4):347-352.

32. Anastasi SM, Hamzeh MA. Does the eccentric nordic hamstring exercise have an effect on isokinetic muscle strength imbalance and dynamic jumping performance in female rugby union players? Isokinet Exerc Sci. 2011;19(4):251-260.

33. van der Plas A, de Jonge S, de Vos RJ, van der Heide HJL, Verhaar JAN, Weir A, Tol JL. A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012;46(3):214-218.

Table 1. Databases, final search strings, and articles yielded that were included for reviewa Date 10/11 2/12 5/12 8/12 11/12 2/13 4/13 Authors’ Last Number Number Number Number Number Number Number Database Search String Name of Hits of Hits of Hits of Hits of Hits of Hits of Hits Peterson et al. (2007) PubMed Rompe et al. Chronic (2007) Tendinopathy and 55 56 56 56 62 63 63 Woodley et al. eccentric exercise (2007) Kingma et al. (2007) systematic[sb] AND Wasielewski and PubMed (eccentric exercise 14 14 15 15 18 22 22 Kotsko (2007) and tendin*) Chronic Tend* Medline AND eccentric None 46 62 62 66 66 71 71 exercise Achilles tendinopathy Medline Yu et al. (2013) 8 8 8 8 8 9 9 improvement AND eccentric exercise Chronic SPORTDiscus Tendinopathy AND None 42 42 42 44 44 44 44 eccentric exercise Chronic tend* AND Van Usen and CINAHL 53 53 55 58 58 62 62 eccentric exercise Pumberger (2007) Patellar Tendinosis Jonsson and CINAHL AND eccentric 4 4 4 4 4 4 4 Alfredson (2005) exercise a Authors’ last names are used to identify each article.

Table 2. The articles included for review and their methodological design Article by Authors Methodological Design Jonsson and Alfredson (2005) RCTa

Kingma et al. (2007) Systematic Review

Petersen et al. (2007) RCT

Rompe et al. (2007) RCT

Van Usen and Pumberger (2007) Systematic Review

Wasielewski and Kotsko (2007) Systematic Review

Woodley et al. (2007) Systematic Review

Yu et al. (2013) RCT a Randomized Controlled Trial.

APPENDIX

This prospective randomized study looked at the comparison between painful eccentric and concentric quadriceps training on a decline board in athletes with patellar tendinosis. A total of 19 tendons, from 15 patients, were analyzed in this study. All of the participants came from the Sports Medicine Unit in Umea, Sweden and were diagnosed by the same orthopedic surgeon and instructed by the same physical therapist throughout the intervention. The intervention consisted of three sets of 15 repetitions performed twice daily for 12 weeks. The outcome measures were patient-reported pain measured on the VAS and VISA scales as well as patient satisfaction. Patients were told that the exercises were going to be painful and when it was no longer painful on the patellar tendon, the load was to be increased. The physical therapist followed up at 6 weeks and if the patients did not have severe pain, they were told to start sport specific training and gradually return to their pre-injury sporting activity. For the eccentric training group, the VAS score decreased and the VISA score increased, both reaching statistical significance. For the concentric training group, neither the VAS nor the VISA improved significantly, and none of the patients were satisfied with the treatment. Seven out of the eight patients in the eccentric group were satisfied with treatment, showing positive results.

Jonsson P, Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper’s knee: A prospective randomized study. Br J Sports Med. 2005;39(11):847-850.

P (patient/population/clinical problem): Athletes with proximal patellar tendon pain I (intervention/indicator/index test): Eccentric squat on 25 degree decline board C (comparator): Concentric squat on 25 degree decline board O (outcome): Pain, VISA, and patient satisfaction

Did the investigators randomly assign (or allocate) subjects to Yes No groups? The authors stated that the patients were randomly assigned to one of the two groups, but they did not provide any details on the randomization. Was each subject’s group assignment concealed from the people Yes No enrolling individuals in the study? The authors did not discuss any type of blinding being performed. Did the groups have similar sociodemographic, clinical, and Yes No prognostic characteristics at the start of the study? The groups were found to have similar baseline characteristics. No statistical difference was found between the groups on the basis of age, weight, height, or duration of symptoms. Were the subjects, clinicians, and outcome assessors masked (or Yes No blinded) to the subjects’ group assignment? One physical therapist gave every participant in the study the instructions on how to perform the exercise. Therefore, the therapist was not blinded. It was not stated whether the patients where blinded to treatment allocation. Did the investigators manage all of the groups in the same way Yes No except for the experimental intervention(s)? Yes, each group was given the same type of instructions and same programme of 3 sets of 15 repetitions, performed twice a day, everyday, for 12 weeks. Both groups were given verbal and hand written instructions. Additionally, both groups were instructed to exercise with pain and that if the pain was no longer present they were to add weight to a back pack. Did subject attrition (e.g. withdrawal, loss of follow up) occur over Yes No the course of the study? Yes, three patients in the concentric treatment group were not able to finish the 12 week program due to severe tendon pain. Were subjects analyzed in the groups to which they were assigned? Yes No Did the investigators collect follow-up data on all subjects over a Yes No time frame long enough for the outcomes of interest to occur? The aim of the study was to see if there was a difference between the two groups over a 12 week time frame and at the end of the

study they were able to reach a conclusion. However, 12 weeks may not have been a long enough time prior to follow up in the study to produce a result applicable to a patient with chronic tendinopathy. Did the investigators repeat the study with a new set of subjects? Yes No They did follow a pilot study that was previously conducted on a different set of patients. However, it was not performed on a new set of subjects. Do you have enough confidence in the research validity Yes No of this paper to consider using this evidence with your Undecided patient/client? There were a few limitations to the study which creates the need to take the results with caution. The drop out rate was high, it was a small sample size, and they did not have a long-term follow up. However, no adverse effects of the EE were found and almost all of the patients were satisfied with the treatment.

