Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy

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Summary

Objective

Achilles tendinopathy is prevalent in athletes, but can also affect sedentary patients. We studied the effects of eccentric exercises in sedentary non-athletic patients with Achilles tendinopathy.

Methods

Thirty-four sedentary patients (18 males, average age 44 years, range 23–67; 16 females, average age 51 years, range 20–76; average BMI: 28.6 ± 4.7, range 22.1–35.4) with a clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance (39 ± S.D. 22.8) and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks.

Results

Fifteen patients (44%) did not improve with eccentric exercise regimen. Three patients improved after perintendinous injections aprotinin and local anaesthetic. Surgery was performed in seven patients as 6 months of conservative management failed to produce improvements. The overall average VISA-A scores at latest follow up was 50 (S.D. 26.5).

Conclusions

Eccentric exercises, though effective in nearly 60% of our patients, may not benefit sedentary patients to the same extent reported in athletes.

Introduction

Achilles tendinopathy mainly affects patients pursuing an active life style.1 In a recent study, 31% of 58 Achilles tendinopathy patients did not participate in vigorous physical activity.2 In our practice, we encounter non-athletic patients with Achilles tendinopathy on a regular basis. These non-athletic patients may lose a significant number of working days, producing marked financial impact on society by adding substantially to workers compensation costs.2

The initial management of Achilles tendinopathy most commonly consists of a multi-oriented approach, using combined rehabilitation modalities, including a combination of rest (complete or modified), medication (analgesics, aprotinin injections), orthotics (heel lift, change of shoes, corrections of malalignments), stretching and massage, and eccentric strengthening exercises.3, 4, 5, 6 Surgery is recommended to patients in whom non-operative management has proved ineffective for at least 6 months. Published evidence suggests that 24–45.5% of the patients with Achilles tendinopathy and/or paratendinopathy fail to respond to conservative treatment and eventually require surgical intervention,7, 8, 9, 10 although it is likely that that these figures are not representative of routine non-tertiary clinical practice.

Randomised controlled trials have shown the effectiveness of eccentric strengthening exercises in the management of Achilles tendinopathy.11, 12 To our knowledge, no study has specifically focused on the outcome of this regimen for the conservative management of Achilles tendinopathy in non-athletic patients. We introduced such exercise programme in our practice since 1998. We had the impression that our non-athletic patients were not responsive to this modality to the same extent as reported in the literature. We therefore report the results of a prospective study of eccentric exercises in non-athletic patients with Achilles tendinopathy.

Section snippets

Patients and methods

After local ethics committee approval, all patients gave written informed consent to take part in the study.

Results

There were 34 patients (18 men, average age 44 years ± 22.5, range 23–67; 16 women, average age 51 years ± 25.2, range 20–76; average height: 168 ± 15.5, range 153–184; average weight 74.5 kg ± 25.3, range 59.1–124.5; average BMI: 28.6 ± 4.7, range 22.1–35.4; average BMI males: 27.1 ± 6.6, range 21.3–37.8; average BMI females: 29.6 ± 2.5, range 27.3–34.1) in our study. The mean follow up was 15 ± 7.3; months (range 9–28). Patients completed an average of 81 ± 7% of the prescribed number of sets and repetitions of

Discussion

Conservative management options for tendinopathy of the main body of the Achilles tendon include modified rest, exercise, analgesics, injections, electrotherapy, identification and correction of possible intrinsic and extrinsic causes.3, 20 Even when early diagnosis of Achilles tendinopathy is combined with appropriate and intensive management, rehabilitation can take several months.11, 12, 18, 20 This abundance of management modalities has arisen from the lack of consensus as to the cause of

Conclusion

Less than 60% of our non-athletic patients benefited from an intensive, heavy load eccentric heel drop exercise regimen alone. The VISA-A has been successfully used in our patients to monitor clinical progress of Achilles tendinopathy.

Practical implications

  • Eccentric exercises of the gastrosoleus complex are a mainstay in the conservative management of Achilles tendinopathy.

  • Heavy load eccentric exercises of the gastrosoleus complex have a high success rate in the conservative management of Achilles tendinopathy of athletic patients.

  • These exercises to the same extent reported in athletes.

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