Eccentric Calf Muscle Training Research Articles

Effect of heavy-load eccentric calf muscle training as a rehabilitation protocol in soccer players with persistent Achilles tendinosis

Background: All of the studies included in the analysis developed scales to assess a variety of outcomes, including tenderness, patient experience, return to sport, degree of improvement, and physical activity engagement. Method: In terms of training principles such as assets, repetitions, and frequency of performance, differences in technique between researches implementing the Heavy Load Eccentric Calf Muscle (HLECM) training regimen were rather minor. Some studies implemented the HLECM routine gradually throughout the first few weeks or reduced the frequency from twice daily (180 repetitions) to once daily (90 repetitions). The HLECM training procedure progressions could have been more diverse. Results: HLECM has received a lot of attention as a therapy for Achilles Tendinosis (AT). Despite the fact that the results are difficult to comprehend, a significant decrease in agony and an increase in work was observed following HLECM training in all studies examined here.

CORR Synthesis: What Is the Role of Platelet-rich Plasma Injection in the Treatment of Tendon Disorders?

CORR Synthesis: What Is the Role of Platelet-rich Plasma Injection in the Treatment of Tendon Disorders?

Clinical commentary of the evolution of the treatment for chronic painful mid-portion Achilles tendinopathy.

The chronic painful Achilles tendon mid-portion was for many years, and still is in many countries, treated with intratendinous revision surgery. However, by coincidence, painful eccentric calf muscle training was tried, and it showed very good clinical results. This finding was unexpected and led to research into the pain mechanisms involved in this condition. Today we know that there are very few nerves inside, but multiple nerves outside, the ventral side of the chronic painful Achilles tendon mid-portion. These research findings have resulted in new treatment methods targeting the regions with nerves outside the tendon, methods that allow for a rapid rehabilitation and fast return to sports.

Effects of 12-wk eccentric calf muscle training on muscle-tendon glucose uptake and SEMG in patients with chronic Achilles tendon pain.

High-load eccentric exercises have been a key component in the conservative management of chronic Achilles tendinopathy. This study investigated the effects of a 12-wk progressive, home-based eccentric rehabilitation program on ankle plantar flexors' glucose uptake (GU) and myoelectric activity and Achilles tendon GU. A longitudinal study design with control (n = 10) and patient (n = 10) groups was used. Surface electromyography (SEMG) from four ankle plantar flexors and GU from the same muscles and the Achilles tendon were measured during submaximal intermittent isometric plantar flexion task. The results indicated that the symptomatic leg was weaker (P < 0.05) than the asymptomatic leg at baseline, but improved (P < 0.001) with eccentric rehabilitation. Additionally, the rehabilitation resulted in greater GU in both soleus (P < 0.01) and lateral gastrocnemius (P < 0.001) in the symptomatic leg, while the asymptomatic leg displayed higher uptake for medial gastrocnemius and flexor hallucis longus (P < 0.05). While both patient legs had higher tendon GU than the controls (P < 0.05), there was no rehabilitation effect on the tendon GU. Concerning SEMG, at baseline, soleus showed more relative activity in the symptomatic leg compared with both the asymptomatic and control legs (P < 0.05), probably reflecting an effort to compensate for the decreased force potential. The rehabilitation resulted in greater SEMG activity in the lateral gastrocnemius (P < 0.01) of the symptomatic leg with no other within- or between-group differences. Eccentric rehabilitation was effective in decreasing subjective severity of Achilles tendinopathy. It also resulted in redistribution of relative electrical activity, but not metabolic activity, within the triceps surae muscle.

English

In a previous uncontrolled pilot study we demonstrated very good clinical results with eccentric calf muscle training on patients with painful chronic Achilles tendinosis located at the 2-6 cm level in the tendon. In the present prospective study patients with painful chronic Achilles tendinosis at the 2-6 cm level in the tendon were randomized to treatment with either an eccentric or a concentric training regimen for the calf muscles with therapeutic ultrasound. The study included 60 patients, with 30 in each group mean age 30 years in each treatment group. The amount of pain during activity (jogging or walking) was recorded by the patients on a visual analogue scale, and patient satisfaction was assessed before and after treatment. The patients were instructed to perform their eccentric or concentric training regimen on a daily basis for 12 weeks. In both types of treatment regimen the patients were told to do their exercises despite experiencing pain or discomfort in the tendon during exercise. The results showed that after the eccentric training regimen 80% of the patients (24/30) were satisfied and had resumed their previous activity level (before injury), compared to 63% of the patients (19/30) who were treated with the concentric training regimen with therapeutic ultrasound as the common modality. The results of means of pain is (0.902) is significant, for range of motion is (0.042) which is not significant and foot ankle ability measure is (0.311) is significant after treatment with eccentric training was significantly better than after concentric training.

