Achilles

[AJ Lievre]

This past weekend there was a discussion about load-induced tendinopathy management, specifically as it relates to the Achilles tendon. Dhinu offered a couple of different perspectives based on the evidence (e.g. Cook’s continuum, the phasic progression) and offered his own opinions too. When considering everything, it seems exercise is the best medicine, but there’s a lot of effective prescriptions. Given the possible variability, it’s important to have a reasoning process to guide your decision making. I would love to hear your thoughts on the following 3 topics:

1) Eccentrics tend to be a staple in the management of tendinopathy, but when and why would you incorporate them? What would your patient present like (objectively) and what would they say in their history to make you think eccentrics would be appropriate?

2) Aside from avoiding eccentrics into end range dorsiflexion, what exercise modifications would you make for people presenting with insertional tendinopathy? What if eccentrics didn’t work?

3) How would you explain the mechanism of eccentrics to a patient? I see people with tendinopathy often and they frequently ask why the exercises help. It would be a good exercise to practice your possible education and consider how to refine it before you actually chat with a patient.

For the above answers please feel free to provide any relevant articles or citations to help you strengthen your argument.

[iwhitney]

1) I feel that eccentrics should most certainly be a component of exercise prescription for patients presenting with tendinopathy, but they shouldn’t be the ONLY component. A somewhat recent article from 2019 by Cardoso et al. does a great job of summarizing the current trends in tendinopathy management with a breakdown of exercise prescription and what the research supports. They discuss the most updated research demonstrating the effectiveness of heavy slow resisted exercise for both Achilles and Patella tendinopathy management as well as the lack of evidence demonstrating eccentrics as an effective standalone treatment. With all that being said, I would incorporate eccentrics, along with concentrics, when I feel the patient has their pain at a manageable level. I certainly wouldn’t incorporate progressive isotonics for a patient presenting with an acute reactive tendinopathy, as this would likely increase or aggravate their symptoms. Progressive isotonics would be much more effective for a patient who can tolerate that load in order to reap the benefits, which includes the stimulation of increased tendon stiffness and strength. In the examination, I would expect those patients to present with a longer history of pain with some sort of chronic attenuation based on sport/hobby/vocation or episodic history, a low to moderate level of pain, observable thickening of the tendon, and perhaps some biomechanical deficits that contributed to torsion or compression to the tendon (e.g. muscle imbalances, ROM loss/excess, lack of adjacent area stability).

2) Pulling from a clinical experience as a student where I saw a patient with insertional tendinopathy who couldn’t tolerate eccentrics in weight bearing despite no movement below plantigrade, one initial modification I would try to make is to reduce the amount of load being placed on the tendon. This includes reducing body weight by using a machine such as a total gym/leg press or trying the exercise in a seated position. Another modification I have used when a patient with tendinopathy can’t tolerate eccentrics is having the patient perform only the concentric phase in single leg on the affected side, then lowering down with both legs eccentrically. The above idea of reduced body weight/load could also be applied in this scenario if weight bearing is too intolerable.

3) I definitely find that it can be difficult to explain exercise physiology to patients in general, especially when they are extra curious on how it works and I need to find a way to explain it in a way that makes sense to them. Usually how I try to describe eccentrics to patients goes something like this: “a majority of the exercise we perform involves two phases, the concentric and eccentric. In the concentric phase, the muscle/tendon we are targeting is shortening while contracting and in the eccentric phase, that same muscle/tendon complex is lengthening while contracting (this is usually where I would demonstrate as well). Both phases are needed for adequate muscle function and you can see that in a lot of daily activities, such as climbing stairs or squatting. Naturally, our muscles can produce more force during an eccentric movement than a concentric. The reason eccentric exercises can be highly effective for improving the strength of your tendon is that they cause more microtears due to the muscle having to produce more force in a lengthened position. These microtears are actually beneficial for our bodies, as they stimulate our natural healing response, which then allows the tendon to heal stronger with a better ability to handle and adapt to increased load.” Now, if the patient was an engineer, I would probably need to go in more depth and pull up a picture of the force-velocity curve. If anyone has any suggestions for how I could phrase that to make more sense, I would definitely appreciate it as I feel like it could probably be explained more simply or in a way that also emphasizes the importance of concentric movements.

