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Load progression criteria in exercise programmes in lower limb tendinopathy: a systematic review

Escriche-Escuder, A., Casaña, J. and Cuesta-Vargas, A.I., 2020. Load progression criteria in exercise programmes in lower limb tendinopathy: a systematic review. BMJ open, 10(11), p.e041433.

In today’s letter

• Overview of the load progression for patients with lower limb tendinopathies

• Rapid Results = There is a lack of evidence to support any specific load progression

• Professional takeaway = Monitoring pain is important and having some sort of discomfort (VAS 3/10) is acceptable. However, each and every rehab plan needs to be adjusted to the patients history, activity level, goals and reaction to prescribed load.

• 3 studies to check out to further your knowledge in exercise progression

• Dank meme! Thanks Doctor 😑 

Aim of study

• The objective of this study is to summarise and analyse the current literature about what progression criteria are applied in loading exercise programmes in Achilles, patellar and gluteal tendinopathies and their evidence and effectiveness.

Did you Know?

• Progressive therapeutic exercise is a primary treatment for tendinopathies backed by extensive evidence over three decades.

• It stimulates mechanical responses, triggering biochemical and mechanical adaptations in tendons.

• Positive outcomes in pain and function have been observed in various tendinopathy locations in upper and lower extremities.

• Abundant evidence supports exercise effectiveness in midportion Achilles, patellar, or gluteal tendinopathies.

• However, evidence supporting exercise in hamstring, insertional Achilles, or upper limb tendinopathies is limited, requiring further studies.

• Examples of exercise modalities include isometric contractions, isolated eccentric training, and heavy slow resistance training.

• Cook and Purdam proposed a continuum model of tendinopathy with three stages:

  1. Reactive

  2. Disrepair

  3. Degenerative tendinopathy.

• Studies indicate sufficient areas with aligned fibrillar structure in pathological tendons, suggesting compensatory mechanisms in non-affected areas.

• Load progression plays a crucial role in tendon management, requiring individualised approaches

Results

30 studies were included in the systematic review.

Exercise Programme

The included studies featured various exercise programs, including:

• Heavy Slow Resistance (HSR)

• Isotonic exercise programs involving both concentric and eccentric phases

• Isotonic exercise programs combined with isometric exercises

• Isolated isometric exercise programs

• Isolated concentric exercise programs

• Eccentric loading programs based on Alfredson's protocol, both original and modified versions

• Isolated or combined stretching programs

6 Load progression criteria

• The identified criteria were categorised into two groups: pain as the primary progression criterion, and pain and symptom control as a secondary criterion.

• The first category included two criteria, while the second category encompassed four criteria.

1. Evoking Pain Based (EPB): Load gradually increased with diminishing pain, aiming to maintain discomfort during exercises.

2. Avoid Pain Based (APB): Exercises performed without pain.

3. Conditioning Stages (CS): Predetermined stages based on increasing percentage of repetition maximum (RM) or complexity of exercises.

4. Fatigue Based (FB): Extra sets or repetitions performed if initial sets don't induce fatigue, with gradual weight increase if necessary.

5. Subjective Perception (SP): Load increase based on patient's perceived ability.

6. Temporary Linear Increase (TLI): Linear time-based increase (e.g., 2.5% weekly).

Clinical outcomes

• Function was assessed using the VISA questionnaire, including VISA-A (for Achilles), VISA-P (for patellar), or VISA-G (for gluteal).

• Pain was measured using various methods such as Visual Analog Scale (VAS), Numerical Rating Scale, isolated questions regarding painkillers intake, global rating of change scales.

• Dimensions from different questionnaires like Foot and Ankle Outcome Score, Hip Dysfunction and Osteoarthritis Outcome Score, Oxford Hip Score, Lateral Hip Pain questionnaire, or self-designed pain scales were also used

Performance outcomes

• Performance outcomes were absent in 20 out of 30 studies analysed in this review.

• The most common performance measures included concentric and eccentric torque assessed using an isokinetic dynamometer, and jumping performance evaluated through the counter-movement jump test.

• Other performance outcomes measured included ankle range of motion and hip abductor torque

Quality assessment

• 12 studies showed a good quality, 14 studies showed a fair quality, while 6 articles were considered of low quality for obtaining a score lower than five points.

• The review highlights the necessity for well-designed, high-quality studies aimed at evaluating the efficacy of load progression criteria within exercise programs

Discussion

Achilles and patellar tendinopathies - Pain-based criteria: Evoking and Avoiding Pain

• Many studies in this review focused on reducing discomfort or pain to increase load.

• The prevalence of these studies could be influenced by the popularity of Alfredson's eccentric loading program.

• Alfredson et al. emphasised the necessity of pain in managing tendinopathies, suggesting a mechanical effect on neurovascular ingrowth.

• Studies applying the pain based criterion in Achilles and patellar tendinopathies showed similar results.

• Gradually increasing load while maintaining discomfort was a common approach, often using a backpack or weights.

• Combining pain based criteria with isolated eccentric training showed significant improvements in the VISA-A questionnaire for Achilles tendinopathy compared to non-intervention.

• However, passive therapies like acupuncture were found to be more effective than this approach.

• Monitoring pain might be important, but it may not be the most suitable criterion for load progression.

Conditioning stage

• Instead of relying solely on pain-based progression criteria, alternative approaches consider individualised aspects of patients, such as their weekly load tolerance or current abilities.

• Predefined conditioning involve determining work intensity weekly or in grouped weeks, often based on a percentage of the 1 rep max or the patient's abilities.

• A prior study on plantar fasciopathy found no pain reduction differences between a staged heavy slow resistance protocol and a self-administered approach, indicating efficacy in working with tolerated loads from the start.

• The effectiveness of conditioning criteria might relate more to individualised load calculations and observing patient capacities rather than the program's stage division.

Fatigue based, subjective perception & temporary linear increase

• Some included studies applied criteria such as temporary linear increase (TLI) (e.g., 2.5% weekly), fatigue control, or subjective increases in volume or intensity.

• Two studies used a 2.5% weekly weight increase as a progression criterion for isolated isometric and isotonic exercise programs.

• Linear criteria like TLI may lack load individualisation, as the same percentage increase can result in varying effects due to individual capacities.

• Only one study used a fatigue criterion, showing significant pain reduction favouring the exercise group compared to non-intervention and whole body vibration groups.

Gluteal tendinopathy

• This review included only three studies on gluteal tendinopathy.

• Both studies employed a conditioning stage criterion for progression.

• Clifford et al. found no significant differences in VISA-G between groups using an isometric isolated eccentric program and an isotonic exercise program.

• The progression criteria for both groups were based on the participants' ability to complete the exercises.

• Despite employing different exercise programs, results did not show significant discrepancies in VISA-G scores.

• The lack of significant differences suggests similar effectiveness in both exercise approaches.

• These findings highlight the need for further research on optimal exercise protocols for gluteal tendinopathy.

Top 3 reads

That will further your knowledge about exercise progression

1. High loading on achilles tendon - BMJ -

   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9768072/

2. Mastering late rehab - Elevating plyometrics

   https://www.sportsmith.co/articles/maximising-vertical-jump-training-with-accentuated-eccentric-loading/

3. Learn more about achilles tendinopathy

   https://sportsmedu.com/2023/10/12/achilles-tendinopathy-assessement/

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