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Research Review By Dr. Ceara Higgins©


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Date Posted:

April 2016

Study Title:

The effectiveness of exercise on recovery and clinical outcomes of soft tissue injuries of the leg, ankle, and foot: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration


Woitzik E, Jacobs C, Wong J, et al.

Author's Affiliations:

UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation; University of Ontario Institute of Technology (UOIT); Canadian Memorial Chiropractic College (CMCC); Department of Emergency Medicine, Kingston General Hospital and Hotel Dieu Hospital, Queen’s University; Toronto Health Economics and Technology Assessment (THETA) Collaborative; Faculty of Pharmacy, University of Toronto; Institute for Work and Health, Toronto, Ontario; School of Public Health, University of Alberta.

Publication Information:

Manual Therapy 2015; 20: 633-645

Background Information:

Injuries of the leg, ankle, and foot are common, making up 17.4% of all workers’ compensation claims in Ontario (18) and occurring in 27.5% of adults in Saskatchewan after a traffic collision (5). Commonly diagnosed soft tissue injuries in these areas include ankle sprains, Achilles tendinopathy, and plantar fasciitis. In the United States, it is estimated that 23,000 lateral ankle sprains occur each day (7) and account for 15-25% of sports related injuries worldwide (3). In Dutch patients mid-portion Achilles tendinopathy was seen in 1.85 patients per 1000 (6) and in the general population is most common in men between 35 and 45 years of age (17). Plantar fasciitis has a lifetime incidence of 10% and every year, approximately two million Americans seek treatment for the condition (14).

Ankle sprains are commonly treated with exercise (8) and previous systematic reviews have shown faster recovery and return to sport when supervised exercise is added to usual care for acute ankle sprains (9) and that exercise, including balance or neuromuscular training, is effective in preventing recurrent ankle sprains (11). Systematic reviews on Achilles tendinopathy have found insufficient evidence to support the effectiveness of eccentric exercise (17).

This review sought to evaluate the effectiveness of exercise therapy for these common soft tissue injuries of the leg, ankle, and foot when compared to other interventions, placebo/sham interventions, or no intervention.

Pertinent Results:

6 studies were included in this review. All were RCTs and all showed a low risk of bias. Two assessed the effectiveness of exercise as a treatment for adults with recent lateral ankle sprains (15, 2), two assessed the effectiveness of stretching for adults with acute (16) and sub-acute (13) plantar fasciitis, and two assessed the effectiveness of eccentric training for adults with chronic (10) and variable duration (19) Achilles tendinopathy. No studies were found that evaluated exercise in children with leg, ankle, or foot injuries. The findings are presented by type of disorder.

Recent Lateral Ankle Sprains

Accelerated exercise program versus standard exercise program:
Bleakley et al. (2) showed similar outcomes for patients with recent grade I-II lateral ankle sprains receiving an accelerated exercise program compared to a standard exercise program. The accelerated program included flexibility, strengthening, proprioceptive exercises and basic advice (ice and compression twice daily) during the first week post-injury. The standard group received the same basic advice, but no exercises for the first week. Both groups were then prescribed exercises by a physiotherapist and underwent five 30-minute sessions of exercises per week for weeks one to four. One session per week was supervised by a physiotherapist and four were performed at home. Statistically significant, but not clinically significant differences in function, favoring the accelerated exercise, were seen within the first two weeks post-intervention.

Supervised exercise program:
van Rijn et al. (15) showed that the addition of progressive exercises to education and advice provided no additional benefits over education and advice alone when managing recent grades I-III lateral ankle sprains. Both groups received information on early ankle mobilization, advice for early home exercise, and early weight bearing. The exercise group also received a 3-month, progressive, supervised exercise program, including balance exercises, walking, running, and jumping progressions. Individuals in the exercise group were more likely to report satisfaction with treatment at a three month follow up. However, there were no statistically significant differences in subjective recovery, range of motion, re-sprain rate, or reported or tested instability either immediately or at 12 months post-intervention.

Mid-portion Achilles tendinopathy

Eccentric training:
Peterson et al. (10) compared eccentric exercise training to wearing an AirHeel brace in patients with persistent mid-portion Achilles Tendinopathy (> 3 months). Participants were placed in one of three groups: 1) eccentric exercise training (straight leg and knee bent eccentric exercises for the gastrocnemius, soleus, and Achilles tendon three times/day for 12 weeks); 2) wearing an AirHeel daytime brace for 12 weeks; or 3) a combination of eccentric exercises and wearing an AirHeel daytime brace. It should be noted that the combination group in this study did not meet inclusion criteria due to the low sample size (n = 28 participants – close!) and was not considered for this review. Statistically significant, but not clinically significant differences were found favoring the exercise group in pain during daily activities and gait and general health status immediately post-intervention. However, Zhang et al. (19) showed eccentric exercises to be less effective than acupuncture for reducing the severity of symptoms in the short-term in individuals with Achilles tendinopathy of variable duration. Participants were randomized to: 1) eccentric exercises of the gastrocnemius and soleus muscles with the option of progressing with weights (frequency and duration of exercises was not reported); or 2) needle acupuncture inserted around the Achilles tendon (three sessions per week over eight weeks). Both groups also received information and reassurance about the course of symptoms and were allowed to use non-steroidal anti-inflammatory medications. Clinically and statistically significant differences favoring acupuncture were seen in severity of symptoms, both immediately post-intervention and at eight weeks. Statistically significant, but not clinically significant, differences were seen favoring acupuncture in severity of symptoms at a 16 week follow-up and in pain reduction immediately post-intervention, but not at 8 or 16 weeks.

