Table 1.
Definitions of, and criteria for, return to sport, as described in the included studies (similar to open coding of the content analysis)
| Study (year of publication) | Design | Population; n, sex; average age ± SD level and type of sport | Diagnosis | Definition of RTS | Criteria for RTS | RR residual symptoms |
|---|---|---|---|---|---|---|
| Alfredson et al. [43] (1998) | CCT | 15 Athletes; 12 F, 3 M; 44.3 ± 7.0 years Recreational running 15 Athletes; 4 F, 11 M; 39.6 ± 7.9 years Recreational running and soccer |
Achilles tendinosis: pain located in the Achilles tendon (2–6 cm above insertion on the calcaneus) for at least 3 months | Back at their pre-injury levels with full running activity Resumption of previous running activity |
Running activity was allowed if it could be performed with only mild discomfort and no pain | RR not reported VAS mean 4.8/10 after returning to pre-injury activity level |
| Alfredson and Cook [20] (2007) | Narrative review | NA | Achilles tendinopathy: Achilles mid-tendon pain, focal or generalized swelling | Back to previous tendon-loading activity level Back to previous activity level |
Not reported | Both not reported |
| Ammendolia et al. [51] (2016) | RCT | 19 Athletes; sex not reported; 28.3 ± 4.9 years 16 athletes; sex not reported; 28.8 ± 4.4 years Elite volleyball |
Overuse Achilles tendinitis | Resumption of training in the gym; Return to play volleyball |
Not reported | RR not reported VAS mean 3.8–4.9 when return to training in the gym VAS mean 0.6–2.4/10 when RTS |
| Barry [33] (2010) | Case study | 1 M; 40 years Recreational running |
Achilles tendinopathy | Returns to his training schedule without limitations | Not reported | Both not reported |
| Beyer et al. [22] (2015) | RCT | 25 Recreational athletes; 7 F, 18 M; 48 ± 2 years 22 recreational athletes; 8 F, 14 M; 48 ± 2 years Recreational level, type not reported |
Chronic unilateral midportion Achilles tendinopathy, based on defined clinical findings (VISA-A score and VAS scale), physical examination, and pain duration of at least 3 months; and US findings needed to be present, i.e. local A-P thickening of the midtendon level, with a hypoechoic area and a color Doppler signal within the hypoechoic area | Resumed their previous activity levels | Sporting activities should be performed with a discomfort not exceeding 30 mm on the VAS | Both not reported |
| Biedert et al. [42] (2006) | Clinical commentary | NA | Not reported | Return to physical fitness/former sport activities. Physical fitness can be divided into general and sports-specific physical fitness The authors further describe a stepwise progression from sports-specific training to match-specific training to match training |
The return to former sports activities depends on different factors such as structural healing, functional re-integration, physical examination, and specific investigations and tests, as well as individual goals and mental aspects | Both not reported |
| Chazan [30] (1998) | Narrative review | NA | Achilles tendinitis, Achilles tendinosis | Return/resumption to full activity | Not reported | Both not reported |
| Chessin [41] (2012) | Narrative review | NA | Achilles tendinitis: an inflammation of the tendon Achilles tendinosis: a chronic, non-inflammatory condition that is consistent with degenerated tissue and disorganized tendon structure |
Not reported | Capable of maintaining full dynamic load and controlling directional and speed changes with confidence. This requires progressive training for a balance of strength and flexibility, as well as building endurance and proprioceptive control | Both not reported |
| Chinn and Hertel [37] (2010) | Narrative review | NA | Achilles tendonitis: an inflammatory condition that involves the Achilles tendon and/or its tendon sheath. Typically, the athlete will suffer from gradual pain and stiffness in the Achilles tendon region, 2–6 cm proximal to the calcaneal insertion | Full participation at full functioning Full competition Graduated return to physical activity Safe return to sport while minimizing the risk of recurrent injuries |
Athletes should be allowed to compete when full range of motion and strength has returned. The athlete should have regained endurance in the involved limb and be capable of completing full practice without pain | Both not reported |
| Cook et al. [16] (2002) | Masterclass report | NA | Not reported | Return to training and competition | Inadequate amounts of load, speed and endurance may result in incomplete rehabilitation and insufficient musculotendinous function to return to sport | Both not reported |
| De Vos et al. [29] (2007) | RCT | 32 Athletic patients; 12 F, 20 M; 44.1 ± 7 years 31 athletic patients; 14 F, 17 M; 45.1 ± 8.9 years Recreational level, type not reported |