What results do the authors report related to your clinical question?

Tests of differences: Wilcoxon signed ranks test: tested difference within each group from baseline to 12 week follow up using the VAS scores Mann-Whitney U: tested differences between concentric and eccentric group using the VAS scores from baseline to 12 week follow up

Effect size: An effect size of 20 patients per group was calculated in order to have an 80% chance at detecting significance at the 0.05 alpha level.

Absolute benefit increases: None reported.

Relative benefit increases: None reported.

Absolute risk reductions: None reported.

Relative risk reductions: None reported.

Number needed to treat (Harm): None reported.

Other: Mean values for VAS and VISA were presented for each group How important are the results?

Obtained p-values for each statistic reported by the authors: Alpha level was set at p<0.05 Mann-Whitney U test: VAS: p<0.01 VISA:p<0.001 Wilcoxon signed ranks test: Eccentric group: VAS p<0.005; VISA p<0.005 Concentric group: VAS p<0.34; VISA p<0.34

Obtained confidence intervals for each statistic reported by the authors: none reported

Do these findings exceed a minimal clinically important difference? Yes No None reported Do the subjects in the study resemble your patients/clients? Yes No Both our patient and these patients have chronic tendon problems. Additionally, the included population was athletes, seven of which were runners, which matches our patient. However, these patients had tendinopathy in the patellar tendon and our patient has tendinopathy in the hamstring so they are not completely comparable. Can you perform this intervention safely and appropriately in your Yes No clinical setting given your current knowledge and skill level and your current resource? Yes, the authors depict the exercise very well and can be followed easily. The exercise also does not require expensive equipment. Does the intervention fit within the patient/client’s expressed values Yes No and preferences? Our patient would like to decrease her pain and this study shows that EE is beneficial. However, the specific intervention used in this study is only applicable to patients with patellar tendinopathy and the exercise would not be able to be used with hamstring tendinopathy. The concept of EE can be transferred from this study to a patient with hamstring tendinopathy, and therefore this study can be used to further conclude the benefits of eccentric loading. Do the potential benefits outweigh the potential risks of using this Yes No intervention with your patient/client? The authors did not describe any adverse reactions except for muscle soreness; therefore the treatment would be safe for the patient. Will you use this intervention for your patient/client? Yes No EE would be a good intervention to try with our patient. The

article showed that most of the patients in the eccentric group were satisfied with the treatment even after an average of 32.6 months post-intervention.

Kingma JJ, Knikker R, Wittink HM, Takken T. Eccentric overload training in patients with chronic achilles tendinopathy: A systematic review. Br J Sports Med. 2007;41(6):e3.

Kingma JJ, Knikker R, Wittink HM, Takken T. Eccentric overload training in patients with chronic Achilles tendinopathy: A systematic review. Br J Sports Med. 2007;41(6):e3.

P (patient/population/clinical problem): Individuals with chronic Achilles tendinopathy I (intervention/indicator/index test): Eccentric Exercise C (comparator): Concentric training, surgery, night splint O (outcome): Pain, stiffness, or physical functioning

Did the investigators limit the review to randomized controlled trials? Yes No The authors included both RCTs as well as clinical controlled trials. Three were RCTs and six were controlled trials. Did the investigators provide details regarding their search and study Yes No selection methods? The authors stated that they searched in the databases: CINAHL, PubMed, Medline, Cochrane Library, EMBASE, PEDro, and Google Scholar. The authors included studies from 1966 to December 2009 and provided a list of key terms. However, they did not include the exact search strings that they used. Additionally, two independent reviewers screened the articles for the inclusion criteria. Did the investigators describe the processes and tools used to assess Yes No the quality of the individual studies? The authors assessed both the methodological quality of the articles as well as the conclusive power. The methodological quality was assessed using the Delphi list and the conclusive power was determined by the Dutch Institute of Healthcare Improvement. For both assessments, two reviewers independently reviewed the articles and disagreements were discussed. For both assessments the reviewers were found to have moderate agreement before discussion. Did the investigators provide details about the research validity (or Yes No quality) of studies included in the review? The Delphi list included criteria that covered both external and internal validity. The Dutch Institute of Healthcare Improvement addressed conclusive power by classifying each article by its level of evidence ranging from expert opinion to systematic review. Did the investigators address publication bias? Yes No The authors described that bias may be an issue because of the inclusion of only Dutch and English articles as well as full-text, peer-reviewed articles. Did subject attrition (e.g. withdrawal, loss of follow up) occur over Yes No the course of the study? The researchers did not state whether there was subject attrition in the individual studies.