Plantar Heel Pain

Radford et al. (13) found that static triceps surae stretching leads to similar outcomes as sham ultrasound as a treatment for subacute plantar heel pain (> 4 weeks). The stretching group was asked to perform a static stretch on a wooden wedge in 1 min intervals for a minimum of 5 min per day over 2 weeks. Both the stretching and control groups received 3 min of sham ultrasound to the painful heel. No clinically or statistically significant differences were found between groups for any outcome measures. Rompe et al. (16) showed statistically significant differences, immediately and four months post-treatment, in foot function and patient relevant outcome measures in favor of static plantar fascia stretching when compared to radial shockwave therapy in patients with acute plantar fasciopathy (< 6 weeks). The differences in foot function immediately post-treatment were also clinically significant. Patients in the stretching group performed a static plantar fascia stretch with specific exercises three times per day for eight weeks, while patients in the shockwave therapy group received three sessions of radial shockwave therapy over a three week period to the area of maximal tenderness.

Adverse Events

Four of the studies included reported on adverse events with no serious adverse events reported. In the Rompe et al. study (16), 100% of the patients receiving shockwave reported transient skin reddening and 8% of the shockwave group and 15% of the stretching group reported pain with treatment. In the study by Peterson et al. (10), 14% of participants dropped out of the study due to severe pain during exercises or discomfort due to poor fitting of the brace. However, no exact group-specific numbers were reported. Finally, in the study by Radford et al. (13), 4% of participants in the stretching group reported increased pain, 4% reported calf pain, 2% reported new lower limb pain, and 2% discontinued due to an unspecified adverse event.

Clinical Application & Conclusions:

In patients with recent lateral ankle sprains, similar outcomes are seen with an accelerated exercise program and exercises given one week post-injury, allowing patient preference and tolerance to play a greater role in guiding the initiation of treatment. In addition, since the addition of supervised exercise offers no additional benefits over education and advice (including home exercises), patient compliance to home care and preference may also be considered.

For patients with mid-portion Achilles tendinopathy of greater than two months duration, exercise may be more effective than a daytime AirHeel brace, but less effective than acupuncture.

In patients with plantar heel pain, plantar fascia stretching was shown to be more effective than shockwave therapy, while calf stretching was no more effective than sham ultrasound. This should lead clinicians to focus on stretching the plantar fascia rather than the calf muscles in these patients.

Study Methods:

MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane Central Register of Controlled Trials were searched from January 1st, 1990 to February 4th, 2015 and citation titles and abstracts were screened by random pairs of independent reviewers, who classified studies as relevant, possibly relevant, or irrelevant. The reviewers then screened the full text of articles deemed possibly relevant to determine eligibility. In the case of disagreements, reviewers met to reach consensus and a third reviewer was consulted if that was not possible.

Inclusion Criteria:
  • Randomized controlled trails (RCTs), cohort studies, or case-control studies published in English.
  • Adults or children with leg, ankle, and foot soft tissue injuries (including grade I-II sprain and strain injuries). Studies including patients with grade III injuries were only included if the results were separated by injury grade or an equal number of individuals with grade III injuries were included in each group.
  • Supervised or unsupervised exercises, with exercise being defined as “specific movements performed as routine practice or physical training to train or develop the body to promote good physical health and restore normal function of the joints and surrounding soft tissues” (1).
  • Studies that compared exercise to other forms of exercise, other interventions, waiting list, or no intervention.
  • Outcome measures including one of the following: 1) self-rated recovery; 2) functional outcomes (ex. Return-to-work, activities, or school); 3) clinical outcomes (ex. pain intensity, disability, quality of life); 4) administrative outcomes (ex. time on disability benefits); or 5) adverse events.
  • A minimum inception cohort of 30 subjects per treatment arm with the specified condition for RCTs, or 100 subjects per exposed group with the specified condition for cohort or case-control studies.
Exclusion Criteria:
  • Studies exclusively on grade III sprains/strains, amputations, joint dislocations/subluxations, fractures, malignancy, infections, and osteoarthritis.
  • Studies that included exercise as a single component of a multimodal program. Exercise combined with patient education/instruction on exercises was not considered a multimodal program.
  • Letters, editorials, commentaries, unpublished manuscripts, dissertations, government reports, books and book chapters, conference proceedings, meeting abstracts, lectures and addresses, consensus development statements, guideline statements.
  • Pilot studies, cross-sectional studies, case reports/series, qualitative studies, clinical practice guidelines, systematic reviews, narrative reviews, biomechanical studies, laboratory studies, studies not reporting on methodology.
  • Cadaveric or animal studies.
Eligible studies were evaluated for internal validity using the Scottish Intercollegiate Guidelines Network (SIGN) criteria (4). This specifically assesses for the presence of selection bias, information bias, and confounding and determines what impact these may have on the internal validity of the study. The reviewers focused on methodological flaws, including:
  1. clarity of the research question;
  2. randomization method;
  3. concealment of treatment allocation;
  4. blinding of treatment and outcomes;
  5. similarity of baseline characteristics between/among treatment arms;
  6. co-intervention contamination;
  7. validity and reliability of outcome measures;
  8. follow-up rates;
  9. analysis according to intention-to-treat principles; and
  10. comparability of results across study sites.
Data was extracted by a single reviewer and independently checked by a second reviewer. Evidence statements were developed using a qualitative synthesis of findings and minimal clinically importance difference (MCID) was used to determine the clinical significance of the results in each trial. Results were then stratified by type of disorder.

