Eccentric Exercise for Achilles Tendinopathy: A Narrative Review and Clinical Decision-Making Considerations
Abstract
:1. Background
2. Historical Perspective
3. Continuum Model of Tendinopathy
4. Proposed Mechanisms of Action
4.1. Pathological Changes with Tendinopathy
4.2. Possible Explanations for Improvement with Eccentrics
5. Clinical Efficacy of Eccentric Exercise for Achilles Tendinopathy
5.1. Eccentric Exercise Versus Control
5.2. Eccentric Exercise Versus other Forms of Exercise
5.3. Eccentric Exercise Versus Orthoses or Therapeutic Modalities
5.4. Multimodal Treatment Approaches with or Without Eccentric Exercise
6. Clinical Decision-Making Considerations
6.1. Patient Presentation
6.2. Reasons for Integrating Eccentric Exercise
6.3. Reasons for not Integrating Eccentric Exercise
6.4. Clinical Suggestions for Incorporating Eccentric Exercise
7. Discussion
Author Contributions
Funding
Conflicts of Interest
References
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First Author | Participants | Primary Eccentric Intervention Group | Comparison(s) | Frequency and Duration of Therapy |
---|---|---|---|---|
Beyer [38] | n = 47 (25 Exp, 22 Comp) Exp mean age: 48 ± 2.0; Comp mean age: 48 ± 2.0 Primary diagnosis: mid-portion Achilles tendinopathy | Unilateral eccentric exercise | Heavy slow resistance exercise | Exp: 3 × 15 repetitions per exercise; 2×/day; 7 days/week; 12 weeks Comp: 3–4 sets per exercise; 3×/week; 12 weeks total; (gradual increase in load and decrease in reps over 12 weeks) |
Herrington [39] | n = 25 (13 Exp, 12 Comp) Exp mean age: 37 ± 9.26; Comp mean age: 36.6 ± 7.14 Primary diagnosis: Achilles tendinopathy | Eccentric exercise, DFM, US, and stretching to gastrocnemius and soleus | DFM, US, and stretching to gastrocnemius and soleus | Exp: eccentric exercise 2×/day; 7 days/week; 12 weeks total; DFM, US, and stretching followed same protocol as comp Comp: DFM and US 1×/week; 6 weeks; 6 sessions total; stretching daily; 12 weeks total |
Horstmann [40] | n = 54 (18 Exp, 22 Comp, 14 controls) Exp mean age: 45.7 ± 8.5; Comp mean age: 46 ± 6.9; control mean age: 44.4 ± 7.7 Primary diagnosis: chronic Achilles tendinopathy | Unilateral eccentric exercise | (1) Comp: whole body vibration training (2) control | Exp: 3 × 15 repetitions per exercise; 12 weeks total; 36 total sessions Comp: 4–7 min per training session; 12 weeks total; 36 total session |
Petersen [41] | n = 100 (37 Exp, 35 Comp, 28 combinations) Exp mean age: 42.1 ± 11.0; Comp mean age: 42.6 ± 10.7; combination mean age: 43 ± 12 Primary diagnosis: Chronic Achilles tendinopathy | Eccentric exercise | (1) AirHeel Brace (2) combination of experimental and comparison groups | Exp: 3 × 15 repetitions per exercise; 3×/day; 7 days/week; 12 weeks Comp: Participants instructed to wear the AirHeel brace during the daytime for 12 weeks Combination: Followed Exp and combination protocols |
Rompe [42] | n = 75 (25 per group) Exp mean age: 48.1 ± 9.9; Comp mean age: 51.2 ± 10.3; control mean age: 46.4 ± 11.4 Primary diagnosis: Mid-portion Achilles tendinopathy | Eccentric exercise | (1) Shock wave Therapy (2) Control | Exp: 3 × 15 repetitions per exercise; 2×/day; 7 days/week; 12 weeks total Comp: 1×/week; 3 consecutive weeks; 3 sessions total |
Tumilty [43] | n = 80 (20 per group) group 1 mean age: 47.2 ± 8.5; group 2 mean age: 46.2 ± 10.9; group 3 mean age: 47.7 ± 10.1; group 4 mean age: 48.5 ± 9.3 Primary diagnosis: Achilles tendinopathy | Exp group 1: Laser + eccentric exercise regime 1 Exp group 2: Laser + eccentric exercise regime 2 | Comp group 1: Placebo + eccentric exercise regime 1 Comp group 2: Placebo + eccentric exercise regime 2 | Exp group 1: laser therapy to Achilles tendon for 90 s, 2x/week, for 4 weeks; eccentric exercise 2x/day; 7 days/week; 12 weeks total Exp group 2: laser therapy to Achilles tendon for 90 s, 2×/week, for 4 weeks; eccentric exercise 2×/day; 2 days/week; 12 weeks total Comp group 1: Placebo laser therapy for 4 weeks; eccentric exercise 2×/day; 7 days/week; 12 weeks total Comp group 2: Placebo laser therapy for 4 weeks; eccentric exercise 2×/day; 2 days/week; 12 weeks total |