Good Results with Painful Eccentric Calf Muscle Training for Patients with Painful Midportion Achilles Tendinosis-Implications for New Treatments

Chronic painful tendons were previously considered to be treated with more or less pain-free rehabilitation exercises. These tendons were considered “degenerative and weak”, and should be handled carefully. The concept of painful eccentric loading for the chronic painful midportion Achilles was started by a co-incidence, and the successful clinical results were unexpected. This is a short review about painful eccentric training-the Umea modeland how the results of this treatment model broke the ice for new research, research findings providing a basis for inventions of new successful treatment methods.

Dynamic contrast enhanced magnetic resonance imaging in chronic Achilles tendinosis

BackgroundChronic Achilles tendinosis is a common problem. When evaluating and comparing different therapies there is a need for reliable imaging methods. Our aim was to evaluate if chronic Achilles tendinosis affects the dynamic contrast-enhancement in the tendon and its surroundings and if short-term eccentric calf-muscle training normalizes the dynamic contrast-enhancement.Methods20 patients with chronic Achilles tendinopathy were included. Median duration of symptoms was 31 months (range 6 to 120 months). Both Achilles tendons were examined with dynamic contrast enhanced MRI before and after a 12- week exercise programme of eccentric calf-muscle training. The dynamic MRI was evaluated in tendon, vessel and in fat ventrally of tendon. Area under the curve (AUC), time to peak of signal, signal increase per second (SI/s) and increase in signal between start and peak as a percentage (SI%) was calculated. Pain and performance were evaluated using a questionnaire.ResultsIn the fat ventrally of the tendon, dynamic contrast enhancement was significantly higher in the symptomatic leg compared to the contralateral non-symptomatic leg before but not after treatment. Despite decreased pain and improved performance there was no significant change of dynamic contrast enhancement in symptomatic tendons after treatment.ConclusionIn Achilles tendinosis there is an increased contrast enhancement in the fat ventrally of the tendon. The lack of correlation with symptoms and the lack of significant changes in tendon contrast enhancement parameters do however indicate that dynamic enhanced MRI is currently not a useful method to evaluate chronic Achilles tendinosis.

English

Introduction Treatment of chronic painful midportion Achilles tendinopathy is known to be difficult. Multiple nontendon-invasive and tendon-invasive methods are used. When traditional non-invasive treatments fail, it has become increasingly popular to try injections of PRP and autologous blood, and intratendinous open surgery is indicated finally. There is little, if any, scientific evidence from human studies backing up intratendinous injection treatment, and intratendinous surgical treatment can also be questioned. The aim of this critical review is to discuss intratendinous surgery and intratendinous treatment with injection for midportion Achilles tendinopathy. Discussion Based on a recent research using immunohistochemical analyses of tissue biopsies from patients with midportion Achilles tendinopathy, new non-tendon-invasive treatment methods combined with short rehabilitation periods have been invented. These methods have shown good clinical results, few complications and decreased tendon thickness along with improved tendon structure, over time. The knowledge about innervation patterns, tendon cells and potentials in the soft tissue on the ventral (deep) side of the Achilles tendon midportion, along with good results using treatment methods focussing on the outside of the tendon, questions the use of tendon-invasive treatment methods for midportion Achilles tendinopathy. Conclusion A new science backing invasive treatment outside the tendon and newlyinvented methods such as ultrasound and Doppler-guided surgical scraping treatment have shown promising results. Introduction Although multiple treatment methods are used, treatment of midportion Achilles tendinopathy is known to be difficult1. Both conservative and surgical treatment methods are used, which can be divided into nonAchillestendon-invasive, and Achilles tendon-invasive methods. Among the non-tendon-invasive conservative methods, painful eccentric calf muscle training is considered to be the most beneficial2,3. There are also indications that shock wave treatment3 and ultrasound (US) + Doppler (DP)-guided sclerosing polidocanol injections4 are beneficial. Tendon-invasive conservative methods include injection treatments with Platelet Rich Plasma (PRP)5,6 and autologous blood (peri-or intratendineously)7,8. Stem cell injection treatment is also being used, but there are no studies on humans9. Surgical treatments include nontendon-invasive procedures such as US and DP-guided scraping10 and scraping combined with plantaris tendon removal11. Among the tendoninvasive methods, tenotomy with excision of degenerative tendon tissue is the most commonly used12–14, which is sometimes combined with a flexor hallucis longus transfer procedure15. Morphologically, in the thickened and painful tendinopathy tendon, there is an altered tendon structure, including irregular fibre bundle arrangement and local high concentrations of glucosaminoglycans (GAGs), hypercellularity and neovascularisation14. Specific studies on the cells in the hyper-cellular region have shown that some of these cells produce transmitter and pain substances, and seem to have a more stemcell-like function16–18. Using US and DP, a localised high blood flow has been found outside and inside (in close relation to regions with structural changes) the ventral side in tendinopathy tendons, but not in normal Achilles tendons19. Immunohistochemical analyses of tissue specimens, obtained with US and DP guidance, outside and inside the region with tendon changes, have shown multiple sympathetic, but also sensory, nerves outside, but very few nerves inside, the Achilles tendon20. This critical review specifically questions the use of Achilles tendon invasive treatment methods without having a scientifically verified background. Discussion The author has referenced some of his own studies in this review. These referenced studies have been conducted in accordance with the Declaration of Helsinki (1964) and the protocols of these studies have been approved by the relevant ethics committees related to the institution in which they were performed. All human subjects, in these referenced studies, gave informed consent to participate in these studies. *Corresponding author Email: hakan.alfredson@idrott.umu.se Department of Surgical and Perioperative Science, Sports Medicine Unit, Umea University, SE-90187 Umea, Sweden