Do you have enough confidence in the research validity Yes No of this paper to consider using this evidence with your Undecided patient/client? The included articles do seem to show that there may be an effect when using EE to treat tendinopathy compared to other interventions. However, the quality of the included articles is low and therefore the results need to be taken with caution. Additionally, the intervention of EE does not seem to be harmful to the patients.

If this is a meta-analysis, did the investigators use individual patient Yes No data in the analysis? Not applicable Were the results consistent from study to study (i.e., homogeneous)? Yes No In each study, pain decreased from baseline to the end of the treatment period being either 6 or 12 weeks. This occurred regardless if the group was either the control or the intervention group. Additionally, there was no significant difference between group in any of the included articles.

What results do the authors report related to your clinical question?

Effect Sizes: None reported.

Likelihood Ratios: None reported.

Odds Ratios: None reported.

Relative Risks: None reported.

Number Needed to Treat (Harm): None reported.

Other: Kappa: Delphi list: K=0.521 Dutch Institute for Healthcare Improvements: Level of evidence: K=0.550 Degree of evidence: K=0.609

Mean pain reduction in the eccentric overload training group was 60% and for the control group was 33%

How important are the results?

Obtained p-values for each statistic reported by the authors: None reported.

Obtained confidence intervals for each statistic reported by the authors: CI for percentage of mean reduction in pain of the nine included studies Eccentric group: 60% (CI 29% to 94%) Concentric group: 33% (CI 13% to 86%)

If this paper is not a meta-analysis, is there a substantive conclusion Yes No that can be drawn about the cumulative weight of the evidence? The methodologically quality of the included studies were low; therefore this information should be used as a guideline and not a definitive answer for treating chronic Achilles tendinopathy. Do the subjects in the systematic review resemble your Yes No patient/client? If no, how are they different? Both the patients in the article and our patient have tendinopathy in the lower extremity. Additionally, both have chronic tendinopathy. However, our patient has hamstring tendinopathy and these patients had Achilles tendinopathy. Can you perform this intervention(s) safely and appropriately in Yes No your clinical setting given your current knowledge and skill level and your current resources? We would be able to perform eccentric training, however the authors did not explain the exact protocols used. Therefore, we cannot draw a conclusion. Does/(do) the intervention(s) fit within the patient/client’s expressed Yes No values and preferences? The interventions performed decreased pain in all groups, so this coincides with our patient’s willingness to decrease pain and improve function. Do the potential benefits outweigh the potential risks of using this Yes No intervention(s) with your patient/client? The article did not express any risks with this intervention and I think EE would be useful to the patient. Will you use this intervention(s) for your patient/client? Yes No EE would be beneficial to our patient. It could be incorporated into her everyday exercise in conjunction with other therapy.

The purpose of this prospective randomized trial was to evaluate the effectiveness of EE, AirHeel brace, or a combination of both for treatment of chronic Achilles tendinopathy. A total of 100 patients comprised the sample population with most of these patients being recreational athletes. After randomization by number selection, the three groups had similar demographic data. A power analysis revealed a sample of 30 individuals per group would be necessary to detect a difference between groups, which was reached in the eccentric training and AirHeel brace group. The combination group only had 23 participants, which was one limitation of the study. The outcome measures were VAS score, American Orthopedic Foot and Ankle Society (AOFAS) score, and Short Form-36 (SF-36) score. The protocol for the eccentric group was two different exercises each performed for three sets of 15 repetitions, three times a day, seven days a week for 12 weeks. When pain became minor, a load was added to increase the level of eccentric loading on the calf muscles. All of the outcome measures improved significantly for each of the three groups from baseline to the last follow up at 12 weeks, but there was no significant difference between groups.

Peterson W, Welp R, Rosenbaum D. Chronic Achilles tendinopathy: A prospective randomized study comparing the therapeutic effect of eccentric training, the AirHeel brace, and a combination of both. The Am J of Sports Med. 2007;35(10):1659-1667.

P (patient/population/clinical problem): Individuals with Achilles Tendinopathy I (intervention/indicator/index test): Eccentric exercise C (comparator): AirHeel Brace, and combination O (outcome): Decrease pain, improve AOFAS, and SF-36

Did the investigators randomly assign (or allocate) subjects to Yes No groups? The subjects were randomly given a number between 1 and 3 in a Microsoft Excel spreadsheet. This determined which of the three groups the participant was in. Was each subject’s group assignment concealed from the people Yes No enrolling individuals in the study? The author did not mention blinding at any of the levels. Did the groups have similar sociodemographic, clinical, and Yes No prognostic characteristics at the start of the study? There were no significant differences between the groups for age, duration of symptoms, gender, height, weight, and body mass index. Were the subjects, clinicians, and outcome assessors masked (or Yes No blinded) to the subjects’ group assignment? The blinding of subjects, clinicians, and outcome assessors was not discussed at any point in the article. Did the investigators manage all of the groups in the same way Yes No except for the experimental intervention(s)? Did subject attrition (e.g. withdrawal, loss of follow up) occur over Yes No the course of the study? The dropout rate was 14% at the 12 week follow up and did not differ between the groups. Were subjects analyzed in the groups to which they were assigned? Yes No Did the investigators collect follow-up data on all subjects over a Yes No time frame long enough for the outcomes of interest to occur? The one-year time frame was sufficient for the outcomes of interest. Did the investigators repeat the study with a new set of subjects? Yes No Do you have enough confidence in the research validity Yes No of this paper to consider using this evidence with your Undecided patient/client? The intervention did show improvement in the outcome measures between baseline and after the intervention period. However, it did not show any benefit over the other two control groups.

