How much compression can we push into for insertional Achilles rehab?
Should we go after compressive positions in insertional Achilles tendinopathy rehab?
Huge congratulations to Lauren Pringels and the team for tackling this tricky debate. Their recent RCT in BJSM compared a low compression rehab (LTCR) approach with a high compression protocol (HTCR) and found significantly better outcomes for the low compression group. The study was rigorous, well-reported, and offers important insights for clinicians navigating this challenging condition.
One issue that stood out was progression: both groups had similar adherence rates (~83%), but we weren’t told how well each group progressed through the exercise stages. This is critical, as the HTCR group may have simply struggled to progress due to provocation—raising the question of whether pain-limited progression through dorsiflexion might have been the fairer comparator, rather than full dorsiflexion from the outset.
In clinical practice, it is hard to justify starting with the high compression approach used here in the comparator group. So while the LTCR group performed better, it may be that the HTCR protocol simply set them up to fail. In my opinion, a more helpful comparison might have been the low compression approach they used vs. progressive dorsiflexion based on symptoms—this is the approach that I take, and I know others also take with these patients.
One of the main reasons I feel it is critical to take this approach, i.e. progress DF as tolerated and in insertional Achilles pain, is that there are potential tissue (muscle and tendon) adaptive benefits that are missed if we are too cautious with dorsiflexion. We also miss the opportunity to provide crucial training and confidence/self-efficacy for DF positions that they will encounter in sport.
These are just my thoughts. This does not detract from a high quality study which did answer the intended question - whether a low compression approach is better than a high compression approach. So the authors have moved is forward, which is commendable.