Safety and outcome of surgical debridement of insertional Achilles tendinopathy using a transverse (Cincinnati) incision

This is a prospective analysis on 30 physically active individuals with a mean age of 48.9 years (35 to 64) with chronic insertional tendinopathy of the tendo Achillis. Using a transverse incision, the tendon was debrided and an osteotomy of the posterosuperior corner of the calcaneus was performed in all patients. At a minimum post-operative follow-up of three years, the Victorian Institute of Sports Assessment scale-Achilles tendon scores were significantly improved compared to the baseline status. In two patients a superficial infection of the wound developed which resolved on antibiotics. There were no other wound complications, no nerve related complications, and no secondary avulsions of the tendo Achillis. In all, 26 patients had returned to their pre-injury level of activity and the remaining four modified their sporting activity. At the last appointment, the mean pain threshold and the mean post-operative tenderness were also significantly improved from the baseline (p < 0.001). In patients with insertional tendo Achillis a transverse incision allows a wide exposure and adequate debridement of the tendo Achillis insertion, less soft-tissue injury from aggressive retraction and a safe osteotomy of the posterosuperior corner of the calcaneum.

Eccentric Calf Muscle Training - The Story

This started 1995. Myself I was a recreational runner, who gradually started to get midportion Achilles tendon pain. I tried rest and alternative training for 3 – 4 months without effect on the painful condition. My friend the radiologist Dr Lars Öhberg had a look with the ultrasound machine, and this showed a thickened midportion (11 mm) with structural abnormalities located on the ventral side of the tendon. At that time I was responsible for the tendon treatments at our clinic, and we treated patients with this condition with open surgery (central longitudinal tenotomy, excision of macroscopically abnormal tendon tissue), followed by immobilization in a cast for 6 weeks and althogether a 4 – 6 months rehabilitation period. I went to talk to my boss, Professor Ronny Lorentzon, about him operating me in my Achilles. He looked at me like I was telling him a joke and said, forget it, you have yourself in a recent study shown that it takes about 4 – 6 months to recover from surgery, and there will be a period with sick leave. We have many patients on our waiting list and cannot afford to have you on sick leave. I went away, being very disappointed and a little angry.