Achilles tendinopathy: a tendon that was tender on palpation and painful during or after sport. The tendon thickening was located approximately 2–7 cm proximal to the distal insertion. Diagnosis was based on clinical examination | Return to their original level of sports | After 4 weeks, gradual return to sports activities was encouraged if the pain allowed it | Both not reported |
| Dijkstra and Van Enst [52] (2003) | Retrospective cohort study | 9 Patients; 4 F, 5 M; 43.2 years (range 26–65) Level not reported, athletics (n = 6) |
Achilles tendinosis; diagnosis based on history and clinical examination | Fully functional at the original sports level | Not reported | Both not reported |
| Fahlström et al. [19] (2003) | Pre-post study | 78 patients; 25 F, 53 M; 46.1 ± 9.5 years Recreational level, running, walking and other sports |
Chronic painful Achilles tendinosis at the midportion of the tendon (2–6 cm from the tendon insertion), with a duration of at least 3 months. Diagnosis based on clinical examination (painful nodular thickening of the Achilles tendon located at the level 2–6 cm from the tendon insertion) and US (local thickening of the tendon, irregular structure with hypoechoic areas and irregular fiber orientation) |
To return to previous (before injury) activity level Come back to previous (before injury) activity level To be able to participate in his/her desired sports/recreational activities Be fully active in their sport |
During the 12-week training regimen, jogging/walking activity was allowed if it could be performed with only mild discomfort and no pain Patients were instructed to start jogging or walking at a slow pace, on flat ground, and for a short distance. Thereafter, their activity could be gradually increased if there was no severe pain in the tendon (similar to Mafi et al. 2001 [7]) |
RR not reported VAS mean 10.2/100 after returning to previous activity level |
| Giombini et al. [26] (2002) | RCT | 44 Athletes; 11 F, 33 M; 26.0 ± 4.6 years Competitive level, type not reported |
Achilles tendinopathy: pain and tenderness on palpation at the midportion of the tendon or at the distal insertion, associated with tendon swelling (diffuse or localized) | Full return to their pre-injury sport level A full return to sport Return to specific sport activity |
Not reported | RR not reported ~ 25% of athletes reported occasional discomfort after RTS |
| Herrington and McCulloch [17] (2007) | RCT | 13 Patients; sex not reported; 37.0 ± 9.3 years 12 patients; sex not reported; 36.6 ± 7.1 years Achilles loading sports, level and type not specifically reported |
Non-insertional Achilles tendinopathy; local Achilles pain, stiffness or functional impairment on activity | Full return to the desired level of activity Full return to activity Returned to their previous activity levels |
Not reported | Both not reported |
| Kountouris and Cook [23] (2007) | Narrative review | NA | Achilles tendinopathy | Return to pre-injury levels of activity Return to competition |
To achieve return to pre-injury activity levels, rehabilitation program must incorporate some general principles of exercise program design, such as strength, endurance, power, and a gradual return to sports-specific function | Both not reported |
| Lakshmanan and O’Doherty [28] (2004) | Pre-post study | 15 Patients (16 tendons); 3 F, 12 M; 48.5 years (range 35–77) Active sports, level and type not specifically reported |
Chronic non-insertional Achilles tendinopathy, for more than 6 months; diagnosis confirmed by US | Return back to their normal activities Return to full training activities with no limitation Returning back to the original level of physical activity in active sports persons Return back to their sports activities |
Not reported | Both not reported |
| Langberg et al. [53] (2007) | CCT | 6 Elite soccer player patients; 6 M; 26 ± 1 year (the non-injured tendon served as a control) Elite soccer |
Unilateral Achilles tendinosis: pain 30–60 mm above the Achilles tendon insertion on the calcaneus | Return to the previous level of physical activity Back playing soccer |
Subjects were allowed to continue soccer training if the pain had not increased | RR not reported VAS mean 13/100 after resuming soccer |
| Mafi et al. [7] (2001) | RCT | 22 Patients; 10 F, 12 M; 48.1 ± 9.5 years 22 patients; 10 F, 12 M; 48.4 ± 8.3 years Recreational level, jogging and walking |
Painful chronic Achilles tendinosis located at the 2–6 cm level in the tendon. Diagnosis based on clinical examination and US | Resumed their previous activity level (before injury) | During the 12-week training regimen, jogging/walking activity was allowed if it could be performed with only mild discomfort and no pain Patients were instructed to start jogging or walking at a slow pace, on flat ground, and for a short distance. Thereafter, their activity could be gradually increased if there was no severe pain in the tendon |
