L4: What the patient can expect

What the patient can expect 

According to a systematic review conducted in 2013 there is an equivalent amount of evidence for using this concentric/eccentric approach as there is for purely eccentric exercises.16 

The recovery rate for Achilles tendinopathy is variable as observed in the following studies: 

• Silbernagel et al.: Returning to sport after injury can range from six weeks to one year.17 
• Silbernagel et al.: At five years 65% of subjects were pain free¹⁸ (non-competitive athletes using return-to-sport exercise programme) 
• Plas et al.: At five years only 39.7% were symptom free (Alfredson heel drop exercise programme and other interventions of patients’ choosing)19 
• Paavola et al.: After nine years 59% of subjects had recovered20 (no specific intervention, an additional 29% recovered with surgery) 
• Johannsen et al.: After 10 years 63% of subjects reported an excellent outcome (no physical limitations) and 27% reported a good outcome (slight physical limitation) using the return-to-sport exercise programme.21 They note: “16% had surgery. Three ruptures occurred five to eight years after the primary study. The improvement from entry to six months in the primary study was maintained until ten year follow-up.” “Twenty-two per cent had changed sport due to Achilles tendon problems.” 

Unfortunately there are no real indicators to determine which patients will respond quickly (6-12 weeks) or slowly (one year or over). It is important to explain that it can take a long time to recover because tendons need mechanical loading to heal and this process takes longer in tendons than in muscles. So even after 12 weeks of exercise complete recovery is not necessarily expected and as long as improvement is occurring there is no reason to cease the exercise programme. Silbernagel et al. suggest that other treatment options (such as surgery or various types of injections) should only be considered after one year.18 

Silbernagel et al. noted that patients with an increased fear of movement did not respond as well to exercise treatment. The pain-monitoring model may be beneficial to alleviate their fear of movement even in the presence of pain.21 In doing so, it is demonstrated to the patient that small, controllable amounts of pain do not make the problem worse in the long term and does not inhibit recovery. 

This programme can also be used for non-athletes (although they don’t have to use the pain-monitoring model or progress to plyometrics). For this population exercise therapy tends to be less effective compared with athletes.22,23