To review assessed the effectiveness of eccentric exercise programmes in the treatment of common tendinopathies. The authors found a lack of. OBJECTIVES To determine the effectiveness of eccentric exercise (EE) programmes in the treatment of common tendinopathies. DATA SOURCES Relevant. Purpose. To systematically review the current evidence and determine the effectiveness of eccentric exercise in the treatment of chronic tendinosis.

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To determine the effectiveness of eccentric exercise EE programmes in the treatment of common tendinopathies. The PEDro and van Tulder scales were employed to assess methodological quality. Levels of evidence were then obtained according to predefined thresholds: Twenty relevant studies were sourced, tendinoopathy of which met the inclusion criteria.

These included studies of Achilles tendinopathy ATpatella tendinopathy PT and tendinopathy of the common wrist extensor tendon of the lateral elbow LET.

Levels of evidence were found to be variable across the tendinopathies investigated. Various modalities have been recommended as appropriate treatment options for tendinopathy, depending upon the phase of presentation.

In the acute phase of treatment, reduction of risk factors such as training errors, 6 flexibility issues 6789exercuse and biomechanical abnormalities, 6811 along with symptom reduction using relative rest, 91012 ice, 7810 and physical modalities such as ultrasound and laser have been suggested. Eccentric exercise EE strengthening programmes have been tendinopatyh recently as a key element of strength training in rehabilitation, 6789111213151718192021222324 in part due to literature supporting their use in the treatment of AT.

Beyond exercose, it is essential that the clinical effectiveness of physical modalities such as EE is exercize as a matter of priority. To date no systematic review has investigated EE and its effectiveness in tendinopathy rehabilitation.

Therefore, this systematic review was undertaken to evaluate the current evidence for the effectiveness of EE programmes in the treatment of common tendinopathies.

The aim of this systematic review was to evaluate the evidence for the effectiveness of EE programmes in the treatment of common tendinopathies.

The following databases were searched using the OVID website: Randomised controlled trials investigating the use of EE to treat tendinopathy of the Achilles tendon, patella tendon, common wrist extensor tendon origin, or rotator cuff tendons were included. Other less common tendinopathies fell outside the scope of this review. Studies where at least one treatment group received an EE programme as the mainstay of treatment were included.

Study participants must have been diagnosed clinically with tendinopathy of the studied tendon. Studies that included participants who had previously effeftiveness, or had undergone surgery of, the involved tendon were excluded as were studies that compared two different types of EE programmes yendinopathy a control group.

Chronic tendinopathy: effectiveness of eccentric exercise

A recent review of pain measurement methods recommended the visual analogue scale VAS 33 and the McGill Pain Questionnaire 34 as the most reliable and sensitive tools for pain measurement. Function may be defined as an activity that is natural to, or the purpose of, a person or thing. Therefore, outcomes that objectively measured any part of function were included in the review: Studies that reported at least one of these three clinically orientated outcomes were included in the systematic review.

The PEDro 31 and van Tulder 39 scales were used to assess methodological quality. The PEDro scale consists of 11 criteria, of which the first is not included in the final internal validity score. The van Tulder scale is the methodological quality scale utilised in the updated guidelines for systematic reviews of the Cochrane Collaboration back review group. Three assessors BW, DB and RNW independently reviewed the included articles and a consensus was reached to determine the final quality scores.

The PEDro scores for articles found in the PEDro database were subsequently compared to those available on the website. Methodological scores were calculated for each study and the two scales were then compared to determine whether these were consistent measures of quality. The studies were then rated as high or low quality based on definitions used in a previous systematic review using the van Tulder scale. Studies that did not meet this level were rated as low quality.


Levels of evidence were then determined using the following criteria: For dichotomous data, the numbers of events in each group were extracted along with the groups’ sample sizes. If a study reported data that were not adequate for inclusion in the analysis, all efforts were made to obtain it from the relevant author. Values were then entered for analysis into Review Manager 4.

Chronic tendinopathy: effectiveness of eccentric exercise.

Sample size effdctiveness were obtained using an online calculator, 44 in collaboration with a biostatistician. The hand search of three sports journals resulted in no further inclusions.

In total, tendons from males and females were included in the 11 trials. Seven studies reported drop outs, 45465052545563 with a mean percentage drop out rate of All studies gave descriptive statistics on age of subjects with an overall mean of The duration of symptoms were reported in nine studies with a mean of Four studies investigated subjects diagnosed with AT, 27505259 four investigated subjects with PT 45535557 and the remaining three investigated subjects with LET.

Studies included interventions of EE programmes of varying lengths: Various outcome measures were used in the included studies. The most common was patient satisfaction or return to activity outcomes, with seven of the 11 studies reporting this outcome. The median score for methodological quality of the included studies was 7 out of 11 for the van Tulder score range of 5 to 9and 6 out of 10 for the PEDro score range of 5 to 8.