RR not reported VAS mean 9–12/100 after resuming previous activity level |
| McShane et al. [34] (2007) | Narrative review | NA | Non-insertional Achilles tendinopathy | Pain-free return to activity Back to their pre-injury level training regimen Returned to pre-injury training levels |
Not reported | Both not reported |
| Nicola and El Shami [35] (2012) | Clinical commentary | NA | Midportion Achilles tendinopathy | Return to running without pain | Daily activities should be pain-free before returning to training For soft tissue injuries, there should be minimal residual tenderness In general, a period of 1–2 weeks of pain-free daily activities should be present before any consideration of return to running No running until patient is able to walk comfortably at 4.0 mph for 10 miles per week |
Both not reported |
| Paavola et al. [24] (2000) | Pre-post study | 83 Patients; 22 F, 61 M; 32 ± 11 years Competitive and recreational level, running and orienteering |
A diagnosis of unilateral, non-chronic Achilles tendinopathy based on clinical examination (defined as exertional pain and palpable tenderness in the Achilles tendon of < 6 months’ duration) | Returned to their pre-injury level of physical activity Fully recovered their physical activity level |
Not reported | Both not reported |
| Paavola et al. [36] (2002) | Review | NA | Combination of Achilles tendon pain, swelling, and impaired performance | To return the patient to the desired level of physical activity without residual pain. In athletes, an additional demand is that the recovery time should be as short as possible Able to return to full levels of physical activity |
Not reported | Both not reported |
| Petersen et al. [25] (2007) | RCT | 37 Patients; 14 F, 23 M; 42.5 ± 11.1 years 35 patients; 15 F, 20 M; 42.6 ± 10.7 years 28 patients; 11 F, 17 M; 43 ± 12 years Recreational level, running, walking and other sports |
Gradually evolving painful condition in the Achilles tendon located at the midportion, for at least 3 months; diagnosis based on clinical examination and US | Return to pre-injury sports level Full recovery to previous activity level |
Jogging, walking and cycling were allowed if they could be performed with only mild discomfort or pain | Both not reported |
| Rompe et al. [31] (2007) | RCT | 25 Patients; 16 F, 9 M; 48.1 ± 9.9 years 25 patients; 14 F, 11 M; 51.2 ± 10.3 years 25 patients; 16 F, 9 M; 46.4 ± 11.4 years Athletic patients, level and type not specifically reported |
Pain over the main body of the Achilles tendon 2–6 cm proximal to its insertion, swelling and impaired function; clinical examination and US | Return to their normal levels of activity Return to full activity is possible |
During the 12-week training regimen, jogging/walking activity was allowed if it could be performed with only mild discomfort and no pain Patients were instructed to start jogging or walking at a slow pace, on flat ground, and for a short distance. Thereafter, their activity could be gradually increased if there was no severe pain in the tendon (similar to Mafi et al. 2001 [7]) |
Both not reported |
| Rompe et al. [21] (2009) | RCT | 34 Patients; 20 F, 14 M; 46.2 ± 10.2 years 34 patients; 18 F, 16 M; 53.1 ± 9.6 years Athletic patients, level and type not specifically reported |
Pain over the main body of the Achilles tendon 2–6 cm proximal to its insertion, swelling and impaired function; clinical examination and US | Return to full activity Return to their previous sports/recreational activity level |
During the 12-week training regimen, jogging/walking activity was allowed if it could be performed with only mild discomfort and no pain Patients were instructed to start jogging or walking at a slow pace, on flat ground, and for a short distance. Thereafter, their activity could be gradually increased if there was no severe pain in the tendon (similar to Mafi et al. 2001 7) |
Both not reported |
| Roos et al. [6] (2004) | RCT | 44 Patients; 23 F, 21 M; 46 years (range 26–60) Active in sport, level and type not specifically reported |
Pain and swelling 2–6 cm proximal of the Achilles tendon insertion | Returned to their pre-injury activity level | Not reported | RR not reported 27–50% of patients reported moderate to extreme difficulties after returning to pre-injury activity level |
| Ross et al. [54] (2018) | Case report | 1 M; 23 years Semi-professional volleyball |
Site of maximal tenderness 4 cm proximal to the Achilles insertion; clinical examination | Return to peak performance Return to volleyball Return to professional sport performance |
Not reported | Both not reported |