What results do the authors report related to your clinical question?

Tests of differences: Repeated-measures analysis was performed

Effect size: None reported.

Absolute benefit increases: None reported.

Relative benefit increases: None reported.

Absolute risk reductions: None reported.

Relative risk reductions: None reported.

Number needed to treat (Harm): None reported.

Other: Mean +/- Standard deviations (SD) Percent in pain reduction: • During Activities of daily living o Eccentric group: ! 6 weeks: 20% ! 12 weeks: 60% ! 1-year: 30% o Airheel brace: ! 6 weeks: 41% ! 12 weeks: no further decrease ! 1-year: 27% o Combination: ! 6 weeks: 22% ! 12 weeks: 56% ! 1-year: 53% • During walking: o Eccentric group: ! 6 weeks: 25% ! 12 weeks: 71% ! 1-year: 45% o Airheel brace: ! 6 weeks: 43%

! 12 weeks: no significant further reduction ! 1-year: 46% o Combination: ! 6 weeks: 36% ! 12 weeks: no significant further reduction ! 1-year: 64% • Pain during sporting activities: 1-year follow up o Eccentric group: 51% o Airheel brace: 47% o Combination: 74%

How important are the results?

Obtained p-values for each statistic reported by the authors: P value < 0.05 is considered significant AOFAS improved significantly in all treatment groups: p< 0.0001 Pain was significantly decrease in all measures and all groups p< 0.0001

Obtained confidence intervals for each statistic reported by the authors: None reported.

Do these findings exceed a minimal clinically important difference? Yes No The authors did not report a minimal clinically important difference. Do the subjects in the study resemble your patients/clients? Yes No The subjects have chronic tendinopathy and are athletes which are similar to our patient. Additionally, our patient falls within the age range of the participants in the study. However, the area of the tendinopathy is different. Can you perform this intervention safely and appropriately in your Yes No clinical setting given your current knowledge and skill level and your current resource? At this current time, EE program could be adequately implemented, but fitting someone for a brace would take some collaboration. Does the intervention fit within the patient/client’s expressed values Yes No and preferences? The intervention contains exercises, which fits in with this particular patient’s values and preferences. Therefore, she would be able to incorporate the exercises into her daily routine. Do the potential benefits outweigh the potential risks of using this Yes No intervention with your patient/client? The authors did not state whether there were any adverse side effects. Will you use this intervention for your patient/client? Yes No The EE demonstrated improvements in the patient’s pain and therefore may be added into the patient’s regular exercise routine.

This RCT compared the effectiveness of three management strategies for Achilles tendinopathy: EE into mild or moderate pain, repetitive low-energy SWT, and a wait- and-see method. Seventy-five patients with chronic tendinopathy with a diagnosis of greater than six months were used in the study. Participants were excluded if they received an anesthesia or corticosteroid injection four weeks prior, bilateral tendinopathy, symptoms beginning less than 6 months prior, or had other conditions that could contribute to posterior ankle pain. Patients with congenital or acquired deformities of the ankle or knee, surgery to the ankle or tendon, prior tendon tear or previous dislocations or fractures in the region within a year were also excluded. All patients had previously been treated with a local anaesthetic or corticosteroid injection, a trial of anti-inflammatory medications, use orthotics and/or a heel lift, and physical therapy. The outcome measure used was the VISA for pain. Results showed significant positive results in the EE and SWT groups compared to the wait-and-see group, with no differences between the EE and SWT groups. Results were based on an intention-to-treat basis. It is important to note that this study cited another study looking at the effectiveness of EE on tendinopathy which showed positive results for EE after a 12-week exercise program and satisfactory outcomes in 90 out of the 101 cases. Mean pain score on the VAS in this study decreased significantly from 6.7 to 1.0.

Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo achillis: a randomized controlled trial. Am J of Sports Med. 2007;35(3):374-383.

P (patient/population/clinical problem): Adults with mid-portion Achilles tendinopathy I (intervention/indicator/index test): Eccentric loading C (comparator): SWT and a control group O (outcome): VISA-A, VAS and NRS

Did the investigators randomly assign (or allocate) subjects to Yes No groups? Was each subject’s group assignment concealed from the people Yes No enrolling individuals in the study? An unbiased person not involved in the study was involved to distribute participants into groups. Did the groups have similar sociodemographic, clinical, and Yes No prognostic characteristics at the start of the study? The groups were not matched. Characteristics and other demographics of the participants were not given. Were the subjects, clinicians, and outcome assessors masked (or Yes No blinded) to the subjects’ group assignment? Did the investigators manage all of the groups in the same way Yes No except for the experimental intervention(s)? The groups were managed the same way, were allowed to cross over, and were given details about the other intervention groups. Did subject attrition (e.g. withdrawal, loss of follow up) occur over Yes No the course of the study? A total of 5 out of 75 patients dropped out of the study. Were subjects analyzed in the groups to which they were assigned? Yes No Did the investigators collect follow-up data on all subjects over a Yes No time frame long enough for the outcomes of interest to occur? A significant difference was found between the first two groups compared to the third group. No spontaneous recovery was expected so the time frame of 12 weeks was long enough. Did the investigators repeat the study with a new set of subjects? Yes No Do you have enough confidence in the research validity Yes No of this paper to consider using this evidence with your Undecided patient/client? There was a multitude of outcome measures and the eccentric group proved just as effective as the SWT group without the expensive equipment.

