eccentric training regimine increases collagen synthesis in injured achilles tendons

Here is a link to another site with a photo... It requires a special machine. Alternatively, you can try doing it with a barbell resting across your thighs.

Hope that helps!

ABSTRACT

Background: Eccentric training has been shown to reduce pain and gain function in patients with chronic Achilles tendinopathy. However, currently no data are available regarding any potential adverse effects of an eccentric training intervention on Achilles tendon microcirculation.

Methods: 59 patients (49 (12) years; body mass index 27 (5); 49 mid-portion, 10 chronic insertional tendinopathy) with 64 symptomatic (54 mid-portion, 10 insertional) Achilles tendons were prospectively enrolled. Baseline tendon microcirculation at four distinct tendon positions from the insertion to the proximal mid-portion area was assessed using a laser Doppler system for capillary blood flow, tissue oxygen saturation and postcapillary venous filling pressure. A 12-week daily painful home-based eccentric training regimen was initiated (3x15 repetitions per tendon and day).

Results: Achilles tendon capillary blood flow was significantly reduced at the insertion (by 35%, p = 0.008) and the distal mid-portion area (by 45%, p = 0.015) at 2 mm and by 22% (p = 0.007) and 13% (p = 0.122) at 8 mm tissue depths, respectively. Achilles tendon oxygen saturation was not decreased after the 12-week eccentric training regimen throughout the insertion to the proximal mid-portion area (insertion 72 (13) vs 73 (10), proximal mid-portion 63 (13) vs 62 (11), both NS). Achilles tendon postcapillary venous filling pressures were significantly reduced at the insertion (51 (16) vs 41 (19), p = 0.001) and the distal mid-portion (36 (13) vs 32 (12), p = 0.037) at 2 mm and at the insertion at 8 mm (63 (19) vs 51 (13), p = 0.0001). Pain was reduced from 5.4 (2.1) to 3.6 (2.4; p = 0.001) in the mid-portion and from 6 (2.5) to 3.2 (2.7; p = 0.002) in the insertional tendinopathy group. No Achilles tendon rupture or any interruption during the eccentric training was noted among the 59 patients.

Here is another interesting possiblity for why the program reduces pain: the raises actually reduce the hypervascularity of the tendons. In this study, the program seems to have worked for both insertional and mid-portion tendonosis.

Dr. S,

A lot of these studies and program descriptions suggest that the eccentric drops should be painful when doing them. How painful should they be? Should I continue to increase the weight when the reps are no longer painful?

Thanks.

Also, since tendonosis is indeed not an inflamatory condition do icing and NSAIDs do anything to help it? Or should I stop these kinds of treatments?

Pain is tough to guage with these things, but I think the best thing to say is it is okay to feel pain. I had pretty bad pain while doing mine, but it worked. Others have said the same thing. The main thing to monitor is if the pain during daily acitivites is getting better or worse.

Because it is a degenerative, not inflammatory condition, the use of NSAIDs is controversial. Some say they hurt the regeneration process, others say they help (and may also prevent any negative consequences of inflammation that the eccentrics may bring on). Tough to say. My general recommendation is to use one, I prefer Aleve, as long as it doesn't bother your stomach.

Same thing applies for icing. Most of the studies have shown the effects of eccentrics in the absence of icing. It is not essential. Some may argue that icing may help any negative inflammatory consequences of the exercise, while others may say that it slows down the metabolism and hence the rate of collagen synthesis. I would say try it without icing and see how you do.

Because it is a degenerative, not inflammatory condition, the use of NSAIDs is controversial. Some say they hurt the regeneration process, others say they help (and may also prevent any negative consequences of inflammation that the eccentrics may bring on). Tough to say. My general recommendation is to use one, I prefer Aleve, as long as it doesn't bother your stomach.

so are there two type of achilles injuries, those that are of the inflammatory condition and those of degenerative condition? If this is right, is the infammatory condition leSs serious and sometimes able to train through?

My understanding is that they are different, but that one (achilles tendonitis) can lead into the other (achilles tendonosis) if you keep trying to run on it. That seems to be my experience with it. Just know that if you try to run through it you are taking a big risk.

My the pain achilles is definately getting less severe as I progess through the eccentric regimine (a good sign I imagine), but should to continually add more weight in order to counter this improvement or should I simply accept that it is improving and do the exercizes sans pain?

For Several years I experienced tight calves, had surgery on my right achilles (1996) and many times I'd suffer through "getting shot in the calf"...IE. My calf would blow out on a run. I'd be out for weeks or months again.

Four years ago I saw the article on eccentric stretching and decided I had nothing to lose. After a couple of months I was able to run again and have never had a calf problem since. I currently run 60 mpw which is ok for an almost 50 year old. I still do the stretches 1-2 times per day with 25lbs in a back pack...I can do them while making coffee in the morning.

I also do other tendon exercises...google exercises to make your tendons like the rock of Gibraltar. It works!! Good luck.

I would gradually add a bit more weight, as long as adding weight doesn't make it any worse. Eventually you should be pain free.

Thanks again for all of the good information. I am up to 45lbs on my back now. How much were you lifting when you did the exercizes?

I don't remember exactly, and surprisingly I didn't write it down in my training log. For the seated calf raises, I know I was doing around 90 pounds much of the time. Don't remember for the standing though. It varies, depending if you are using free weights, a calf machine, a leg press machine, etc. 45 is a good start though, a few people I know were having trouble with 10-15 pounds because their muscles/tissues were so weak/damaged.

Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up

L Öhberg1, R Lorentzon2, H Alfredson2

1 Department of Radiation Sciences, Diagnostic Radiology, Umeå University, Umeå, Sweden

2 Department of Surgical and Perioperative Science, Sports Medicine and National Institute for Working Life, University of Umeå

Correspondence to:

Correspondence to:

Dr Öhberg

Department of Radiology, University Hospital of Umeå, 901 85 Umeå, Sweden;

lars.ohberg.us@vll.se

Objective: To prospectively investigate tendon thickness and tendon structure by ultrasonography in patients treated with eccentric calf muscle training for painful chronic Achilles tendinosis located at the 2–6 cm level in the tendon.

Methods: The patients were examined with grey scale ultrasonography before and 3.8 years (mean) after the 12 week eccentric training regimen. At follow up, a questionnaire assessed present activity level and satisfaction with treatment.

Results: Twenty six tendons in twenty five patients (19 men and six women) with a mean age of 50 years were followed for a mean of 3.8 years (range 1.6–7.75). All patients had a long duration of painful symptoms (mean 17.1 months) from chronic Achilles tendinosis before treatment. At follow up, 22 of 25 patients were satisfied with treatment and active in Achilles tendon loading activities at the desired level. Ultrasonography showed that tendon thickness (at the widest part) had decreased significantly (p<0.005) after treatment (7.6 (2.3) v 8.8 (3) mm; mean (SD)). In untreated normal tendons, there was no significant difference in thickness after treatment (5.3 (1.3) mm before and 5.9 (0.8) mm after). All tendons with tendinosis had structural abnormalities (hypoechoic areas and irregular structure) before the start of treatment. After treatment, the structure was normal in 19 of the 26 tendons. Six of the seven patients with remaining structural abnormalities experienced pain in the tendon during loading.

Conclusions: Ultrasonographic follow up of patients with mid-portion painful chronic Achilles tendinosis treated with eccentric calf muscle training showed a localised decrease in tendon thickness and a normalised tendon structure in most patients. Remaining structural tendon abnormalities seemed to be associated with residual pain in the tendon.

Here is a study that suggests that eccentric training may actually normalize structural abnormalities in the tendon. This is another possibility for why this program works, and it seems true to my experience. My injuried tendon was thick and had a large bump on it nabout 1.5cm up the tendon, and while it is still thicker than normal and the bump partially remains, both abnormalities seem to be significantly reduced 2 months into the lifts.

Does anyone know if the same priciples of eccentric training would be applicable to other tendons other than achilles?

I know that hamstring tendonitis/osis tends to be another chronic injury involving a tendon with a limited blood supply like the achilles. Anyone know if eccentric loading to the hamstring would have the same physiologic effect as noted in the achilles studies?

That's a good question, but so far I haven't run into any studies suggesting that this may be the case. The one problem is the eccentric movement of the achilles provides a particular kind of stress that may be difficult to duplicate in other tendons.

But also mind you that I am not really an expert in this field, just someone who has been forced to deal with achilles pain.

I really don't have a straight up answer for this, but will give you what I know.

Most of the research I did about it was geared towards the Achilles tendon, so I really don't know the specifics about the other tendons themselves. That said, eccentric training is useful for muscle injuries (including hamstring injuries) and tendons in general do adapt to the conditions they are subject to (although different ones adapt differently, ie, flexor vs. extensor tendons).

One thing that makes doing the hamstring eccentrics a little different is that the knee joint is a lot more delicate (for lack of better word) to work with. Normally, we have coactivitation of muscles (quads and hams) to stabilize the joint, whereas any exercises that specifically isolate knee flexors or extensors often do not promote this stabilization. The knee extension exercise (for the quads) is a great example of this, as it can produce considerable anterior shear force when heavy weight is used. Doing some sort of heavy eccentric exercise at the knee joint may be a bit dangerous for this reason... I am staying on the cautious side of things though.

The other thing about hamstring eccentrics is there are medial and lateral tendons, whereas the Achilles is a central tendon. If you are trying to load the lateral tendon, the medial musculature may still take over and bear some of this weight, so specific techniques would be important to place the stress in the appropriate place, but not too much that it risks injuring the joint.

Lying leg curls can be done for eccentrics, as you can lift the weight up with both legs, and then concentrate on lowering the injured leg down slowly, using the non-injured to help control the movement. Things like using a glute-ham bench (see link below) provide a lot of eccentric load, and you can somewhat control the load on the injured side by concentrating on how much force you are producing on the non injured side.

For all who have has chronic achilles tendonosis, how did you know when to start running again? Was the pain completely gone or only partially? Did it hurt when you started running again? Do you have any residual soreness today?

I started running when most, but not all, of the pain was gone, and this seems to work for many. If the pain starts getting any worse, cut back on the running or take a few days off

With any injuries, I am ultraconservative with return to running. We normally think that a 30-minute easy run feels exactly that, very easy, and like no work whatsoever. But you can do a lot of damage in that 30 minutes. That's why I start out just by testing it with a 2-3 minute run at first, and build up to about 10 minutes over a week. Then build back up to 30 minutes over the course of about 2 weeks if everything is going okay.

So, you can make the very short duration runs (less than 5 minutes) part of your rehab to guage how you are responding to therapy.

When all was said and done, I was completely pain free. That took a few months, but eventually the pain was completely gone - no soreness before, during, or after runs.

The reason I like to be conservative is because it provides some realistic stress to the injured site, allowing the athlete to test it out and see how well it is healed, and also lets the site adapt to that stress. Often runners start with too much, and then wind up having to take some days off or get completely reinjured and lose more time from training that way.