In terms of incorporating an eccentric calf raise protocol, I would initially begin to gravitate towards this exercise if the patient’s pain is more mild to moderate in nature as I typically would want to avoid overstraining the muscles and tendon if it elicits a significant pain response. After last weekend’s course series and learning that the achilles tendon is potentially a site of central sensitization (Tompra, et al, 2016), I would want to avoid putting the patient through an excessive amount of pain which is what the protocol calls for. This would be especially true if the patient had been dealing with significant pain for multiple years. Moreover, when it comes to this protocol, I would utilize it with a patient that had long term dysrepair/degeneration to the tendon that has been driving pain for multiple years. I would avoid this kind of stress in a patient that is more in the reactive acute phase as I know this style of exercise can be counterproductive for that patient and further aggravate the tendon.

I would encourage the patient with insertional tendinopathy to spend a short time wearing a heel lift in their shoe if they are presenting with high levels of pain and must stand or walk for their job. The idea of this would be mainly for pain modulation and to control symptoms early on. My goal is to avoid excess strain through the stretch-shortening cycle that the tendon undergoes during gait and reduce the patient’s pain and disability while trying to maintain as much function as possible. If the patient is not responding well to an eccentric protocol due to increases in pain and disability as a result, I might resort to long duration isometrics as we can still intervene from a strength perspective but in a way that is more tolerable to the patient. I would explain the importance of stimulating the muscles in a pain-free manner to better encourage healthy adaption of the muscles and promote healthy retention of the tendon fibers. Also, I would encourage the patient to engage in a self soft tissue mobilization protocol as there is evidence presented by McCormack et. al supporting self STM to the tendon and supporting myofascial tissues in conjunction with strength exercises provided greater benefit than strengthening alone. I would encourage this approach of self STM as a way to keep the tendon and muscles mobile while not over stretching the ankle into dorsiflexion which would lead to further compression to the distal aspect of the tendon.

For education and explanations of why I would be taking on a strengthening approach in the form of eccentrics, I would explain the importance of strengthening and loading of tendons as an imperative strategy to allow the tendon to heal and come back stronger. I would explain that with complete rest, the tendon does not know how to organize itself in terms of which direction to orient fibers and loading the tissue safely is the best way to go about this. I would also reiterate the importance of making our strength program functionally specific in terms of the amount of resistance we ultimately want to build ourselves up to and the importance of the types of contractions we subject the tendon to. I think the research done by Kjaer and Heinemeier helps people understand why eccentric exercises can be beneficial. This is especially true when they say: “When a tendinopathic tendon region is subjected to explosive loading, the load development in the sick region is potentially markedly lower than in the surrounding healthy region, while the slow eccentric (or concentric) contractions may lead to a beneficial stimulation of the entire tendon” (Kjaer, 2014). I would explain to the patient that with time, the contractions can change in velocity and load as they apply to their functional goals, but we must stress the tendon to encourage it to heal back stronger and more functional.

Work Cited:

Tompra N, van Dieën JH, Coppieters MW. Central pain processing is altered in people with Achilles tendinopathy. Br J Sports Med. 2016 Aug;50(16):1004-7. doi: 10.1136/bjsports-2015-095476. Epub 2015 Dec 23. PMID: 26701922.

McCormack JR, Underwood FB, Slaven EJ, Cappaert TA. Eccentric Exercise Versus Eccentric Exercise and Soft Tissue Treatment (Astym) in the Management of Insertional Achilles Tendinopathy. Sports Health. 2016 May/Jun;8(3):230-237. doi: 10.1177/1941738116631498. PMID: 26893309; PMCID: PMC4981065.

Kjaer, M., & Heinemeier, K. M. (2014). Eccentric exercise: acute and chronic effects on healthy and diseased tendons. Journal of applied physiology, 116(11), 1435-1438.