What results do the authors report related to your clinical question?

Tests of differences: Wilcoxon test and a one way ANOVA were used.

Effect size: None reported.

Absolute benefit increases: None reported.

Relative benefit increases: None reported.

Absolute risk reductions: None reported.

Relative risk reductions: None reported.

Number needed to treat: None reported.

Other: Means, standard deviations, and confidence intervals for all of the outcome measures for the three groups were reported.

The authors found that 140 patients were needed for an 80% power.

How important are the results?

Obtained p-values for each statistic reported by the authors: Yes, these were reported for all of the outcome measures.

Obtained confidence intervals for each statistic reported by the authors: Yes, for all of the outcome measures

Do these findings exceed a minimal clinically important difference? Yes No None reported. Do the subjects in the study resemble your patients/clients? Yes No These patients had Achilles tendinopathy while our patient has hamstring tendinopathy. Can you perform this intervention safely and appropriately in your Yes No clinical setting given your current knowledge and skill level and your current resource? The EE require some training for proper body mechanics, but are feasible at this point. Does the intervention fit within the patient/client’s expressed values Yes No and preferences? Yes, a reduction in pain is the ultimate goal and both the eccentric loading and SWT treatments achieved this. However, the intervention was specifically for patellar tendinopathy so only the concept of eccentric loading can be applied to the patient with hamstring tendinopathy. Do the potential benefits outweigh the potential risks of using this Yes No intervention with your patient/client? The risks outlined by the article include transient redness at SWT treatment site and muscle ache in the calf. These are minor risks and will resolve quickly. Will you use this intervention for your patient/client? Yes No

Van Usen C, Pumberger B. Effectiveness of eccentric exercises in the management of chronic Achilles tendinosis. Internet J Allied Health Sci Pract. 2007;5(2):1-14.

Van Usen C, Pumberger B. Effectiveness of eccentric exercises in the management of chronic achilles tendinosis. Internet J Allied Health Sci Pract. 2007;5(2):1-14.

P (patient/population/clinical problem): Individuals age 16 and older with chronic Achilles tendinosis I (intervention/indicator/index test): Eccentric exercise program C (comparator): Other approaches in chronic Achilles tendinosis treatment (medication, exercises/stretching, electrotherapy and surgery) O (outcome): Management of chronic Achilles tendinosis

Did the investigators limit the review to randomized controlled trials? Yes No Did the investigators provide details regarding their search and study Yes No selection methods? The databases, keywords and inclusion and exclusion criteria are listed. Did the investigators describe the processes and tools used to assess Yes No the quality of the individual studies? The Lloyd-Smith model which is based off the PEDro scale. Did the investigators provide details about the research validity (or Yes No quality) of studies included in the review? Used the Lloyd-Smith model which is based off the PEDro scale which gives details about study validity. Did the investigators address publication bias? Yes No Not mentioned. Did subject attrition (e.g. withdrawal, loss of follow up) occur over Yes No the course of the study? Not mentioned. Do you have enough confidence in the research validity Yes No of this paper to consider using this evidence with your Undecided patient/client? This article shows clinical significance of an intervention that has a low cost compared to other interventions that can still be beneficial.

If this is a meta-analysis, did the investigators use individual patient Yes No data in the analysis? Were the results consistent from study to study (i.e., homogeneous)? Yes No

What results do the authors report related to your clinical question?

Effect Sizes: Yes

Likelihood Ratios: None reported.

Odds Ratios: None reported.

Relative Risks: None reported.

Number Needed to Treat (Harm): None reported.

Other: None reported

How important are the results?

Obtained p-values for each statistic reported by the authors: None reported.

Obtained confidence intervals for each statistic reported by the authors: None reported.

If this paper is not a meta-analysis, is there a substantive conclusion Yes No that can be drawn about the cumulative weight of the evidence? EE are simple to perform, safe, and cost effective in treating individuals with Achilles tendinosis. Do the subjects in the systematic review resemble your Yes No patient/client? If no, how are they different? These patients had Achilles tendinosis, while our patient has hamstring tendinopathy. Can you perform this intervention(s) safely and appropriately in Yes No your clinical setting given your current knowledge and skill level and your current resources? A specific protocol or explanation was not given about how the exercises were constructed making safety of how the intervention is carried out a concern. Of the articles used, only one presented their detailed protocol. Does/(do) the intervention(s) fit within the patient/client’s expressed Yes No values and preferences? Yes. Values of the patient match the outcomes of the study, including decreasing pain and improving range of motion. Do the potential benefits outweigh the potential risks of using this Yes No intervention(s) with your patient/client? The only risk is muscle soreness, which is minor. Will you use this intervention(s) for your patient/client? Yes No This article analyzes multiple outcome measures comparing different interventions. Good results are shown, and values of the patient are parallel to the study, so an intervention including EE may be beneficial to the patient.

