Exercise parameters to consider for Achilles tendinopathy: a modified Delphi study with international experts

Yoann Demangeot^{1

2

3

4}, Seth O'Neill^#⁵, Francis Degache^#⁶, Amandine Rapin^{2

7}, Umer Asgher^{8

9}, Hakan Alfredson¹⁰, Rachel Chester¹¹, Ruth L Chimenti¹², Robert-Jan de Vos¹³, Adrian Escriche-Escuder¹⁴, Kenneth Farnqvist¹⁵, Bas Habets¹⁶, Nicola Maffulli¹⁷, Stig Peter Magnusson¹⁸, Peter Malliaras¹⁹, Myles C Murphy²⁰, Craig R Purdam²¹, Jonathan D Rees²², Ebonie K Rio²¹, Igor Sancho²³, Alex Scott²⁴, Karin Gravare Silbernagel²⁵, Vincent Gremeaux^#^{6

26}, François C Boyer^#^{2

7}, Redha Taiar^#^{27

2}

Affiliations

¹ MATériaux et Ingéniérie Mécanique, University of Reims Champagne-Ardenne, Reims, France ydemangeot@chu-reims.fr.
² Department of Physical and Rehabilitation Medicine, University Hospital Centre Reims, Sébastopol Hospital, Reims, France.
³ Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
⁴ Therapeutic and Performance Sports Institute, MotionLab, Le Mont-sur-Lausanne, Switzerland.
⁵ School of Healthcare, Department of Life Sciences, University of Leicester, Leicester, UK.
⁶ Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland.
⁷ UR 3797, UFR Medicine, University of Reims Champagne-Ardenne, Reims, France.
⁸ Laboratory of Human Factors and Automation in Aviation, Department of Air Transport, Faculty of Transportation Sciences, Czech Technical University in Prague, Prague, Czechia.
⁹ School of Interdisciplinary Engineering and Sciences (SINES), National University of Sciences and Technology, Islamabad, Pakistan.
¹⁰ Department of Community Medicine and Rehabilitation, Sports Medicine, Umea University, Umea, Sweden.
¹¹ School of Health Sciences, Faculty of Medicine and Health, University of East Anglia, Norwich, Norfolk, UK.
¹² Department of Physical Therapy & Rehabilitation Science, University of Iowa, Iowa City, Iowa, USA.
¹³ Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands.
¹⁴ Department of Physiotherapy, University of Valencia, Valencia, Spain.
¹⁵ Karolinska Institute, Stockholm, Sweden.
¹⁶ Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Brain Center, Utrecht University, Utrecht, Netherlands.
¹⁷ Department of Trauma and Orthopaedic Surgery, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy.
¹⁸ Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark.
¹⁹ Department of Physiotherapy, School of Primary Health Care, Monash University, Frankston, Victoria, Australia.
²⁰ Nutrition and Health Innovation Research Institute, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia.
²¹ La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.
²² Fortius Clinic, London, UK.
²³ Deusto Physical TherapIker Group, Physical Therapy Department, Faculty of Health Sciences, University of Deusto, Donostia - San Sebastian, Spain.
²⁴ Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada.
²⁵ Department of Physical Therapy, University of Delaware, Newark, Delaware, USA.
²⁶ Unit of Sports Medicine, Swiss Olympic Medical Center, Lausanne University Hospital, Lausanne, Switzerland.
²⁷ MATériaux et Ingéniérie Mécanique, University of Reims Champagne-Ardenne, Reims, France.

^# Contributed equally.

PMID: 40877027
DOI: 10.1136/bjsports-2025-110183

Free article

Exercise parameters to consider for Achilles tendinopathy: a modified Delphi study with international experts

Yoann Demangeot et al. Br J Sports Med. 2025.

Free article

. 2025 Aug 28:bjsports-2025-110183.

doi: 10.1136/bjsports-2025-110183. Online ahead of print.