Study Strengths / Weaknesses:

  • The search strategy was robust and developed with the assistance of a health sciences librarian and reviewed by a second librarian.
  • Inclusion and exclusion criteria were explicitly defined.
  • Only studies with adequate sample sizes and clearly defined cohorts of individuals with leg, ankle, or foot injuries were considered.
  • Two independent reviewers were involved in the critical appraisal and screening in order to minimize error and bias and the SIGN criteria was used to standardize the critical appraisal process.
  • All conclusions were based on the best evidence synthesis method to minimize the risk of bias with using low quality studies.
  • Despite being strong and comprehensive, the search may not have retrieved all relevant citations, partly because only English language studies were included.
  • Requiring an n ≥ 30 per treatment arm may exclude studies with adequate power to detect a statistically significant difference.

Additional References:

  1. Abenhaim L, Rossignol M, Valat JP, et al. The role of activity in the therapeutic management of back pain. Report of the International Paris Task Force on Back Pain. Spine 2000; 25(4 Suppl): 1S-33S.
  2. Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomized controlled trial. BMJ 2010; 340: c1964.
  3. Ferran NA, Maffulli N. Epidemiology of sprains of the lateral ankle ligament complex. Foot Ankle Clin 2006; 11(3): 659-662.
  4. Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ 2001; 323(7308): 334-336.
  5. Hincapie CA, Cassidy JD, Cote P, et al. Whiplash injury is more than neck pain: a population-based study of pain localization after traffic injury. J Occup Environ Med 2010; 52(4): 434-440.
  6. deJonge S, van den Berg C, de Vos RJ, et al. Incidence of midportion Achilles tendinopathy in the general population. Br J Sports Med 2011; 45(13): 1026-1028.
  7. Kannus P, Renstrom P. Treatment for acute tears of the lateral ligaments of the ankle. Operation, cast, or early controlled mobilization. J Bone Joint Surg (Am) 1991; 73(2): 305-312.
  8. Kerkhoffs GM, van den Bekerom M, Elders LA, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med 2012; 46(12): 854-860.
  9. van Os AG, Bierma-Zeinstra SM, Verhagen AP, et al. Comparison of conventional treatment and supervised rehabilitation for treatment of acute lateral ankle sprains: a systematic review of the literature. J Orthop Sports Phys Ther 2005; 35(2): 95-105.
  10. Peterson W, Welp R, Rosenbaum D. Chronic Achilles tendinopathy: a prospective randomized study comparing the therapeutic effect of eccentric training, the AirHeel brace, and a combination of both. Am J Sports Med 2007; 35(10): 1659-1667.
  11. Peterson W, Rembitzki IV, Koppenburg AG, et al. Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg 2013; 133(8): 1129-1141.
  12. Pijnenburg AC, Van Dijk CN, Bossuyt PM, et al. Treatment of ruptures of the lateral ankle ligaments: a meta-analysis. J Bone Joint Surg (Am) 2000; 82(6): 761-773.
  13. Radford JA, Landorf KB, Buchbinder R, et al. Effectiveness of calf muscle stretching for the short-term treatment of plantar heel pain: a randomized trial. BMC Musculoskelet Disord 2007; 8: 36.
  14. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int 2004; 25(5): 303-310.
  15. van Rijn RM, van Os AG, Kleinrensink GJ, et al. Supervised exercises for adults with acute lateral ankle sprain: a randomized controlled trial. Br J General Pract 2007; 57(543): 793-800.
  16. Rompe JD, Cacchio A, Weil Jr L, et al. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg (Am) 2010; 92(15): 2514-2522.
  17. Wasielewski NJ, Kotsko KM. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review. J Athl Train 2007; 42(3): 409-421.
  18. Workplace safety and Insurance board (WSIB) Statistical Supplement. 2012.
  19. Zhang BM, Zhong LW, Xu SW, et al. Acupuncture for chronic Achilles tendinopathy: a randomized controlled study. Chin J Integr Med 2013; 19(12): 900-904.

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