This systematic review aimed to critically review evidence for the effectiveness of EE to treat lower extremity tendinosis (patellar and Achilles). The authors selected 11 studies that had an average methodologic score of 5.3 out of 10 based on PEDro criteria. EE was compared to no treatment, CE, stretching, night splinting and physical agents. Outcome measures included VAS, VISA, and FAOS. Studies comparing EE to CE mostly found that EE groups showed slightly less pain at the end of the treatment session. Both EE groups and stretching groups had modest but significant decreases in pain when comparing these two interventions. When comparing EE to US, there were significant improvements in pain for the EE group compared to the US group. In the end, authors acknowledge that there is evidence to support the use of EE for the treatment of tendinosis, however more evidence is needed to determine if EE is superior in comparison to other treatment methods. An important consideration to take from this review is that when a study did not allow the participants to participate in sports activity, EE was found to have a greater effect on pain reduction than if they were allowed to continue their normal activities.

There may be some threats to the usefulness of this systematic review. None of the studies included blinding, concealed allocation, or intention-to-treat analysis. Also, low sample sizes were used, and other outcome measures that have higher reliability and validity could have been used. These studies showed that EE is may be superior when compared to other treatments; however further studies need to be conducted to determine the effect of EE compared to other modes of treatment options for treatment of tendinosis.

P (patient/population/clinical problem): Physically active adults with clinically diagnosed lower extremity tendinosis I (intervention/indicator/index test): Eccentric exercise C (comparator): No treatment, concentric exercise, alternative eccentric protocol, stretching, night splinting and physical agents O (outcome): Pain and strength

Did the investigators limit the review to randomized controlled trials? Yes No Did the investigators provide details regarding their search and study Yes No selection methods? The criteria for the articles included in the review articles were written in English, a RCT research design, the study participants were adults with a clinical diagnosis of tendinosis, the outcome measures of the included studies must measure pain or strength and EE must have been used to treat a lower extremity tendinosis. Did the investigators describe the processes and tools used to assess Yes No the quality of the individual studies? They used the PEDro criteria scale. Did the investigators provide details about the research validity (or Yes No quality) of studies included in the review? The average score on the PEDro scale was 5.3/10, which is fairly low but not in relation to the information available on this subject. Did the investigators address publication bias? Yes No Did subject attrition (e.g. withdrawal, loss of follow up) occur over Yes No the course of the study? Some studies included had subjects that dropped out because of poor progress. Do you have enough confidence in the research validity Yes No of this paper to consider using this evidence with your Undecided patient/client? The study presented with a few limitations such as lack of blinding and concealed allocation as well as small sample sizes. This creates the need to take the results with caution. However, there were no serious adverse reactions and many of the patients did improve in the outcome measures.

If this is a meta-analysis, did the investigators use individual patient Yes No data in the analysis? Not applicable

Were the results consistent from study to study (i.e., homogeneous)? Yes No However, some studies found a difference from baseline to the end of treatment within groups but not between groups.

What results do the authors report related to your clinical question?

Effect Sizes: Yes, most studies reported effect sizes and with a 95% confidence interval. These values can be found in Table 1.

Likelihood Ratios: No ne reported.

Odds Ratios: None reported.

Relative Risks: Yes, some studies reported these values with a 95% confidence interval and can be found in Table 1.

Number Needed to Treat (Harm): None reported.

Other: Statistical power and PEDro scores were reported for most of the articles.

How important are the results?

Obtained p-values for each statistic reported by the authors: None reported.

Obtained confidence intervals for each statistic reported by the authors: Reported for effect size and for relative risk as seen in Table 1.

If this paper is not a meta-analysis, is there a substantive conclusion Yes No that can be drawn about the cumulative weight of the evidence? EE is more beneficial than splinting, non-thermal ultrasound and friction massage, but has not been shown to be superior to other therapeutic exercise. Do the subjects in the systematic review resemble your Yes No patient/client? If no, how are they different? These patients had patellar and Achilles tendinosis, while our patient has hamstring tendinosis. Can you perform this intervention(s) safely and appropriately in Yes No your clinical setting given your current knowledge and skill level and your current resources? The EE that were mentioned could be done in a clinic and require minimal equipment. Does/(do) the intervention(s) fit within the patient/client’s expressed Yes No values and preferences? Do the potential benefits outweigh the potential risks of using this Yes No intervention(s) with your patient/client? The only risks would be soreness and possible pain so these are mild risks. Will you use this intervention(s) for your patient/client? Yes No The exercises and other treatment options are relatively easy and cost effective, especially the EE. It could be incorporated into her daily exercise routine.

Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med. 2007;41(4):188-189.

Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med. 2007;41(4):188-199.