Yu [44] | n = 32 (16 per group) Exp mean age: 20.14 ± 1.84; Comp mean age: 20.40 ± 1.27 Primary diagnosis: Achilles tendinopathy | Eccentric exercise | Concentric exercise | Exp: 3 × 15 repetitions per exercise; 50 min/session; 3 days/week; 8 weeks total Comp: 3 × 15 repetitions per concentric strengthening exercise; 5 × 10” hold per stretch; 50 min/session; 3 days/week; 8 weeks total |
First Author | Outcome Timeline | Outcome(s) Utilized | Results † |
---|---|---|---|
Beyer [38] | Baseline, after 12-week intervention, 52-week follow-up | (1) VAS | Eccentric-running: 49 ± 5.5, 20 ± 5.7, 12 ± 4.2 HSR-running: 54 ± 5.4, 17 ± 4.1, 5 ± 2.6 Eccentric-heel raises: 19 ± 5.0, 12 ± 3.6, 6 ± 2.6 HSR-heel raises: 29 ± 5.5, 7 ± 2.4, 5 ± 2.5 No statistically significant differences between groups at 52 weeks for VAS while running (p = 0.71) or during heel raises (p = 0.77). |
Herrington [39] | Baseline, 4 weeks, 8 weeks, and 12 weeks | (1) VISA-A | Eccentric % change between time points: 30.4, 15.8 *, 5.6, 51.8 * (0–12 week % change) Comparison: 9.7, 12.8, 9.4, 31.9 * (0–12 week % change) The eccentric group demonstrated significantly higher (F = 5.21, p = 0.014) VISA-A scores than the comparison group over the 12-week period |
Horstmann [40] | Baseline, after 12-week intervention | (1) VAS | Eccentric group impact of pain on household responsibilities: 13.0 ± 17.7, 5.5 ± 15.8 * Eccentric group impact of pain on recreation: 21.9 ± 23.0, 9.4 ± 16.9 * Eccentric group impact of pain on social activities: 9.4 ± 15.8, 1.0 ± 2.0 * Eccentric group impact of pain on running training: 76.3 ± 27.3, 24.7 ± 30.3 * Vibration group impact of pain on household responsibilities: 8.4 ± 19.7, 3.8 ± 6.2 Vibration group impact of pain on recreation: 27.2±27.3, 15.8 ± 21.3 * Vibration group impact of pain on social activities: 5.8 ± 12.9, 3.3 ± 7.0 * Eccentric group impact of pain on running training: 60.2 ± 35.0, 35.3 ± 34.7 * Control group impact of pain on household responsibilities: 16.0 ± 28.1, 10.2 ± 26.5 Control group impact of pain on recreation: 29.7 ± 30.0, 19.8 ± 26.2 Control group impact of pain on social activities: 7.2 ± 17.1, 9.9 ± 16.9 Control group impact of pain on running training: 63.9 ± 33.6, 51.0 ± 38.1 Eccentric exercise and vibration groups had significant improvements in outcomes, as compared to wait-and-see control. Eccentric group performed better in pain reduction than vibration group. |
Petersen [41] | Baseline, 6 weeks, 12 weeks, 52-week follow-up | (1) VAS | Eccentric-ADLs: 20% reduction after 6 weeks *, 60% reduction after 12 weeks *, 30% reduction at 1 year * Eccentric-walking: 25% reduction after 6 weeks, 71% reduction after 12 weeks, 45% reduction at 1 year * Eccentric-sports activities: 51% reduction at 1 year * AirHeel brace-ADLs: 41% reduction after 6 weeks *, 35% reduction after 12 weeks, 27% reduction at 1 year * AirHeel brace-walking: 43% reduction after 6 weeks *, 50% reduction after 12 weeks, 46% reduction at 1 year * AirHeeel brace-sports activities: 47% reduction at 1 year * Combination-ADLs: 22% reduction after 6 weeks *, 56% reduction after 12 weeks *, 53% reduction at 1 year * Combination-walking: 36% reduction after 6 weeks *, 56% reduction after 12 weeks, 64% reduction at 1 year * Combination-sports activities: 74% reduction at 1 year * No significant between group differences seen at 1 year |
Rompe [42] | Baseline, 4-month follow-up | (1) NRS | Eccentric group: 7.03 ± 0.8. 3.6 ± 2.3 Shockwave therapy group: 6.8 ± 0.9, 4.0 ± 2.2 Control group: 7.9 ± 0.6, 5.9 ± 1.8 No statistically significant difference between eccentric and SWT group (p = 0.494). Statistically significant differences between eccentric and control groups (p < 0.001) * and SWT and control groups (p < 0.001) * |
