No Difference in Clinical Effects When Comparing Alfredson Eccentric and Silbernagel Combined Concentric-Eccentric Loading in Achilles Tendinopathy: A Randomized Controlled Trial

Bas Habets; Robert E H van Cingel; Frank J G Backx; Hilco J van Elten; Peter Zuithoff; Bionka M A Huisstede

doi:10.1177/23259671211031254

No Difference in Clinical Effects When Comparing Alfredson Eccentric and Silbernagel Combined Concentric-Eccentric Loading in Achilles Tendinopathy: A Randomized Controlled Trial

Orthop J Sports Med. 2021 Oct 27;9(10):23259671211031254. doi: 10.1177/23259671211031254. eCollection 2021 Oct.

Authors

Bas Habets^{1

2}, Robert E H van Cingel^{1

3}, Frank J G Backx², Hilco J van Elten⁴, Peter Zuithoff⁵, Bionka M A Huisstede²

Affiliations

¹ Sports Medical Center Papendal, Arnhem, the Netherlands.
² Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Brain Center, Utrecht University, Utrecht, the Netherlands.
³ Research Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands.
⁴ Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands.
⁵ Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.

Abstract

Background: Alfredson isolated eccentric loading and Silbernagel concentric-eccentric loading have both shown beneficial effects on clinical symptoms in midportion Achilles tendinopathy (AT), but they have never been compared directly.

Purpose: To test for differences in clinical effects at 1-year follow-up between Alfredson and Silbernagel loading in midportion AT.

Study design: Randomized controlled trial; Level of evidence, 2.

Methods: A total of 40 recreational athletes were allocated to the Alfredson group (AG) or the Silbernagel group (SG). The primary outcome was the difference in the Victorian Institute of Sports Assessment-Achilles (VISA-A) at 1-year follow-up. Secondary outcomes were the visual analog scale for pain during activities of daily living (VAS-ADL) and sports activities (VAS-sports), the EuroQol 5 Dimensions instrument (EQ-5D), and global perceived effect score. Measurements were performed at baseline and 12-week, 26-week, and 1-year follow-up. Analysis was performed using a linear mixed-regression model with intervention (AG vs SG), time (12 weeks, 26 weeks, and 1 year postoperatively), and intervention-by-time interaction.

Results: The VISA-A score improved for both AG and SG, from 60.7 ± 17.1 at baseline to 89.4 ± 13.0 at 1-year follow-up and from 59.8 ± 22.2 to 83.2 ± 22.4, respectively (P < .001 for both). Because the interaction term did not significantly improve the model, we reported a treatment effect without interaction term, indicating a constant difference at each follow-up. The linear mixed model with correction for baseline VISA-A and confounders revealed a nonsignificant treatment effect (2.4 [95% CI, -8.5 to 13.3]; P = .656). In addition, after adjustment for the respective baseline values and confounders, nonsignificant treatment effects were found for the VAS-ADL (-2.0 [95% CI, -11.3 to 7.3]; P = .665) and VAS-sports (1.3 [95% CI, -12.8 to 15.3], P = .858). The EQ-5D subscales improved in both groups. After 1 year, significantly more SG participants considered themselves improved (77.3% [SG] vs 50.0% [AG]; P = .04).

Conclusion: No differences in clinical effects were found between Alfredson and Silbernagel loading at up to 1-year follow-up. Both programs significantly improved clinical symptoms, and given their high adherence rates, offering either of them as a home-based program with limited supervision appears to be an effective treatment strategy for midportion AT.

Registration: NTR5638 (Netherlands Trial Register number).

Keywords: Achilles tendon; concentric; eccentric; exercise; loading; tendinopathy.