P (patient/population/clinical problem): Individuals with chronic tendinopathy of the Achilles tendon (AT), patella tendon (PT), lateral elbow, or rotator cuff I (intervention/indicator/index test): Eccentric exercise C (comparator): Concentric exercise, stretching, splinting, frictions, and ultrasound O (outcome): Decrease in pain, increase in function, or increase in patient satisfaction

Did the investigators limit the review to randomized controlled trials? Yes No In this review, the authors only included RCTs. One exclusion criteria included studies that compared two different types of EE because they did not consist of a control group. Did the investigators provide details regarding their search and study Yes No selection methods? The authors provided a list of databases they used as well as a chart with the search strings. Did the investigators describe the processes and tools used to assess Yes No the quality of the individual studies? The authors used both the van Tulder scale as well as the PEDro scale. Three assessors independently scored each article using both of these scales and disagreements were discussed. Additionaly, for articles found in the PEDro database the PEDro scale provided online was compared to the assessors’ rating of the article. Did the investigators provide details about the research validity (or Yes No quality) of studies included in the review? The authors provided charts to demonstrate characteristics of the included articles. Additionally, they created a cut-off point of a score 6 on both scales in order for the study to be considered high quality. Studies that fell below 6 on the quality assessment scales were considered to be low quality. Did the investigators address publication bias? Yes No Did subject attrition (e.g. withdrawal, loss of follow up) occur over Yes No the course of the study? Seven out of the included studies reported drop out rates. The mean percentage of drop outs of these seven studies was 12.5% with the lowest being 6.5% and the highest being 17.4%. Do you have enough confidence in the research validity Yes No of this paper to consider using this evidence with your Undecided patient/client? The authors found very few articles to demonstrate significant changes in the treatment group for decrease in pain and improving function. The articles that did find a significant change were also of low methodological quality. Therefore the

conclusions drawn from these studies need to be taken with caution.

If this is a meta-analysis, did the investigators use individual patient Yes No data in the analysis? Not applicable Were the results consistent from study to study (i.e., homogeneous)? Yes No The authors varied greatly in the different outcome measures, especially for measuring function. The population, interventions, controls, and outcome measures also varied.

What results do the authors report related to your clinical question?

Effect Sizes: weight mean differences were reported

Likelihood Ratios: None reported.

Odds Ratios: None reported.

Relative Risks: Stasinopoulos et al: EE to ultrasound: 21 (95% CI 1.4 to 315.98) at 16 weeks EE to friction: 5 (95% CI 1.45 to 17.27) at 16 weeks Patient Satisfaction: PT for EE compared to concentric exercise (CE) 4.14 ( 95% CI 0.08 to 206.41) at 12 weeks

Number Needed to Treat (Harm): None reported.

Other: 58% of the studies did not report intention to treat. Of the ones that did, mean drop out rate for studies: 12.5%

How important are the results?

Obtained p-values for each statistic reported by the authors: Some are significant, but the studies showing significance are either low quality RCTs or used an outcome measure that is not validated.

Obtained confidence intervals for each statistic reported by the authors: Each outcome from all 11 studies reported confidence intervals.

If this paper is not a meta-analysis, is there a substantive conclusion Yes No that can be drawn about the cumulative weight of the evidence? The outcome measures used in the individual studies were very different and no clear conclusions can be culminated. Most articles showed positive results, but were not strong studies. Do the subjects in the systematic review resemble your Yes No patient/client? If no, how are they different? The patients included in this systematic review had most common types of tendinopathy. Our patient has proximal hamstring tendinopathy, which is mentioned in the article as less common and was therefore not included. The patient population differed between the studies and may not all be matched to our patient. Can you perform this intervention(s) safely and appropriately in Yes No your clinical setting given your current knowledge and skill level and your current resources? The authors provided a table with details of the interventions of the included studies. Does/(do) the intervention(s) fit within the patient/client’s expressed Yes No values and preferences? The patient would like to decrease the amount of pain she experiences and many of the included studies looked at pain as an outcome. Additionally, the patient is very active and the intervention used is a very intense exercise program, which would also fit the patient’s values and motivation. Do the potential benefits outweigh the potential risks of using this Yes No intervention(s) with your patient/client? The authors do not mention any adverse reactions to the treatments and some of the patients improved and were able to return to their previous activity. Will you use this intervention(s) for your patient/client? Yes No Although this article has limited evidence to suggest the beneficial outcome of EE, it does not reveal any negative aspects.

Therefore, I would not only focus on EE, but would incorporate it into the patient’s treatment. Additionally, I would re-evaluate to determine if the patient is making gains.

This RCT was designed to compare the effects of EE to CE in males with chronic Achilles tendinopathy. The dependent variables measured were pain, muscle strength, muscle endurance, and functional fitness including balance, dexterity and agility. The 32 participants were randomly assigned to either an experimental group performing EE or a control group performing CE. The subjects and researchers were blinded to the group assignments. Each group participated in their respective exercise programs for 50 minutes, three times a week for eight weeks. Measures were taken at baseline and after the eight week intervention. Both treatment groups made gains regarding the outcomes of interest and the EE group demonstrated significant improvements in pain, ankle strength, endurance, total balance index and agility after the eight week intervention. Additionally, the EE group demonstrated greater improvements in pain, ankle plantarflexion endurance, ankle dorsiflexion endurance, total balance index, and agility compared to the CE group.

P (patient/population/clinical problem): Males with Achilles tendinopathy I (intervention/indicator/index test): Eccentric strengthening C (comparator): Concentric strengthening O (outcome): Pain, isokinetic muscle strength, endurance, and functional fitness including balance, dexterity and agility.

