Can infrared light therapy help with achilles tendinopathy, together with the usual eccentric exercises?
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Low level infrared light therapy and eccentric exercise for achilles tendinopathy
No need for eccentric exercises twice a day for achilles tendinopathy
Less frequent eccentric exercises make more biomechanical sense]
Higher power density infrared light therapy works better
Less frequent (painful) eccentric exercises for achilles tendinitis means better adherence to the training regime
Low level light therapy + Eccentric exercises twice a week = Improved results with achilles tendinopathy
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Low level infrared light therapy and eccentric exercise for achilles tendinopathy
The most common treatment regime for achilles tendon injury involves eccentric exercises to effect fibre remodelling.
However, low level light therapy (LED or laser), usually in the infrared range for improved penetration, is also used for soft tissue / sports injuries, such as tendinopathies, always in combination with exercise.
The randomized controlled trial listed below investigated the clinical effectiveness of an eccentric exercise regime for achilles tendinopathy and evaluated the additional benefits of photobiomodulation (low level light therapy, LLLT) as an adjunct treatment.
The study challenged the necessity of the intensive Alfredson protocol, which involves twice-daily eccentric exercises, and explores whether a reduced exercise regime combined with light therapy can yield superior outcomes in pain reduction and functional improvement.
The study’s primary objective was to determine the most effective eccentric exercise regimen for Achilles tendinopathy and assess whether light therapy could enhance treatment outcomes. Participants were divided into four groups: two groups followed the Alfredson protocol (twice-daily exercises), and two groups performed a reduced regime of two exercise sessions per week.
Within each exercise regime, one group received light therapy, while the other did not. Outcomes were measured using the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire and the Numeric Pain Rating Scale (NPRS), alongside tendon thickness measurements.
No need for eccentric exercises twice a day for achilles tendinopathy
A key finding was that the Alfredson protocol, despite its widespread use, is not essential for achieving meaningful improvements in pain and function.
The groups performing the reduced regimen of two sessions per week showed comparable results to those following the Alfredson protocol.
In fact, a moderate effect size of 0.7 favoured the reduced regime, suggesting that less frequent exercise may be equally or more effective.
This finding aligns with a Scottish study that compared the Alfredson protocol to a "do as tolerated" approach, reporting no significant differences at six weeks. The current study extends this observation over a 12-week period, a common intervention duration in similar trials.
Less frequent eccentric exercises make more biomechanical sense
The rationale for the reduced regime is rooted in tendon mechanotransduction, the process by which mechanical loading stimulates tendon remodelling.
Research indicates that remodelling peaks 72 hours post-exercise, supporting the idea that spacing exercise sessions 2–3 days apart may optimise tendon repair. In contrast, the twice-daily Alfredson protocol lacks justification for its frequency, as it does not align with the biological timeline of tendon remodelling.
Another study comparing twice-daily eccentric loading to a three-times-weekly heavy slow resistance regimen also reported comparable outcomes, further questioning the necessity of intensive daily exercises.
Higher power density infrared light therapy works better
Low level light therapy, or photobiomodulation, was introduced as an adjunct to the exercise regimens. While evidence for light therapy in tendinopathy has been mixed, this study used infrared laser light at 810 and 980 nm wavelengths and at a high power density (222 mW/cm² over the treated area, for 30 seconds) exceeding recommended guidelines, yet still achieved positive results.
Both LLLT groups exhibited greater improvements in VISA-A and NPRS scores compared to the non-light therapy groups. However, the most significant gains were observed in the group combining light therapy with the reduced exercise regimen. This group demonstrated statistically significant improvements over the other three groups, with effect sizes ranging from large to very large.
Infrared light therapy works slowly but has long-term results
Interestingly, the benefits of light therapy were not immediately apparent at the end of the four-week treatment phase but became more pronounced at the 12-week follow-up. This delayed effect mirrors findings from a meta-analysis of laser acupuncture for musculoskeletal pain, suggesting that light therapy may contribute to longer-term tissue repair or pain modulation. The exact mechanism for this delayed benefit remains unclear and warrants further investigation.
Less frequent (painful) eccentric exercises for achilles tendinitis means better adherence to the training regime
Compliance was another critical factor. The Alfredson protocol, which requires exercising with pain and performing multiple daily sessions, often raises adherence issues. In this study, compliance was 100% for the reduced regimen groups but only 70% for the Alfredson protocol groups.
Systematic reviews on eccentric exercise for tendinopathy have highlighted the lack of standardised compliance reporting, making it challenging to establish the most efficacious regimen. The high compliance in the reduced regimen groups suggests that less demanding protocols may be more practical for patients, potentially improving real-world outcomes.
Low level light therapy + Eccentric exercises twice a week = Improved results with achilles tendinopathy
In conclusion, this trial provides compelling evidence that a reduced eccentric exercise regimen of two sessions per week is as effective as, or potentially more effective than, the intensive Alfredson protocol for achilles tendinopathy.
The addition of high-dose light therapy further enhances outcomes, particularly when combined with the reduced regimen, offering large to very large effect sizes.
These findings challenge the conventional reliance on arduous daily exercises and highlight the potential of photobiomodulation as a valuable adjunct therapy.
Future studies could explore optimal exercise dosing, the mechanisms of light therapy’s delayed benefits, and strategies to improve patient compliance, ultimately refining treatment protocols for Achilles tendinopathy.
Photobiomodulation and eccentric exercise for Achilles tendinopathy: a randomized controlled trial
Research paper link: https://pubmed.ncbi.nlm.nih.gov/26610637
Abstract: Background: The common regime of eccentric exercise in use for Achilles tendinopathy is somewhat arduous and compliance issues can arise. This is the first study to investigate the effectiveness of a regime of fewer exercise sessions combined with photobiomodulation for the treatment of Achilles tendinopathy. Methods: A double blind randomized controlled trial and intention-to-treat analysis were performed. Eighty participants, 18-65 years with Achilles tendinopathy and symptoms for longer than 3 months, were included in the trial. Participants randomized into one of four groups; 1 (Placebo + Ex Regime 1) or 2 (Laser + Ex Regime 1) or 3 (Placebo + Ex Regime 2) or 4 (Laser + Ex Regime 2). The primary outcome measure was the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. Outcomes were collected at baseline, week 4 and week 12. Results: Sixteen participants were lost to follow-up at 12 weeks, 4 of which due to adverse reactions. As per intention to treat, missing data were imputed, 80 participants were included in the final analysis. For VISA-A at 12 weeks, group 4 achieved significant gains over the other 3 groups: group 1 (18.5 [9.1, 27.9]), group 2 (10.4 [1.5, 19.2]), group 3 (11.3 [3.0, 19.6]). There was a moderate effect size in favour of exercise twice per week (7.2 [-1.8, 16.2], ES .7). Conclusions: Twice-daily exercise sessions are not necessary as equivalent results can be obtained with two exercise sessions per week. The addition of photobiomodulation as adjunct to exercise can bring added benefit.
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