Rehabilitation Exercises for Achilles Tendinopathy
Achilles tendinopathy is a common cause of pain on the backside of the heel, especially in athletes who frequently run and jump. Formerly referred to as Achilles tendinitis, Achilles tendinopathy is an overload condition leading to the development of heel pain. Eccentric exercises have long been the standard treatment approach for tendinopathy. However, is it necessary to isolate the eccentric muscle contraction for Achilles tendinopathy? This post will discuss the rehabilitation exercise programs for the treatment of Achilles tendinopathy.
A randomized controlled trial by Rikke Beyer, et al compared the use of a heavy, slow resistance protocol compared to an eccentric loading protocol for Achilles tendinopathy.
Eccentric Exercise for Achilles Tendinopathy
Eccentric exercise programs are traditionally used for the treatment of Achilles tendinopathy. The eccentric loading protocol, popularized by the research of Alfredson, consisted of 3 sets of 15 for both bent knee and straight knee heel raises with each heel lowering lasting 3-seconds. The exercises were performed twice per day seven days a week for 12 weeks. A 2-minute rest break was given between sets and a 5-minute rest break was given between bent and straight knee sets. The weight used in the exercises was gradually increased using a backpack.
Heavy, Slow Resistance Achilles Tendinopathy
Another exercise program for Achilles tendinopathy is the heavy, slow resistance program. The heavy, slow resistance protocol consisted of three exercises: (1) a seated calf raise, (2) a straight leg calf raise on a leg press machine, and (3) a standing straight leg calf raise in a squat rack. Both the concentric and eccentric muscle contractions durations were for 3 seconds. The exercises were to be performed three times per week. The weight progression used in the HSR protocol was as follows:
- Week 1 3 sets of 15 RM
- Weeks 2-3 3 sets of 12 RM
- Weeks 4-5 4 sets of 10 RM
- Weeks 6-8 4 sets of 8 RM
- Weeks 9-12 4 sets of 6 RM
What the trial found was that both eccentric loading and heavy, slow resistance programs for Achilles tendinopathy resulted in improvement. However, the heavy, slow resistance protocol had greater satisfaction after 12 weeks compared to eccentric loading.
Isolating Eccentric Muscle Contractions
Although eccentric loading has been recommended for Achilles tendinopathy, a systematic review by Peter Malliaras, et al found little evidence to support isolating the eccentric muscle contraction. The review suggested that clinicians should consider eccentric-concentric exercises loading with or in place of isolated eccentric exercises for Achilles tendinopathy.
Rehabilitation for Achilles Tendinopathy
Both of these studies highlight a couple of important aspects of rehabilitation for Achilles tendinopathy.
The first is rehabilitation programs for Achilles tendinopathy should prioritize controlled loading. The heavy, slow resistance program starts with 15 RM while the eccentric loading program starts with 3 sets of 15 for both bent knee and straight leg heel raises. It’s not uncommon for rehabilitation programs to underload the Achilles tendon in an effort to protect the tendon from further pain and damage. However, both of these programs incorporated loading relatively early on and produced positive outcomes.
Time under load is also an important consideration for rehabilitation programs. The eccentric loading program uses a 3-second eccentric muscle contraction while the heavy, slow resistance program uses a 3-second muscle contraction for both the concentric and eccentric phases. The 3 to 6 seconds under tension for each repetition is most likely an increase compared to what is usually used in the clinic.
A final consideration is to simplify the rehabilitation program by using concentric and eccentric heel raises and not isolating the eccentric muscle contraction. Compliance with an exercise program is vital to produce successful outcomes. Since the heavy, slow resistance program uses both concentric and eccentric muscle contractions and the systematic review by Peter Malliaras found little evidence supporting isolating eccentric loading, this might be unnecessarily be complicating rehabilitation for Achilles tendinopathy.
References:
- Beyer, Rikke, et al. “Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy.” The American Journal of Sports Medicine, vol. 43, no. 7, 2015, pp. 1704–1711., doi:10.1177/0363546515584760.
- Malliaras, Peter, et al. “Achilles and Patellar Tendinopathy Loading Programmes.” Sports Medicine, vol. 43, no. 4, 2013, pp. 267–286., doi:10.1007/s40279-013-0019-z.