The effect of eccentric and concentric calf muscle training on Achilles tendon stiffness

Objective: To compare in vivo effects of eccentric and concentric calf muscle training on Achilles tendon stiffness, in subjects without tendinopathy. Methods: Thirty-eight recreational athletes completed 6 weeks eccentric (6 males, 13 females, 21.6 ± 2.2 years) or concentric training (8 males, 11 females, 21.1 ± 2.0 years). Achilles tendon stiffness, tendon modulus and single-leg jump height were measured before and after intervention. Exercise adherence was recorded using a diary. Results: All data are reported as mean ± SD. Groups were matched for height and weight but the eccentric training group were more active at baseline (P < 0.05). Tendon stiffness was higher in the eccentrically trained group at baseline compared to the concentrically trained group (20.9 ± 7.3 N/mm v 13.38 ± 4.66 N/mm; P = 0.001) and decreased significantly after eccentric training (to 17.2 ( ± 5.9) N/mm (P = 0.035)). There was no stiffness change in the concentric group (P = 0.405). Stiffness modulus showed similar changes to stiffness. An inverse correlation was found between initial, and subsequent, reduction in stiffness (r = −0.66). Jump height did not change and no correlation between stiffness change and adherence was observed in either group (r = 0.01). Conclusions: Six weeks of eccentric training can alter Achilles tendon stiffness while a matched concentric programme shows no similar effects. Studies in patients with Achilles tendinopathy are warranted.

New regimen for eccentric calf muscle training in insertional achilles tendinopathy: a pilot study

Chronic painful insertional achilles tendinopathy is seen both in physically active and non-active population. The conventional eccentric protocol which loaded the achilles in dorsiflexion does not show good result and...

The long-term clinical and MRI results following eccentric calf muscle training in chronic Achilles tendinosis

To evaluate the long-term results following eccentric calf-muscle training in patients with chronic Achilles tendinopathy. A total of 24 patients with chronic Achilles tendinopathy were included in a study evaluating MRI findings and clinical symptoms before and after 3 months of daily eccentric calf-muscle strength training. Median duration of symptoms was 18 months (range 6-120). Four of the patients did not perform the prescribed treatment for different reasons and were followed for 14 months. The resulting 20 treated patients completed 4.2-year (range 29-58 months) follow up. Tendon volume was evaluated by using 3D seed growing technique and signal abnormalities were visually semi-quantitatively graded. Level of pain and performance was categorized using a questionnaire completed by the patient. In the symptomatic treated patients, median intensity level of pain decreased from moderate/severe at time of inclusion to mild at follow up (p < 0.05). Median level of performance increased from severe impairment at time of inclusion to normal at follow up (p < 0.05). 12 out of 20 patients had raised intratendinous signal at time of inclusion compared to 2 out of 20 patients at follow up (p < 0.001). Mean tendon-volume measured 6.7 cm(3) (SD 2.0) at time of inclusion and 6.4 cm(3) (SD 2.0) at follow up (p = 0.18). The four symptomatic non-treated tendons did not improve regarding pain, performance, intratendinous signal or tendon volume. We found decreased pain, improved performance and decreased intratendinous signal both compared to index examination and immediately after the 3 months training regimen in a 4.2-year clinical and MRI follow up, in a group of patients treated with heavy loaded eccentric calf-muscle training for chronic Achilles tendinopathy. The improvements were greater at 4.2-year follow up, despite no further active treatment, than immediately after the treatment. This may indicate a good long-term prognosis for Achilles tendinosis patients.

New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study

New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study

New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study

Background:Chronic painful insertional Achilles tendinopathy is seen in both physically active and non-active individuals. Painful eccentric training, where the patients load the Achilles tendon into full dorsiflexion, has shown good...

Eccentric calf muscle training in athletic patients with Achilles tendinopathy

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.

Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain—A pilot study

A number of studies have indicated that eccentric calf muscle training has beneficial effects in the management of Achilles tendon pain for recreational athletes. The purpose of this prospective randomised single blind pilot study was to investigate their potential effectiveness compared with therapeutic ultrasound in subjects with relatively sedentary lifestyles in an NHS hospital setting. Eleven men and five women (mean age 53±21 years) with Achilles tendon pain of minimum duration 4 months were randomised to one of two treatment groups; either eccentric loading or ultrasound. Administration of ultrasound and regular supervision of exercises occurred over a period of 6 weeks, with unsupervised exercises continuing for another 6 weeks. Outcome measurements were taken prior to and after 2, 4, 6 and 12 weeks after commencing treatment. They included: pain on a visual analogue scale, functional index of the leg and lower limb, and the five question EuroQol generalised health questionnaire. The difference in mean score was calculated together with 95% confidence intervals assuming a normal distribution. There were no statistically significant differences between groups or clear trends over time. In addition there was considerable overlap between the confidence intervals. This is not unexpected given the small sample size. Both interventions proved acceptable to the patients with no adverse effects. On this basis we intend conducting a full multi-centred study.

Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy

Achilles tendinopathy is prevalent in athletes, but can also affect sedentary patients. We studied the effects of eccentric exercises in sedentary non-athletic patients with Achilles tendinopathy. Thirty-four sedentary patients (18 males, average age 44 years, range 23-67; 16 females, average age 51 years, range 20-76; average BMI: 28.6+/-4.7, range 22.1-35.4) with a clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance (39+/-S.D. 22.8) and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks. Fifteen patients (44%) did not improve with eccentric exercise regimen. Three patients improved after perintendinous injections aprotinin and local anaesthetic. Surgery was performed in seven patients as 6 months of conservative management failed to produce improvements. The overall average VISA-A scores at latest follow up was 50 (S.D. 26.5). Eccentric exercises, though effective in nearly 60% of our patients, may not benefit sedentary patients to the same extent reported in athletes.

The chronic painful Achilles and patellar tendon: research on basic biology and treatment

The etiology and pathogenesis of chronic tendon pain are unknown. Even though tendon biopsies having shown an absence of inflammatory cell infiltration, anti-inflammatory agents (non-steroidal anti-inflammatory drugs, corticosteroidal injections) are commonly used. We have demonstrated that it is possible to use intratendinous microdialysis to investigate human tendons, and found normal prostaglandin E2 (PGE2) levels in chronic painful tendinosis (Achilles and patellar) tendons. Furthermore, gene technological analyses of biopsies showed no upregulation of pro-inflammatory cytokines. These findings show that there is no PGE2-mediated intratendinous inflammation in the chronic stage of these conditions. The neurotransmitter glutamate (a potent modulator of pain in the central nervous system) was, for the first time, found in human tendons. Microdialysis showed significantly higher glutamate levels in chronic painful tendinosis (Achilles and patellar) tendons, compared with pain-free normal control tendons. The importance of this finding is under evaluation. Treatment is considered to be difficult, and not seldom, surgery is needed. However, recent researches on non-surgical methods have shown promising clinical results. Painful eccentric calf-muscle training has been demonstrated to give good clinical short- and mid-term results on patients with chronic painful mid-portion Achilles tendinosis. Good clinical results were associated with decreased tendon thickness and a structurally more normal tendon with no remaining neovessels. Using ultrasonography (US)+color Doppler (CD), and immunhistochemical analyses of biopsies, we have recently demonstrated a vasculo/neural (Substance-P and Calcitonin Gene-Related Peptide nerves) ingrowth in the chronic painful tendinosis tendon, but not in the pain-free normal tendon. A specially designed treatment, using US- and CD-guided injections of the sclerosing agent Polidocanol, targeting the neovessels outside the tendon, has been shown to cure tendon pain in pilot studies, in a majority of the patients. A recent, randomized, double-blind study verified the importance of injecting the sclerosing substance Polidocanol.

Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis?

The background to the good clinical results reported using painful eccentric calf-muscle training as treatment for chronic painful mid-portion Achilles tendinosis is not known. Recently, using ultrasound and colour Doppler technique, we showed that painful tendinosis was associated with a local neovascularisation. Furthermore, in a pilot study, destroying these neovessels by sclerosing therapy cured the pain in most patients. Dynamic ultrasound and colour Doppler examination has shown that the flow in the neovessels stops during dorsiflexion in the ankle joint. Therefore, it was of interest to study the occurrence of neovascularisation before and after eccentric training. Forty-one tendons in 30 patients (22 men and 8 women, mean age 48 years) with chronic painful mid-portion Achilles tendinosis were examined with ultrasonography and colour Doppler, before and after 12 weeks of eccentric calf-muscle training. Before treatment, there was a local neovascularisation in the area with tendon changes (hypo-echoic areas, irregular fibre structure) in all tendons. At follow-up after treatment (mean 28 months), there was a good clinical result (no tendon pain during activity) in 36/41 tendons, and a poor result in 5/41 tendons. In 34/36 tendons with a good clinical result of treatment there was a more normal tendon structure, and in 32/36 tendons there was no remaining neovascularisation. In 5/5 tendons with a poor clinical result there was a remaining neovascularisation in the tendon, and in 2/5 tendons there were remaining structural abnormalities. In conclusion, in patients with chronic painful mid-portion Achilles tendinosis, a good clinical result after eccentric training seems to be associated with a more normal tendon structure and no remaining neovascularisation. Action on the area with neovessels during the eccentric training regimen might possibly be responsible for the good clinical results.