Did the investigators randomly assign (or allocate) subjects to Yes No groups? The authors stated that the patients were randomly allocated to either an experimental group or a control group using a computer-based randomized controlled system. Was each subject’s group assignment concealed from the people Yes No enrolling individuals in the study? The authors state that the subjects, researchers and the research assistants were blinded to the group assignments. Did the groups have similar sociodemographic, clinical, and Yes No prognostic characteristics at the start of the study? The groups were found to have similar baseline characteristics including age, height, and weight. The experimental group had a shorter duration of symptoms compared to the control group. The mean duration was 0.94 years and 1.01 years respectively. There were no significant differences between groups regarding any of the variables. Were the subjects, clinicians, and outcome assessors masked (or Yes No blinded) to the subjects’ group assignment? The authors state that the subjects, researchers and research assistants were blinded to the subject’s group assignment, but later the article states that the research assistants demonstrated the exercises to the treatment groups. Did the investigators manage all of the groups in the same way Yes No except for the experimental intervention(s)? Yes. Both groups performed exercises for 50 minutes, 3 times a week for 8 weeks. The research assistants demonstrated the exercises to each group prior to the participants starting the exercise program. As the program progressed and resistance was added, both groups were allowed to return to the previous week’s parameters if pain was experienced, but this did not occur in either group. Did subject attrition (e.g. withdrawal, loss of follow up) occur over Yes No the course of the study? No, all participants completed the study. Were subjects analyzed in the groups to which they were assigned? Yes No

Did the investigators collect follow-up data on all subjects over a Yes No time frame long enough for the outcomes of interest to occur? Data was obtained at the beginning and end of the study. The study occurred for 8 weeks and this time frame was long enough for there to be significant changes in pain, muscle strengthening, endurance, total balance and agility, but not in dexterity. This time frame may not have been long enough overall since a change was not seen in all of the outcome measures in this sample population. Did the investigators repeat the study with a new set of subjects? Yes No Do you have enough confidence in the research validity Yes No of this paper to consider using this evidence with your Undecided patient/client? There were a few limitations in this study that make these results less generalizable to our patient. There was a small sample size, all of the participants were male, they all had Achilles tendinopathy and the authors did not complete a long term follow up. Although there were significant results, these limitations will be considered when applying this information.

What results do the authors report related to your clinical question?

Tests of differences:

Wilcoxon’s signed rank test: tested differences within each group from baseline to 8 weeks. Mann-Whitney U test: tested the differences between groups in all of the dependent variables. An alpha level of 0.05 was considered to be statistically significant.

Effect size: None reported.

Absolute benefit increases: None reported.

Relative benefit increases: None reported.

Absolute risk reductions: None reported.

Relative risk reductions: None reported.

Number needed to treat (Harm): None reported.

Other:

Mean values and standard deviations were presented for each dependent variable.

A Shapiro-Wilk test was used to conduct a normality test on the variables.

How important are the results?

Obtained p-values for each statistic reported by the authors: Alpha level was set at p<0.05

Pain significantly decreased (p<0.05) within groups after the 8 week interventions and the EE group had a significantly greater decrease in pain compared to the CE group (p<0.05).

Knee extension, ankle dorsiflexion and ankle plantarflexion muscle strength increased significantly (p<0.05) in the EE group

Ankle plantarflexion endurance increased significantly in the EE group (p<0.05)

Ankle dorsiflexion endurance increased significantly in both groups (p<0.05)

The difference in ankle dorsiflexion endurance from baseline to 8 weeks was significantly larger in the EE group than the CE group (p<0.05)

The total balance index decreased significantly in the EE group (p<0.05)

The difference from baseline to 8 weeks in the total balance index was significantly larger in the EE group (p<0.05)

The medial-lateral balance index decreased significantly in both groups (p<0.05)

Dexterity and agility increased significantly in both groups (p<0.05)

The difference in agility from baseline to 8 weeks was significantly larger in the eccentric group (p<0.05)

Obtained confidence intervals for each statistic reported by the authors: None reported.

Do these findings exceed a minimal clinically important difference? Yes No None reported Do the subjects in the study resemble your patients/clients? Yes No Both our patient and these patients have chronic tendon problems. However, our patient has hamstring tendinopathy and the study participants had Achilles tendinopathy. Additionally, the included population was all male and they only had tendinopathy unilaterally, making the subjects not

completely comparable to our patient. Can you perform this intervention safely and appropriately in your Yes No clinical setting given your current knowledge and skill level and your current resource? Yes, the authors depict the exercise protocol for each week of the 8 week study making it easy to follow. The exercises also do not require any equipment. Does the intervention fit within the patient/client’s expressed values Yes No and preferences? Our patient would like to decrease her pain and this study shows that EE is beneficial in decreasing pain. However, the eccentric strengthening protocol targets the Achilles tendon and not the hamstring tendon. The concept of EE can be applied to our patient, and the benefits that this training method has on tendinopathy in the lower extremity. Do the potential benefits outweigh the potential risks of using this Yes No intervention with your patient/client? The authors did not describe any adverse reactions during this study and the exercises are feasible to reproduce in any setting. Will you use this intervention for your patient/client? Yes No EE showed a deceased in pain in participants with chronic tendinopathy. Since decreasing pain is a goal for our patient, the concept of this intervention will be beneficial to use when treating our patient.