Tumilty [43] | Baseline, 4 weeks, 12 weeks | (1) NPRS (pain) | Eccentric exercise regimen 1 + Laser: 8.3, 4.5 *, 2.9 * Eccentric exercise regimen 2 + Laser: 7.8, 2.4 *, 0.05 * Eccentric exercise regimen 1 + Placebo: 7.4, 4.9 *, 2.5 * Eccentric exercise regimen 2 + Placebo: 8.6, 3.5 *, 2.3 * Group 4 had statistically significant improvement in pain at 12-week follow-up. Otherwise, no significant changes in pain. |
Yu [44] | Baseline, after 8-week intervention | (1) VAS | Eccentric: 5.72 ± 0.89, 2.16 ± 0.42 * Concentric: 5.72 ± 0.79, 3.26 ± 0.78 * Statistically significant changes between eccentric and concentric group in favor of eccentric |
First Author | Outcome Timeline | Outcome(s) Utilized | Results † |
---|---|---|---|
Beyer [38] | Baseline, after 12-week intervention, 52-week follow-up | (1) VISA-A | Eccentric: 58 ± 3.9, 72 ± 3.7, 84 ± 3.5 HSR: 54 ± 3.2, 76 ± 3.7, 89 ± 2.8 No statistically significant differences between groups at 52 weeks (p = 0.62). |
Herrington [39] | Baseline, 4 weeks, 8 weeks, and 12 weeks | (2) VISA-A | Eccentric % change between time points: 30.4 *, 15.8 *, 5.6, 51.8 * (0–12 week % change) Comparison: 9.7, 12.8, 9.4, 31.9 * (0–12 week % change) The eccentric group demonstrated significantly higher (F = 5.21, p = 0.014) VISA-A scores than the comparison group over the 12-week period |
Petersen [41] | Baseline, 6 weeks, 12 weeks, 52-week follow-up | (1) AOFAS (2) SF-36 | Eccentric AOFAS: 10% improvement at 1 year * Eccentric SF-36: 76.1 ± 21.6, 85.0 ± 16.4, 87.7 ± 12.2 * AirHeel brace AOFAS: 10% improvement at 1 year * AirHeel brace SF-36: 76.3 ± 19.8, 84.2 ± 14.4, 88.0 ± 13.0 * Combination AOFAS: 12% improvement at 1 year * Combination SF-36: 71.8 ± 24.0, 83.6 ± 21.8, 89.3 ± 17.9 * No statistically significant differences between groups |
Rompe [42] | Baseline, 4-month follow-up | (1) VISA-A | Eccentric group: 50.6 ± 11.5, 75.6 ± 18.7 Shockwave therapy group: 50.3 ± 11.7, 70.4 ± 16.3 Control group: 48.2 ± 9.0, 55.0 ± 12.9 No statistically significant difference between eccentric and SWT group (p = 0.259). Statistically significant differences between eccentric and control groups (p < 0.001) * and SWT and control groups (p < 0.001) * |
Tumilty [43] | Baseline, 4 weeks, 12 weeks | (1) VISA-A | Eccentric exercise regimen 1 + Laser: 59.9, 77.9 *, 88.6 * Eccentric exercise regimen 2 + Laser: 57.5, 81.1 *, 99.0 * Eccentric exercise regimen 1 + Placebo: 56.7, 74.7 *, 80.4 * Eccentric exercise regimen 2 + Placebo: 56.8, 77.8 *, 87.6 * Eccentric exercise regimen 2 + laser showed statistically significant improvements as compared with all other groups at 12 weeks |
Yu [44] | Baseline, after 8-week intervention | (1) Biodex total Balance index | Eccentric: 36.38 ± 8.51, 8.0 ± 5.39 * Concentric: 29.0 ± 16.02, 22.50 ± 7.52 Statistically significant changes between eccentric and concentric group in favor of eccentric |
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Jayaseelan, D.J.; Mischke, J.J.; Strazzulla, R.L. Eccentric Exercise for Achilles Tendinopathy: A Narrative Review and Clinical Decision-Making Considerations. J. Funct. Morphol. Kinesiol. 2019, 4, 34. https://doi.org/10.3390/jfmk4020034
Jayaseelan DJ, Mischke JJ, Strazzulla RL. Eccentric Exercise for Achilles Tendinopathy: A Narrative Review and Clinical Decision-Making Considerations. Journal of Functional Morphology and Kinesiology. 2019; 4(2):34. https://doi.org/10.3390/jfmk4020034
Chicago/Turabian StyleJayaseelan, Dhinu J., John J. Mischke, and Raymond L. Strazzulla. 2019. "Eccentric Exercise for Achilles Tendinopathy: A Narrative Review and Clinical Decision-Making Considerations" Journal of Functional Morphology and Kinesiology 4, no. 2: 34. https://doi.org/10.3390/jfmk4020034
APA StyleJayaseelan, D. J., Mischke, J. J., & Strazzulla, R. L. (2019). Eccentric Exercise for Achilles Tendinopathy: A Narrative Review and Clinical Decision-Making Considerations. Journal of Functional Morphology and Kinesiology, 4(2), 34. https://doi.org/10.3390/jfmk4020034