Eccentric calf muscle training in athletic patients with Achilles tendinopathy

Eccentric calf muscle training in athletic patients with Achilles tendinopathy. Maffulli N, Walley G, Sayana MK, Longo UG, Denaro V. Disabil Rehabil. 2008;30(20-22):1677-84. 

PURPOSE: To evaluate the effects of eccentric strengthening exercises (ESE) in athletic patients with Achilles tendinopathy.
METHODS: Forty-five athletic patients (29 men, average age 26 years +/- 12.8, range 18 – 42; 16 women, average age 28 years +/- 13.1, range 20 – 46; average height: 173 +/- 16.8, range 158 – 191; average weight 70.8 kg +/- 15.3, range 51.4 – 100.5) with a clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks.
RESULTS: The mean pre-management VISA-A scores of 36 (SD 23.8; 95% CI: 29 – 46) improved to 52 (SD 27.5; 95% CI: 41.3 – 59.8) at the latest follow up (p = 0.001). Twenty seven of the 45 patients responded to the eccentric exercises. Of the 18 patients who did not improve with eccentric exercises, 5 (mean age: 33 years) improved with two peritendinous aprotinin and local anaesthetic injections. 10 of the 18 patients (9 men, mean age 35 years; 1 woman aged 40 years) who did not improve with eccentric exercises and aprotinin injections proceeded to have surgery. The remaining three patients (3 women, mean age 59.6 years) of the 18 non-responders to eccentric exercises and aprotinin injections declined surgical intervention.
CONCLUSIONS: ESE in athletic patients provide comparable clinical outcome compared to our previous results in non-athletic patients. ESE are a viable option for the management of AT in athletes, but, in our hands, only around 60% of our athletic patients benefited from an intensive, heavy load eccentric heel drop exercise regimen alone. If ESE fail to improve the symptoms, aprotinin and local anaesthetic injections should be considered. Surgery is indicated in recalcitrant cases after 3 to 6 months of non operative management.

Diagnosis: Mid portion Achilles tendinitis (2-6 cm above insertion)

Outcome: VISA-A. Average score increased from 36 to 52. 60% were considered successful, unsuccessful was judged if pain still interfered with normal activities and if VISA-A score did not improved less than 10 points.

When Assessed: 12 weeks

Subjects: 45 athletic patients, 29 men average age 26, and 16 women average age 26

Protocol: Subjects worked up 3 sets of 15 reps with knee bent and with knee straight, twice per day, 7 days a week. Allowed to work through mild to moderate pain, starting with body weight (1 set of 10 reps) and adding 5 kg at a time if 3rd set painless. They did work from a slow to fast pace then increased weights, working a slow to fast pace again in later weeks of the study.

Other Activity: No mention of other activity during or after protocol.

Chad’s Comments:  This is an interesting study in that they did not find the same results as did Alfredson (60% effective vs better than 80% effective as reported by Alfredson). Differences I see, is that these patients worked to increase rep speed rather than just resistance levels while keeping speed constant like Alfredson. Could be the increased rep speed lessens time of tension on eccentric exercise and thus lessens adaptation? Also there is no mention about return to running, or sports during the course of treatment. It has been my experience that patients do better with relative rest (less duration), but not complete rest from the offending activity, and that with complete rest the pain just returns as they start the activity again, regardless exercise intervention. Another difference is the use of ice massage after treatment, but other studies have found ice to have no effect on outcomes rather than deleterious effect.  All data that’s worth knowing when designing physical therapy programs for tendinopathy.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

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