This review compared the effectiveness of eccentric exercise programmes with other treatments to manage chronic Achilles tendinosis in adults. The authors concluded that eccentric exercises should be considered as first line treatment. Given the variability in study methodology, interventions and outcome measures, the limited data reported by the studies and the limited data analysis, the authors' conclusions should be interpreted with caution.

To assess the evidence on the effectiveness of eccentric exercise programmes compared with other treatments for chronic Achilles tendinosis in adults.

MEDLINE, CINAHL, SPORTDiscus, PubMed, The Cochrane Central Register of Controlled Trials, AMED and Google Scholar were searched for articles in English and published between 1990 and September 2006. Search terms were reported.

Eligible studies were of patients aged 16 or over and treated with an intervention for clinically diagnosed symptoms of Achilles tendinosis. Symptoms were required to have been present for at least three months in one limb. Patients diagnosed with underlying pathologies such as rheumatoid arthritis or a previously ruptured tendon were excluded. Eligible studies could report any outcome measure for Achilles tendinosis (present for at least three months in one limb and confirmed by a clinical diagnosis) if it encompassed part of the International Classification of Functioning (impairments, activity limitations and participation restrictions), quality of life and patient satisfaction. Descriptive and observational/retrospective studies were excluded.

Included studies compared eccentric exercises, surgery, medication and electrotherapy with various comparators, administered at home or in a clinical setting and lasting between two weeks and six months. Included studies used varying outcome measures (a visual analogue scale (VAS) used most frequently) and reported pain on activity, rest or palpitation, strength, functional ability and patient satisfaction. Studies were conducted mainly in Scandinavia, but also the UK, Australia, Belgium and Italy.

The principal author identified relevant papers for inclusion, validated by a liaison librarian.

A modified version of the PEDro rating scale was used to critically appraise the included studies. Questions relating to patient and therapist blinding and allocation concealment were replaced by questions considered to be of greater clinical relevance to research on Achilles tendons: was there a clear description of the intervention?; were the outcome measures relevant and well described?; and were the outcome measures valid and reliable?. Studies were given a score out of 11 (11 representing the greatest methodological quality). Two reviewers independently assessed studies for methodological quality. Discrepancies were resolved through consensus.

Where reported, effect sizes were extracted directly from each study, where not reported they were calculated from the available data. The authors did not state how many reviewers performed the data extraction.

Data were presented as a narrative synthesis and in tables. The significance of the intervention results was classified as good (significant primary and secondary outcomes), fair (significant primary outcome) or equivocal (no significant change in any outcome).

Twenty five studies were included in the review (number of patients included was not reported and was not calculable): eight randomised controlled trials (RCTs); six randomised non-controlled studies; and 11 other design experimental studies. Five studies scored 10 or 11 on the PEDro scale and the remaining studies scored between five and nine.

All five studies using medication as the intervention and the majority of studies using eccentric training (seven studies) reported good results: significant changes in primary and some secondary outcome measures. Surgical studies (six studies) were spread evenly over good and fair results. One of each of the three electrotherapy studies was classified under each result category. Studies reporting effect sizes showed small and moderate treatment effects ranging from 0.14 to 0.6 (seven studies).

Eccentric exercises should be considered as first line management to improve function for chronic Achilles tendonosis.

The review objective was clear and the supporting inclusion criteria were broad. A comprehensive literature search was conducted using seven electronic databases. However, publications were restricted by language and, as it does not appear that a search was undertaken for unpublished papers, the potential for language and publication bias cannot be ruled out. Validity was assessed using a reliable scale. Steps were taken to try and minimise reviewer error and bias for study selection and validity assessment, but the same cannot be said for the data extraction process. Considering the methodological differences in studies and limited ability to calculate effect sizes from the study data available, a narrative synthesis was appropriate. The lack of patient characteristics presented in the review meant that it was difficult to determine whether the comparisons and included patients were comparable or relevant to the review question. The authors acknowledged that three of the studies reporting good results for eccentric exercises were only fair in quality. Given the variability in study methodology, interventions and outcome measures, the limited data reported by the studies and the limited data analysis, the authors' conclusions should be interpreted with caution.

Practice: the authors stated that surgery should not be used as the first line of management but the last resort as costs, rehabilitation time and inconvenience to the patient needed to be accounted for.

Research: The authors stated that future research should assess the effectiveness of any intervention for Achilles tendinosis using a standardised assessment protocol, including valid and reliable outcome measures that allowed comparison of results across studies. Future studies should use a valid, reliable and functional test for measuring outcomes that are relevant to the situations patients may encounter in real life. Further research was required to directly compare the effectiveness of eccentric exercises with other single or multiple treatment interventions.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.