| Silbernagel et al [39]. (2011) | Case series (follow-up of an RCT) | 34 Athletes; 16 F, 18 M; 51.0 ± 8.2 years Recreational level, type not specifically reported |
Clinical diagnosis of a combination of Achilles tendon pain, swelling and impaired performance | Not reported | LSI below the level of 90% often used as a guideline for return to sports | 5/34 Patients reported recurrence of symptoms after 5 year follow-up Symptoms not reported |
| Silbernagel and Crossley [8] (2015) | Clinical commentary | NA | Overuse injury, characterized by a combination of pain, swelling (diffuse or localized) and impaired performance; midportion Achilles tendinopathy is located 2–6 cm proximal to the insertion of the tendon on the calcaneus; based on history and physical examination | Return to sport with a low risk of re-injury or risk for other injuries Return to sport and previous activity level Back to sport participation Full return to sports Full sports participation Return to full sports activity |
Resumption of activities such as running and jumping is generally recommended when the symptoms have subsided There are various factors that need to be considered when planning a return to sport after Achilles tendinopathy. The most obvious factor is the level of pain with physical activity. Other important factors that need to be included in the decision-making process are the healing and recovery of the tendon tissue, the recovery of strength, range of motion, and function, as well as the demands of the specific sport Return-to-sport activity may be started prior to complete absence of symptoms Addressing calf muscle weakness and/or muscle imbalance, and altered joint mobility of the foot and ankle complex, with the aim of regaining full capacity, is important for athletes prior to full sports participation Return to full sports activity should involve gradual loading progression Knowledge of the rate and magnitude of Achilles tendon loads Before an athlete is allowed to return to any running or jumping activity, he or she should have minimal (1–2/10 on the NPRS) to no pain with all activities of daily living The return-to-sport program is initiated when the athlete meets the requirement of performing activities of daily living with pain no higher than 2/10 |
Both not reported |
| Sorosky et al. [44] (2004) | Clinical commentary | NA | The combination of pain, swelling and impaired performance | Not reported | During the functional phase, jogging should be introduced gradually, and increased only when there is no pain during or after exercise | Both not reported |
| Van Linschoten et al. [27] (2007) | Guideline report | NA | Not reported | Return to the original level of sports | Not reported | Both not reported |
| Verrall et al. [32] (2011) | Retrospective cohort study | 190 Patients; 82 F, 108 M; 39 years Running and walking (n = 108), level not specifically reported |
Tenderness on palpation and visible swelling of the mid-substance of the Achilles tendon; based on clinical assessment | Return to their preferred activity/sport Return to full activity Resumed unrestricted activity Resuming full activity but with some ongoing symptoms Return to their physical activity |
Not reported | RR not reported 21% of patients had ongoing symptoms after return to full activity |
| Werd [38] (2007) | Narrative review | NA | Not reported | Promptly returning to activity and avoiding repeated injury Safe and rapid return to activity Returning an injured athlete to sports as quickly and safely as possible |
Return-to-play decisions should be based on an absence of pain, strength and range of motion equal to those of the contralateral limb, a gradual stepwise training protocol, and the ability of the athlete to perform the necessary skills of the sport without restriction | Both not reported |
| Wetke et al. [40]. (2014) | Pre-post study | 93 Patients; 43 F, 52 years (range 18–73) 50 M, 46 years (range 21–73) Active in sports, level and type not specifically reported |
Local tenderness at palpation of tendon, tenosynovium or tendon insertion impairing the daily activities of the patient; clinical examination and US | Back to their former sports activity | All jumping and running exercises were paused until the patient could do 20 one-legged heel lifts on the stairs, in three series, without increased pain, and then walking/running activities were slowly resumed | Both not reported |
RTS return to sport, RR recurrence rate, SD standard deviation, CCT clinically controlled trial, F female, M male, NA not applicable, RCT randomized controlled trial, VISA-A Victorian Institute of Sports Assessment—Achilles, VAS visual analog scale, US ultrasound, A-P anterior–posterior, LSI Limb Symmetry Index, NPRS numerical pain rating scale, mph miles per hour