References:
Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Prac Res Clin Rheum. 2019;33(1):122-140. doi:10.1016/j.berh.2019.02.001

Current concepts review: Management of Achilles tendinopathy overview. J Arthro and Join Surg. 2021;8(3):216-221. doi:10.1016/j.jajs.2021.03.002

[ebusch19]

1) This past weekend course was a little eye opening for me with the introduction of heavy slow resistance training vs eccentric training for tendinopathies. I always thought to use eccentric training within the more chronic stage where a patient is coming in with a subjective report of 3+ months of pain. I don’t want to introduce loading too early within reactive or early dysrepair phase to allow adequate time for the tendon to heal. I had a patient come in with achilles tendinopathy who was a runner and was training for a half marathon in September when her pain started. She stopped running and was afraid to keep doing it due to her pain. She had mid-portion achilles pain and had signs of tendon thickening compared to her unaffected side. She also reported increased pain at the end of the day and swelling after being on her feet and walking. She told me she was doing a lot of stretching which was not helping. She came to me about 3 months from when her pain first began and wanted to get back to running, so I started her with eccentric training going off the Alfredson protocol. To me she had been taking it easy, and modifying her activity for 3 months now and needed guidance to start loading her tendon again to get back to running. I think for her since she is a runner, she needs to be able to tolerate repetitive loading to her tendons so the protocol may be more appropriate. However, for a patient coming in with achilles tendinopathy who has a more sedentary lifestyle, or does not need to get back to a sport, eccentric training with Alfredson protocol is excessive and I can see the benefit of using the heavy slow resistance training protocol. I can also see patients having more compliance with that protocol as well from not having to do as much during the week since keeping up with a HEP seems almost impossible at times. Again, I think with most treatments, it should be patient specific and based on their goals and what they need to get back to doing.

2) I haven’t worked with a lot of people in clinic with insertional achilles tendinopathy and the one patient that I have, had psoriatic arthritis which made it tricky with exercise prescription and knowing when to progress/regress exercises. Other than avoiding end range dorsiflexion, for her I modified the load with doing calf raises on the leg press, still working with both knees straight and knees bent and gradually building up her loading tolerance on there. Then I added in body weight DL calf raises in standing working on both concentrics and eccentrics. When I was trying to look up research articles for guidance with treatments and loading for insertional tendinopathy, most of the articles were focused on mid-portion tendinopathies. I think the heavy slow resistance protocol is a good guideline to use with modifying position, but allows the pt to work in both unloaded and loaded positions.

3) I get asked this question often in general when I do eccentric training with patients and find myself struggling with providing a good explanation. I often explain the difference in concentric vs eccentric if they are not familiar with the differences and how with concentric the muscle is shortening and eccentric the muscle is lengthening. With eccentric loading they are able to work higher loads compared to concentrics to help improve muscle strength and loading tolerance. I try not to go into the specifics since that’s when I start to muddy the waters. I would be interested to hear other go-to explanations and what you say when people start to ask for the more specifics. This is definitely something I need to brush up on.

References

1.Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine. 2009;43(6):409-416. doi:10.1136/bjsm.2008.051193
2.Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. Am J Sports Med. 2015;43(7):1704-1711. doi:10.1177/0363546515584760

[cmocarroll]

1. I think that the decision for incorporating eccentrics in the management of tendinopathy is multifaceted. Often I think of using eccentrics when the pt can tolerate that increased amount of load with low irritability. If the pt can stop the eccentric exercise and feel “no worse” I usually think it is appropriate to carry on. This may be the patient that falls into the tendon dysrepair/degenerative tendinopathy vs the reactive tendinopathy. Objectively, I think of this as the pt with full PF/DF strength, possible painful muscle contraction into PF/DF.. This pt may have reduced DF ROM and pain with palpation of the tendon. This pt may engage in some sort of functional repetitive task that is part of their daily/almost daily life. They may have history of achilles pain on/off for years as well as fluctuating pain levels when performing tasks; there may be a “sweet spot” of time when they don’t have pain, but likely start and end the activity with it.
2. Some other modifications might include not stretching or mobilizing in a full DF position as well as avoiding high loads or high impact exercises until tolerated with minimal to no pain in order to not increase strain/compression of the tendon. If eccentrics don’t work I’d likely continue treating the impairments through stretching, mobilization, and strengthening concentrically/isometrically as well. When researching treatment for insertional achilles tendinopathy, I had difficulty finding substantial evidence for exercises other than eccentrics and most articles refer to ESWT as the next line of treatment. The first article in my reference list discusses the compressive forces on the achilles tendon at its insertion during DF as recorded with ultrasound which supports the idea of reducing exercises into increased DF ROM for pts with insertional achilles tendinopathy.
3) When explaining the mechanism of eccentrics to patients, I think that I try to explain concentrics first as I feel that more people recognize this type of strengthening. Then I say that eccentrics is “just a different way of working the muscle – it has to exert control and work harder through the entire ROM or full lengthened position of the muscle. I go on to explain that this is why “I want you to do this exercise slow and controlled.” I tend to pair my education with examples so I might show them what it looks like when their calf musculature is shortened vs lengthened and how eccentrics work from there by demonstrating myself. In terms of why eccentrics work, I think I just tend to say “well, research shows that….” and then ramble on from there and I don’t think I’ve had any patients looking for a specific reason for “why” yet. I should probably change my approach to this and try to offer a better explanation. From the research I’ve done thus far, it looks like there are various reasons that we think eccentrics are helpful from structural tendon adaptation to changing tendinous stiffness to neuromuscular output changes and more research is needed to determine the most likely reason for the benefit.
1. Chimenti, R. L., Flemister, A. S., Ketz, J., Bucklin, M., Buckley, M. R., & Richards, M. S. (2016). Ultrasound strain mapping of Achilles tendon compressive strain patterns during dorsiflexion. Journal of biomechanics, 49(1), 39–44. https://doi.org/10.1016/j.jbiomech.2015.11.008