Studies are ordered by PEDro score. Criteria 1 omitted as not included in internal validity scores. Studies are ordered by van Tulder score. The PEDro scale results showed that in all studies subjects were randomly allocated to groups criteria 2and between group statistical comparisons were reported for at least one key outcome criteria The PEDro values were compared to the online scores available and were found to fall within one point of each other.

The quality rating of only one study would have changed from high to low quality if online scores were used. Only three studies using the pain VAS as an outcome measure were able to be included in data analysis; 454652 no pooling of data was achievable due to the low number of studies. Overall, this study showed no statistically significant differences between EE and any comparison group. In summary, only two of the 11 included studies, both investigating PT, reported statistically significant results using a validated outcome measure of pain.

Owing to small trial numbers and very large confidence intervals, there is no evidence available to suggest whether EE is effective in reducing pain in either AT or LET. Various measures of functional outcome were used to determine whether EE was effective in increasing function in tendinopathy, and due to this variation, pooling of data was not possible. Other outcomes, including plantarflexion range of motion WMD 2. Cannell et al 57 also investigated PT, and measured hamstring and quadriceps moments as a functional outcome.

No statistically significant difference was found between the two intervention groups for either hamstrings moment WMD 5. The same study also assessed grip strength as a functional measure, but again there were no statistically significant results. Selvanetti et al 63 also studied the common extensor tendon origin to determine the effect of EE compared to ultrasound, and found a significant difference in Ko 70 scores at 4 weeks WMD This scale was taken from a previous study that investigated another type of treatment for LET, but had not been validated.

No firm conclusions can be derived from these studies regarding the effect of EE on function due to the variety of outcome measurement used and the small number of available studies.

This systematic review was undertaken with the aim of determining the effectiveness of EE in the treatment of various common tendinopathies. RCTs investigating the effect of EE on rotator cuff tendinopathy were not found using the defined search strategy. There is also limited evidence suggestive of an increase in function using EE compared to ultrasound in the treatment of LET, although the validity of the outcome measure used in this study is unclear.


Another systematic review known to have investigated the effect of different physical interventions in the treatment of LET came to similar conclusions regarding the effectiveness of exercise therapy. Other systematic reviews investigating exercise therapy in PT or AT were not found. Overall, the methodological quality was considered high in only six studies of the 11 included in this review. It was assumed that the risk of misclassification was low, as reliable and valid measures of methodological quality were used.

The blinding of subjects and therapists will always remain difficult when implementing exercise therapy interventions in research. If this item was deleted in both methodological scores used in this review, quality ratings of all included studies would not have changed. Findings from this review are limited by the fact that included trials were based upon small sample sizes, and these numbers were often too small to reach adequate statistical power.

Heterogeneity of the studies included in the review was considered another problem, with differences in study population, interventions, controls and outcome measures. Only a eccentroc studies reported similar outcomes, making the pooling of data impossible for the majority of outcome measures. The treatment regime most commonly used in the included studies was derived from an initial study of AT. Upon correspondence with one of the authors of this study, it was found that the chrronic was based on clinical experience, rather than evfectiveness from any empirical evidence; e.

However, the lack of understanding about the basic pathophysiology of tendinopathy makes determining the optimal dosage of intervention difficult. A recent review of EE in AT tried to address the issue of treatment dosage 21 and concluded that because the studies in this area have not used an underlying rationale to determine loading parameters, progressions and frequency of treatment, further research needs to be undertaken before an optimal dosage can be determined.

Due to low sample numbers, large confidence intervals were present in many studies, making the majority of results inconclusive. Limited to moderate levels of evidence exist in a number of areas, thus warranting further research in this field. However, a recent study suggests that sedentary subjects with AT may show less promising results with EE therapy compared to athletic subjects. It is only then that the clinical benefit of EE in the treatment of tendinopathy may be fully elucidated compared to other treatment modalities.

While clinicians may opt to continue to utilise EE programmes in the treatment of common tendinopathies, they should be aware of the lack of evidence for the superior effectiveness of this approach in comparison with other active modalities such as concentric exercise and stretching. National Center for Biotechnology InformationU.

Br J Sports Med.

Published online Oct Author information Article notes Copyright and License information Disclaimer. Accepted Oct This article has been cited by other articles in PMC. Methodology Aim The aim of this chdonic review was to evaluate the evidence for the effectiveness of EE programmes in the treatment of common tendinopathies.

Phase 1 Phase 2 Phase 3 1. Open in a separate window. Inclusion and exclusion criteria Randomised controlled trials investigating the ov of EE to treat tendinopathy of the Achilles tendon, patella tendon, common wrist extensor tendon origin, or rotator cuff tendons were included. Load increase over 4 levels and dependent on tendinopatny weight. Activity level could increase over this period.

Weights increased as per table over 4 levels. Activity increased over this period as able.