Achilles Tendinopathy

145 Achilles Tendinopathy

Domiziano Tarantino MD1, Rocco Aicale MD1 and Nicola Maffulli MD MS PhD FRCS (Orth)1,2

1 Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Salerno, Italy

2 Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK

Clinical scenario

  • A 41‐year‐old male runner presents with swelling 2.5 cm in diameter, 4 cm proximal to the insertion of the Achilles tendon. For three months, he has felt pain at the beginning and at the end of training sessions, with diminished discomfort in between.
  • There is tenderness of the Achilles tendon. He has no neurovascular deficits. The physician makes a diagnosis of Achilles tendinopathy (AT).
  • Eccentric exercise is presented as an option for this patient. However, the patient would like to apply a wait‐and‐see policy or undertake a program of concentric exercises.
  • After failed management with eccentric exercises alone, the physician proposes to the patient that he should undertake extracorporeal shockwave therapy (ESWT).
  • After searching the internet, the patient asks the doctor to give him information about platelet‐rich plasma (PRP) injections.

Top three questions

  1. In patients with AT, does a program of eccentric exercises result in better clinical outcomes compared to control?
  2. In patients with AT, does a program of eccentric exercises result in better clinical outcomes compared to shockwave therapy?
  3. In patients with AT, does a program of eccentric exercises result in better clinical outcomes compared to PRP injections plus eccentric exercises?

Question 1: In patients with AT, does a program of eccentric exercises result in better clinical outcomes compared to control?


Current opinion suggests that the majority of health professionals consider eccentric exercises as an appropriate management tool for AT. Eccentric exercises have been proposed to promote collagen fiber cross‐link formation within the tendon, thereby facilitating tendon remodelling.1

Clinical comment

Several management options have been proposed to allow recovery of patients with AT. However, outcomes with long‐term follow‐up of the different options are not well defined.

Available literature and quality of the evidence

A range of randomized controlled trials (RCTs) and case control studies are available to answer this question.


Comparison of eccentric exercise versus wait‐and‐see strategy

Horstmann et al. conducted an RCT comparing the effectiveness of whole‐body vibration versus eccentric training or a wait‐and‐see approach for chronic AT.2 After a 12‐week intervention phase, pain improvements at the midsection of the tendon were greater in the vibration and eccentric training groups than in the wait‐and‐see group, but only the eccentric training intervention reduced pain at the musculotendinous junction. Improvements in sonographic parameters and changes in muscle strength were similar for the vibration training and the eccentric training groups.

Comparison of eccentric exercises versus concentric exercises

Rowe et al. performed a systematic review on the conservative management of midportion AT.3 They pointed out that eccentric loading exercises have the strongest supporting evidence of all the conservative treatment modalities. There is moderate evidence to suggest that concentric calf muscle training is not as effective as an eccentric training regimen. Two studies randomized participants to either eccentric or concentric calf muscle training for 12 weeks.4,5 The results from both studies showed significantly greater reductions in pain for the eccentric training group compared with the concentric training group. However, in both studies, patients reported some improvement with concentric exercises and, in practice, combined concentric/eccentric exercises were frequently prescribed initially where eccentric exercises were intolerable because of pain or because the patient was too weak to start with eccentric exercises right away.

In a case control study, Yu et al. assessed the effect of eccentric strengthening on pain, muscle strength, endurance, and functional fitness factors in male patients with AT.6 Eccentric strengthening, in comparison with concentric strengthening, showed significant improvement in pain, ankle dorsiflexion endurance, total balance index, and agility after the intervention.

One year later, in a single‐blind, cross‐sectional study, Yu et al. aimed to identify changes in muscle activation by comparing muscle activities of the affected side (AS) and nonaffected side (NAS) during eccentric and concentric exercise in runners with unilateral AT.7 Concentric exercise induces higher maximum muscle activation in every muscle studied, except the medial gastrocnemius of the AS, where eccentric exercise induced higher maximum muscle activation when compared with concentric exercise. Relatively high levels of statistical significance were found for the rectus femoris, tibialis anterior, peroneus longus, and lateral gastrocnemius.

Beyer et al., in an RCT comprising 58 recreational athletes, evaluated the effectiveness of eccentric training (ECC) and heavy slow resistance (HSR) training among patients with midportion AT.8

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Achilles Tendinopathy
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