2. O’Neill S, Watson PJ, Barry S. WHY ARE ECCENTRIC EXERCISES EFFECTIVE FOR ACHILLES TENDINOPATHY? Int J Sports Phys Ther. 2015 Aug;10(4):552-62. PMID: 26347394; PMCID: PMC4527202.

3. Dilger, C. P., & Chimenti, R. L. (2019). Nonsurgical Treatment Options for Insertional Achilles Tendinopathy. Foot and ankle clinics, 24(3), 505–513. https://doi-org.ezp.slu.edu/10.1016/j.fcl.2019.04.004

….

[cmocarroll]

1. I think that the decision for incorporating eccentrics in the management of tendinopathy is multifaceted. Often I think of using eccentrics when the pt can tolerate that increased amount of load with low irritability. If the pt can stop the eccentric exercise and feel “no worse” I usually think it is appropriate to carry on. This may be the patient that falls into the tendon dysrepair/degenerative tendinopathy vs the reactive tendinopathy. Objectively, I think of this as the pt with full PF/DF strength, possible painful muscle contraction into PF/DF.. This pt may have reduced DF ROM and pain with palpation of the tendon. This pt may engage in some sort of functional repetitive task that is part of their daily/almost daily life. They may have history of achilles pain on/off for years as well as fluctuating pain levels when performing tasks; there may be a “sweet spot” of time when they don’t have pain, but likely start and end the activity with it.
2. Some other modifications might include not stretching or mobilizing in a full DF position as well as avoiding high loads or high impact exercises until tolerated with minimal to no pain in order to not increase strain/compression of the tendon. If eccentrics don’t work I’d likely continue treating the impairments through stretching, mobilization, and strengthening concentrically/isometrically as well. When researching treatment for insertional achilles tendinopathy, I had difficulty finding substantial evidence for exercises other than eccentrics and most articles refer to ESWT as the next line of treatment. The first article in my reference list discusses the compressive forces on the achilles tendon at its insertion during DF as recorded with ultrasound which supports the idea of reducing exercises into increased DF ROM for pts with insertional achilles tendinopathy.
3) When explaining the mechanism of eccentrics to patients, I think that I try to explain concentrics first as I feel that more people recognize this type of strengthening. Then I say that eccentrics is “just a different way of working the muscle – it has to exert control and work harder through the entire ROM or full lengthened position of the muscle. I go on to explain that this is why “I want you to do this exercise slow and controlled.” I tend to pair my education with examples so I might show them what it looks like when their calf musculature is shortened vs lengthened and how eccentrics work from there by demonstrating myself. In terms of why eccentrics work, I think I just tend to say “well, research shows that….” and then ramble on from there and I don’t think I’ve had any patients looking for a specific reason for “why” yet. I should probably change my approach to this and try to offer a better explanation. From the research I’ve done thus far, it looks like there are various reasons that we think eccentrics are helpful from structural tendon adaptation to changing tendinous stiffness to neuromuscular output changes and more research is needed to determine the most likely reason for the benefit.

1. Chimenti, R. L., Flemister, A. S., Ketz, J., Bucklin, M., Buckley, M. R., & Richards, M. S. (2016). Ultrasound strain mapping of Achilles tendon compressive strain patterns during dorsiflexion. Journal of biomechanics, 49(1), 39–44. https://doi.org/10.1016/j.jbiomech.2015.11.008

2. O’Neill S, Watson PJ, Barry S. WHY ARE ECCENTRIC EXERCISES EFFECTIVE FOR ACHILLES TENDINOPATHY? Int J Sports Phys Ther. 2015 Aug;10(4):552-62. PMID: 26347394; PMCID: PMC4527202.

3. Dilger, C. P., & Chimenti, R. L. (2019). Nonsurgical Treatment Options for Insertional Achilles Tendinopathy. Foot and ankle clinics, 24(3), 505–513. https://doi-org.ezp.slu.edu/10.1016/j.fcl.2019.04.004

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