Authors

Affiliations

¹ MATériaux et Ingéniérie Mécanique, University of Reims Champagne-Ardenne, Reims, France ydemangeot@chu-reims.fr.
² Department of Physical and Rehabilitation Medicine, University Hospital Centre Reims, Sébastopol Hospital, Reims, France.
³ Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
⁴ Therapeutic and Performance Sports Institute, MotionLab, Le Mont-sur-Lausanne, Switzerland.
⁵ School of Healthcare, Department of Life Sciences, University of Leicester, Leicester, UK.
⁶ Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland.
⁷ UR 3797, UFR Medicine, University of Reims Champagne-Ardenne, Reims, France.
⁸ Laboratory of Human Factors and Automation in Aviation, Department of Air Transport, Faculty of Transportation Sciences, Czech Technical University in Prague, Prague, Czechia.
⁹ School of Interdisciplinary Engineering and Sciences (SINES), National University of Sciences and Technology, Islamabad, Pakistan.
¹⁰ Department of Community Medicine and Rehabilitation, Sports Medicine, Umea University, Umea, Sweden.
¹¹ School of Health Sciences, Faculty of Medicine and Health, University of East Anglia, Norwich, Norfolk, UK.
¹² Department of Physical Therapy & Rehabilitation Science, University of Iowa, Iowa City, Iowa, USA.
¹³ Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands.
¹⁴ Department of Physiotherapy, University of Valencia, Valencia, Spain.
¹⁵ Karolinska Institute, Stockholm, Sweden.
¹⁶ Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Brain Center, Utrecht University, Utrecht, Netherlands.
¹⁷ Department of Trauma and Orthopaedic Surgery, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy.
¹⁸ Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark.
¹⁹ Department of Physiotherapy, School of Primary Health Care, Monash University, Frankston, Victoria, Australia.
²⁰ Nutrition and Health Innovation Research Institute, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia.
²¹ La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.
²² Fortius Clinic, London, UK.
²³ Deusto Physical TherapIker Group, Physical Therapy Department, Faculty of Health Sciences, University of Deusto, Donostia - San Sebastian, Spain.
²⁴ Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada.
²⁵ Department of Physical Therapy, University of Delaware, Newark, Delaware, USA.
²⁶ Unit of Sports Medicine, Swiss Olympic Medical Center, Lausanne University Hospital, Lausanne, Switzerland.
²⁷ MATériaux et Ingéniérie Mécanique, University of Reims Champagne-Ardenne, Reims, France.

^# Contributed equally.

PMID: 40877027
DOI: 10.1136/bjsports-2025-110183

Abstract

To assess the level of agreement among experts on the heel raise exercise parameters that influence midportion and insertional Achilles tendinopathy (AT) rehabilitation outcomes.An international expert panel in AT rehabilitation was invited to complete a three-round Delphi survey. In the first two rounds, experts were asked to review a pregenerated list of exercise parameters (based on the heel raise exercise) and rate their perceived influence on rehabilitation outcome, using a 5-point Likert scale. For each parameter, consensus criteria for major influence on rehabilitation were (a) median≥4, (b) ≥75% of scoring 4 or 5 and (c) IQR≤1. The third round aimed to rank the exercise parameters according to importance (from most to least important) during rehabilitation.17 experts participated in the entire Delphi process. A total of 16 exercise parameters were assessed, of which 4 (intensity of contraction, total time under tension, number of repetitions and sets, type of contraction) reached consensus as having a major influence on rehabilitation for midportion AT and 3 reached consensus for insertional AT (range of ankle dorsiflexion during the exercise, intensity of contraction, number of repetitions and sets). The rankings of parameters that reached consensus showed that contraction intensity was perceived as the most important variable for midportion AT rehabilitation, while range of ankle dorsiflexion was deemed the most important variable for insertional AT rehabilitation.This study identified key exercise parameters for mid-portion and insertional AT rehabilitation based on expert opinion. This information should assist practitioners in optimising their approach to deliver more effective, patient-specific exercises for AT rehabilitation.

Keywords: Achilles Tendon; Consensus; Exercise; Rehabilitation; Tendinopathy.

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Conflict of interest statement

Competing interests: MCM reports having an editorial role in the BJSM outside of the submitted work. EKR reports to be associate editor in the BJSM outside of the submitted work. NM reports to be editor in chief of the British Medical Bulletin and of the Journal of Orthopaedic Surgery and Research. All other authors declare no competing interest.

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Exercise parameters to consider for Achilles tendinopathy: a modified Delphi study with international experts

Affiliations

Exercise parameters to consider for Achilles tendinopathy: a modified Delphi study with international experts

Authors

Affiliations

Abstract

Conflict of interest statement

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