Achilles tendinopathy exercise prescriptions

[Dhinu Jayaseelan]

Hi all –

This past weekend we were able to talk about load-induced tendinopathy management, specifically as it relates to the Achilles tendon (poor guy’s mom couldn’t dip his entire leg in that river…). I offered a couple of different perspectives based on the evidence (e.g. Cook’s continuum, the phasic progression) and offered my 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.

[David Brown]

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.

[Sarah Frunzi]

Hey Dave!

Good thoughts here! I would like to mention though that not all patients might understand the concept of velocity and load when explaining the benefits of eccentrics, and that reframing this in simpler terms might be helpful as well, or being able to explain those concepts as an educational opportunity would be great! I would also caution using the phrase “sick region” if using that quote during patient education, as this could potentially be a harmful phrase to patients. The intention of this quote is wonderful, but may be misconstrued to a patient that might already be fearful or avoidant. Just food for thought! I do appreciate how you have redirected the thought back to their functional goals, where this is stuff patients appreciate when they see us being specific in our treatment for the purpose of getting them back to the activities they want to do.

[Sarah Frunzi]

Eccentrics are a great exercise technique if used properly for the appropriate patient. Typically, I will use eccentrics for the chronic tendinopathy (no longer in the acute/inflammatory phase) as a method of restarting a mild inflammatory process to reproduce optimal blood flow and nutrition to that degenerative area. This patient would likely present with pain at Achilles tendon (mid portion or insertional) describing tenderness or sharpness. They would likely have pain/discomfort with ambulating or activities that put that area/tissues on stretch. Potential hypertrophy or thickening of the tendon may be noted compared to the opposite side as well. If pain is at insertional site, I would recommend eccentrics to neutral versus into dorsiflexion to not encourage increased compression. If actively monitoring symptoms and tracking latent symptom response post-session, eccentrics can be a great addition when treating chronic/degenerative tendinopathies.

In addition to avoiding end range dorsiflexion, I would educate on avoiding stretching in that area if provocative to symptoms since this adds extra compression to the insertional site. Interestingly though, the study done by Gatz et al determined that isometrics do not provide additional benefit when added to an eccentric program (Gatz et al, 2020). However, I do feel isometrics would be appropriate if the patient was of high irritability and would be a good starting point. If eccentrics were not providing the intended outcome, one study showed that heavy slow resistance training also provides just as much benefit for Achilles tendinopathies as eccentrics (Beyer et al, 2015). Addressing any physical impairments at the foot and ankle with appropriate manual therapy techniques (STM, joint mobilization/manipulation, etc.) should also be incorporated when indicated as well.

When explaining eccentric exercises, I like to use the analogy of a bicep curl first since this a fairly understood/common exercise to most patients regardless of educational background. I first explain concentric shortening with the curl up, and the eccentric lengthening phase on the down portion of the curl. I find that patients can understand this concept better this way and then transition the concept to a heel raise or similar exercise regarding the Achilles tendon. I also mention, when dealing with the degenerative/chronic tendinopathy, that the eccentric exercise is a good method of “restarting” or “jump starting” a slight inflammatory process to the tendon we are treating so that their tendon gets the nutrients it needs to heal more optimally and to become stronger. I try to not get overly anatomical with patients but explain the purpose of it followed by symptom monitoring education.

Work Cited:
1. Gatz, M. et al. Eccentric and Isometric Exercises in Achilles Tendinopathy Evaluated by the VISA-A Score and Shear Wave Elastography. Sports Health. Jul/Aug 2020;12(4):373-381. doi: 10.1177/1941738119893996. Epub 2020 Jan 31. PMID: 32003647

2. Beyer, R. et al. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. Am J Sports Med. 2015 Jul;43(7):1704-11. doi: 10.1177/0363546515584760. Epub 2015 May 27. PMID: 26018970

[David Brown]

Sarah,

Great thoughts of trying to improve the strength of a chronically pathological achilles tendon! One thing I would be wary of however is when you are trying to facilitate an inflammatory response there will be a secondary nociceptive response of the body which can drive moderate to severe pain. It is important to listen and monitor your patient’s response to these exercises as we do not want to evoke too much discomfort for a patient who has already been undergoing persistent pain in this region. I strongly encourage you to read Tompra et al’s article on central pain processing and central sensitization in the region of the achilles tendon and let this guide your dosage and parameters surrounding this exercise. I enjoy your insights to modifications and education surrounding how to present these exercises in a meaningful and impactful manner for the patient. Great work!

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