In one of our earlier blog entries, we recommended against manual therapy as a treatment option for tendinopathy. Today, we came across new research suggesting pressure massage to be superior to eccentric exercises. Were we wrong?

For context, you should check out Nine High Value Tips For Your Tendon Pain: From a Chiropractor’s Perspecive.

We are big on exercise and we used the latest research evidence to justify why we became an exercise-only practice six months ago. Imagine our surprise this morning when we came across a study published last month telling us that massage might just work as well as exercise. Well, does it?

Eccentric exercise for Achilles Tendinopathy

In this particular study, the first group of participants were assigned to a 12-week eccentric exercise program. The exercise was based on a 1998 eccentric training model published in the highly regarded paper Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis by Alfredson et al.

In the 1998 protocol, participants were instructed on how to perform the exercises at the start and in the middle of the 12-week program. They were asked to do their exercises twice daily for seven days a week through the entire 12 weeks. The two exercises were a straight-leg eccentric loading of the calf muscle as well as a bent-leg eccentric loading of the soleus (also part of the calf). They were to do 3 sets of 15 repetitions for each of the exercises. Participants were advised that some soreness in the first two weeks are expected.

chiropractor singapore, singapore chiropractor, sports chiropractor
The 2019 eccentric exercise protocol

In this 2019 study, participants were prescribed with the same exercises. However, the protocol was tweaked so that participants only reach 3×15, twice daily dose from the third week onwards.

Also, in this study, participants only had one session with a physiotherapist with no follow ups.

Massage for Achilles Tendinopathy

This is when things get really, really bizarre.

The massage group saw a physiotherapist for a total of 18 times through the 12-week program (compared to just once for the eccentric group)! They participants received massage twice a week for the first six weeks followed by once weekly for the remaining six weeks. The treatment provided by the physiotherapists were comparable to pressure point or trigger point massage where pressure is applied to a tender spot until the tenderness resolves.

Combination group

The combination group received both interventions. I.e. the 18 sessions of massage plus the eccentric exercise instruction and home exercise program.

What did the study find?

Pressure massage did result in better outcomes than eccentric exercises at four weeks but what the authors failed to highlight was that there was no difference in long-term results.

It should also be mentioned that 20% (double what the authors expected) of the participants from the eccentric exercise group dropped out of the study.

Lastly, there was no report on adherence to the exercise program.

So, does trigger point massage work for tendinopathy?

Um, no. The study is poorly designed and we are not convinced that massage is a favourable treatment option for Achilles tendinopathy. As we mentioned in our previous post on tendon pain, exercise has been the cornerstone of tendinopathy treatment for the past decades. As of today, research supporting manual therapy are still poorly designed and does not allow us to draw any meaningful information from it.

Yes, this study did indeed demonstrate that massage showed favourable results to eccentric exercises at four weeks. We are not contesting that. However, it should be well noted that the massage group participants received pressure massage twice a week for the first six weeks. We already know that there is some, but weak to moderate, evidence supporting that manual therapy does help with short-term pain. So, this is no surprise. It is likely that the improvement is from the last massage received by the participants. As this study also demonstrated, there is no long-term superiority in spite of the participants still receiving weekly massages!

It is completely bizarre to compare a 18-treatment program against a 1-treatment program. To make things worse, there was no reporting on if the participants in the eccentric exercise group even did their exercises. This is a big, big fault of the study design. If we do not know if the participants did the home exercise in the first place, how do we know if the program works? It seems this study was designed to fail in the first place.

We are sorry but we still certain manual therapy is not the solution for you.

To find out more about what we do at Square One, check out our other blog posts at: