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Review
Eccentric exercise protocols for chronic non-insertional Achilles
tendinopathy: how much is enough?
A. Meyer, S. Tumilty, G. D. Baxter
Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
Corresponding author: Steve Tumilty, Centre for Physiotherapy Research, School of Physiotherapy, University of Otago,
Dunedin, New Zealand. Tel: 164 03 479 3485, Fax: 164 03 479 8414, E-mail: steve.tumilty@otago.ac.nz
Accepted for publication 25 April 2009
Eccentric exercises for the calf muscles have been shown to
be effective for chronic non-insertional Achilles tendinopa-
thy (AT). However, the relative effectiveness of various
dosages is unknown. A systematic review of randomized-
controlled trials (RCTs) was designed to determine whether
an optimum dose of eccentric exercises could be recom-
mended. Three selected RCTs showed positive effects of
very similar eccentric exercise protocols for chronic non-
insertional AT. Owing to insufficient reported compliance
data, a conclusion on the relative effectiveness of various
compliances was not feasible. According to our review,
the relative effectiveness of various dosages of eccentric
exercises for AT is still unclear. However, it appears that
highly variable compliance rates result in similar positive
outcomes; these findings, therefore, highlight the need for
further investigations.
Tendinopathy, also known as tendonitis or tendinosis,
is a common work- and sport-related tendon injury
(Satyendra & Byl, 2006; Sayana & Maffulli, 2007).
Additionally, even sedentary patients can be affected
by this pathology (Sayana & Maffulli, 2007). Chronic
Achilles tendinopathy (AT) is variably defined. It
ranges from 4 weeks to 3 months of symptoms’
duration (Satyendra & Byl, 2006). It affects the
calcaneal insertion, as well as the mid-portion of
the tendon, and it is sometimes difficult to distinguish
from peritendinopathies where the paratenon and/or
the tendon sheath are affected (Paavola et al., 2002).
Other common clinical findings are tenderness in a
localized swollen area and patient reports of morning
stiffness in the tendon (Alfredson, 2003).
In the past, the term Achilles tendonitis was widely
used because the etiology of this condition was
reasoned as repetitive overuse pathology associated
with an inflammatory process. Therefore, the main
treatment has been based on anti-inflammatory
medication (McLauchlan & Handoll, 2001). Patho-
anatomic studies for AT do not confirm this
approach due to the lack of inflammatory changes
found in tendons (Alfredson & Lorentzon, 2000;
Alfredson, 2003), and subsequently ‘‘chronic tendi-
nopathy’’ as a term for degenerative changes in
tendons seems to be more appropriate (Almekinders
& Temple, 1998; Khan et al., 2002; Alfredson, 2003).
However, degeneration is a broad term and does
little to indicate which entity is abnormal. Almost
every aspect of the structure in question, namely the
tendon, has been investigated. Cellular pathology,
matrix abnormality, collagen separation and neovas-
cularization, along with associated nerve endings,
are the accepted mechanisms contributing to the
problem (Kibler, 2003).
Treatment approaches for chronic AT have focused
on the correction of intrinsic and extrinsic etiological
factors such as biomechanical faults and overuse of the
Achilles tendon, as well as symptomatic physical ther-
apy and specific strengthening exercises (Rees et al.,
2006). Eccentric exercises have proved to be an effective
form of treatment for chronic non-insertional AT
(Alfredson & Lorentzon, 2000; Shalabi et al., 2004b;
Satyendra & Byl, 2006; Sayana & Maffulli, 2007). Since
the work of Alfredson et al. (1998), many clinical
studies refer to their protocol for the treatment of this
condition (Mafi et al., 2001; Fahlstro
¨m et al., 2003;
Roos et al., 2004; Shalabi et al., 2004c; Brown et al.,
2006; de Vos et al., 2007; Herrington & McCulloch,
2007; Nørregaard et al., 2007; Petersen et al., 2007;
Rompe et al., 2007). However, some studies have
modified the protocol (Roos et al., 2004; Rompe
et al., 2007; Sayana & Maffulli, 2007), while others
used different inclusion and exclusion criteria for their
subjects (Brown et al., 2006; de Vos et al., 2007;
Nørregaard et al., 2007; Knobloch et al., 2007b). For
instance, eccentric exercises as described by Alfredson
et al. (1998) cannot be performed according to protocol
with bilateral tendinopathy because the contralateral
leg has to work concentrically to lift the body up for the
next eccentric repetition. Furthermore, Alfredson et al.
Scand J Med Sci Sports 2009: 19: 609–615 &2009 John Wiley & Sons A/S
doi: 10.1111/j.1600-0838.2009.00981.x
609
(1998) only included subjects with non-insertional
AT and it has been shown that insertional AT does
not respond as positively to such an eccentric exercise
protocol (Fahlstro
¨m et al., 2003).
For the purpose of systematic review and metaa-
nalysis of the available data, these anomalies make it
difficult to pool results and therefore it is important
to define adequately the population of interest, and
to use uniform selection criteria to provide compar-
able results. Moreover, although clinical studies de-
scribe their protocol for eccentric exercises for AT,
they fail to provide detailed information about the
compliance of subjects and therefore, to the best of
our knowledge, the relevance of the amount of
eccentric exercises to effectiveness is still unknown.
The optimal dosage for rehabilitation has yet to be
definitely established and the effectiveness of various
doses remains unclear (Woodley et al., 2007).
The aim of this study was to evaluate published high-
quality randomized-controlled trials (RCTs) that used
eccentric exercises for the treatment of chronic non-
insertional AT to answer the questions: are eccentric
exercises effective and is there an optimum dose?
Materials and methods
Criteria for considering studies to review
Studies
In line with other reviews (van Tulder Maurits et al., 2003;
Woodley et al., 2007), only high-quality RCTs with scores
45/10 on the PEDro scale (Maher et al., 2003) were evaluated
to ensure that any conclusions from this review were made
using the best-available evidence.
Participants
Participants in selected trials might be males or females of any
age with unilateral chronic non-insertional AT. No restriction
in activity level was applied.
Interventions
Trials in which at least one group received eccentric exercises
for the calf muscles were included; the group receiving
eccentric exercises needed to be controlled against no treat-
ment and/or any other treatment modality. Trials in which all
groups received eccentric exercises with the same protocol
were excluded.
Outcome measures
The main outcomes of interest were the VISA-A (Robinson
et al., 2001) or pain. Where these two measurements were not
used, other outcomes including American Orthopaedic Foot
and Ankle Society ankle score, Short Form-36, Foot and
Ankle Outcome score, patient’s satisfaction, overall improve-
ment and return to activity were also considered.
Search strategy for identifying studies
Relevant studies were identified by searching seven databases
(Fig. 1) from the earliest record available to February 2008. A
sensitive search strategy to identify RCTs was applied (Hig-
gins & Green) in combination with the search terms: achil
*
,
tend
*
, eccentric and exercise outlined for the search in MED-
LINE via Ovid (Table 1). Furthermore, the reference list of
reviews (Bains & Porter, 2006; Goesele-Kopenburg, 2006;
Rees et al., 2006; Satyendra & Byl, 2006; Alfredson & Cook,
2007; Kingma et al., 2007; Kountouris & Cook, 2007; Lind-
ner, 2007; Roig Pull & Ranson, 2007; Woodley et al., 2007),
which included eccentric exercises for AT published in 2006 or
2007, and the reference lists of the included studies were
screened for additional studies.
Review methods
Article selection
After one reviewer (A. M.) discarded duplicates, two reviewers
(A. M. and S. T.) independently selected the trials to be included
in the review. Titles and abstracts of articles were screened and
divided into six categories (Fig. 1). Articles were excluded in the
order of the first five categories: (1) Achilles tendon, (2)
tendinopathy, (3) eccentric exercises, (4) RCT but review and
(5)RCT.Fulltextsoftheremainingarticlesincategory6–not
excluded were retrieved and screened in detail for the criteria
considered in this review. In cases of disagreement of article
selection, a third reviewer (D. B.) independently assessed the
trial, and a consensus was reached through discussion.
Methodological quality
The methodological quality of the included trials was assessed
independently by two reviewers (A. M. and S. T.) using the
PEDro scale. When there was disagreement, a third reviewer
(D. B.) independently assessed the trial, and a consensus was
reached through discussion. Studies with a PEDro score o6/
10 were excluded from the final analysis.
Results
The databases’ search revealed 276 articles. The
initial review (Fig. 1) resulted in 17 articles (Lowdon
et al., 1984; Niesen-Vertommen et al., 1992; Mafi
et al., 2001; Silbernagel et al., 2001, 2007; Paoloni
et al., 2004; Roos et al., 2004; Shalabi et al., 2004a;
Brown et al., 2006; de Vos et al., 2007; Herrington &
McCulloch, 2007; Nørregaard et al., 2007; Petersen
et al., 2007; Rompe et al., 2007; Knobloch et al.,
2007a, b; Rompe et al., 2007, 2008) retained and full
text screened. Five of these (Niesen-Vertommen
et al., 1992; Mafi et al., 2001; Roos et al., 2004;
Herrington & McCulloch, 2007) fulfilled all inclusion
criteria and were rated with the PEDro scale. The
results of the article selection process are shown
in Fig. 1. No additional articles were identified by
screening the reference lists of 10 reviews (Bains &
Porter, 2006; Goesele-Kopenburg, 2006; Rees et al.,
2006; Satyendra & Byl, 2006; Alfredson & Cook, 2007;
Kingma et al., 2007; Kountouris & Cook, 2007;
Lindner, 2007; Roig Pull & Ranson, 2007; Woodley
Meyer et al.
610
et al., 2007) and the RCTs included (Niesen-Vertom-
men et al., 1992; Mafi et al., 2001; Roos et al., 2004;
Herrington & McCulloch, 2007; Rompe et al., 2007).
The methodological quality of the included articles is
shown in Table 2. Scores ranged from 5 to 8/10 on the
PEDro scale. Two studies (Niesen-Vertommen et al.,
1992; Mafi et al., 2001) did not meet the minimum
PEDro score inclusion criteria and were excluded.
Of the three remaining studies (Roos et al., 2004;
Herrington & McCulloch, 2007; Rompe et al., 2007),
Total: n = 276
SCOPUS from 1996: n = 97
Cochrane Controlled Trial Register: n = 26
MEDLINE from 1950: n = 55
AMED from 1985: n = 14
CINAHL from 1982: n = 8
EMBASE from 1988: n = 63
PEDro from 1929: n = 13
Discarded duplicates: n = 113
Exclusion after screening titles and abstracts: n = 146
1 - Not about Achilles tendon: n = 30
2 - Not about tendinopathy: n = 59
3 - Not about eccentric exercises: n = 23
4 - Review: n = 16
5 - No RCT: n = 18
6 - Not excluded, full text retrieved: n = 17
Exclusion after screening full text: n = 12
No randomised controlled trial: n = 1
No eccentric exercises only group: n = 3
All groups received eccentric exercises: n = 3
Bilateral tendinopathy included: n = 2
Insertional tendinopathy included: n = 3
Rating of PEDro score: n = 5
PEDro score below 6: n = 2
Included articles: n = 3 Fig. 1. Search results and article
selection process.
Table 1. Search strategy in MEDLINE via Ovid
Phase 1 Phase 2 Phase 3
1. tend$.mp. 13. randomized-controlled trial.pt. 22. clinical trial.pt.
2. soft tissue injuries/ 14. controlled clinical trial.pt. 23. exp clinical trials/
3. tendon injuries/ 15. randomized-controlled trials/ 24. (clinic adj25 trial$).tw.
4. achillod$.mp. 16. random allocation/ 25. ((singl$ or doubl$ or trebl$ or tripl$)
adj (mask$ or blind$)).tw.
5. 1 or 2 or 3 or 4 17. double-blind method/ 26. placebos/
6. achil$.mp. 18. single-blind method/ 27. placebo$.tw.
7. 5 and 6 19. 13 or 14 or 15 or 16 or 17 or 18 28. random$.tw.
8. exercise.mp. 20. animal/not human/ 29. research design/
9. physical therapy modalities/ 21. 19 not 20 30. or/22-29
10. eccentric$.mp. 31. 30 not 20
11. 8 or 9 or 10 32. 31 not 21
12. 7 and 11 33. 12 and 21
34. 12 and 32
35. 33 or 34
Eccentric exercises for Achilles tendinopathy
611
one evaluated the effects of eccentric training as an
addition to deep friction massage, ultrasound and
stretching (Herrington & McCulloch, 2007). The sec-
ond compared eccentric loading to shock-wave treat-
ment and a wait-and-see policy, and the third study
compared the effects of eccentric exercises to a night
splint and a third group that received both treatments
(Roos et al., 2004). Further details of the subjects and
methods of the studies are shown in Table 3.
All included studies used a protocol for the ec-
centric exercises similar to that reported by Alfred-
son et al. (1998). Herrington and McCulloch (2007)
added different speeds of the eccentric exercises to the
protocol as described by Stanish et al. (1986), as part
of which subjects were instructed to increase the
speed of the eccentric exercise movement, before
increasing the load with a slow speed. Rompe et al.
(2007), on the other hand, instructed their subjects to
increase the amount of repetitions within the first
week of treatment from one set of 10 repetitions
to three sets of 15 repetitions. Similarly, Roos et al.
(2004) attempted to prevent muscle soreness by gra-
dually increasing the number of repetitions. They
instructed their subjects to increase the amount of
exercises from one set of 15 repetitions in the first 2
days to two sets of 15 repetitions on days 3 and 4 and
finally, three sets of 15 repetitions from days 5
onwards. However, both groups who performed the
eccentric exercises still reported muscle soreness.
All groups of subjects who completed eccentric
exercises in all included studies improved signifi-
cantly over the follow-up times (Po0.01), and in
two studies the eccentric exercise groups showed
significantly better results in VISA-A than the con-
trol groups [(Rompe et al., 2007, Po0.001); (Her-
rington & McCulloch, 2007, Po0.014)]. Although
the difference between groups in Roos et al. (2004)
was not statistically significant, differences of 410
Table 2. PEDro scoring of included RCTs
RCTs PEDro criteria
*
Score in
total
1234567891011
Herrington and McCulloch, (2007) ( p)pxpxx ppppx6
Mafi et al. (2001) ( p)ppxxxx pppx5
Niesen-Vertommen et al. (1992) (x) pxpxxx pppx5
Rompe et al. (2007) ( p)pppxx ppppp8
Roos et al. (2004) ( p)pppxxxx ppp6
*
PEDro criteria: 4 – Baseline comparability? 8 – Adequate follow-up?
1 – Eligibility criteria? 5 – Blind subjects? 9 – Intention-to-treat analysis?
2 – Random allocation? 6 – Blind therapists? 10 – Between-group comparisons?
3 – Concealed allocation? 7 – Blind assessors? 11 – Point estimates and variability?
p, criterion met; x, criterion not met; ( ), eligibility criteria item does not contribute to the total score; RCTs, randomized-controlled trials.
Table 3. Characteristics of included RCTs
RCTs Herrington and McCulloch (2007) Rompe et al. (2007) Roos et al. (2004)
Subjects
Number 25 75 44
Age Mean: 36.8 years Mean: 48.6 years Mean: 46 years
Male/female Both gender included 29/46 21/23
Affected Achilles tendon part Non-insertional 2–6 cm from insertion 2–6 cm from insertion
Duration of symptoms Mean: 24.5 months Mean: 10.8 months Median: 5.5 months
Methods
Eccentric exercise protocol Combined Alfredson et al. (1998)
and Stanish et al. (1986) protocol
Similar to Alfredson
et al. (1998)
Similar to Alfredson
et al. (1998)
Other interventions Deep friction massage, ultrasound
and stretching
Shock-wave treatment or
wait-and-see policy
Night splint
Compliance data for
eccentric exercises
Use of an exercise diary;
no data reported
No data reported Use of a compliance diary;
limited data reported
Outcome measurements VISA-A VISA-A, success rate
questionnaire,
pain and ultrasonography
Foot and Ankle Outcome Score
(including pain)
Follow-ups 4, 8, and 12 weeks 4 months and 12 months
after crossover
6, 12, 26, and 52 weeks
RCTs, randomized-controlled trials.
Meyer et al.
612
points in the mean pain scores at 12 and 26 weeks
were present in favor of the group completing
eccentric exercises, which the authors found to be
clinically significant. Pooling of data, due to different
outcome measurements and follow-up intervals, was
not possible.
Owing to the lack of reported compliance data in
included studies, an investigation of associations
between compliance and outcome was not possible
(either for individual studies or through pooling of
data). Two studies (Roos et al., 2004; Herrington &
McCulloch, 2007) used diaries for subjects to note
the amount of exercises completed during the 12-week
treatment period. Herrington and McCulloch (2007)
did not report any detailed data on subjects’ compli-
ance but planned to exclude subjects who failed to
exercise on any given day, or if they carried out only a
single exercise session on 2 consecutive days. However,
no subjects were excluded for this reason. Roos et al.
(2004) provided information on compliance of their
subjects on a weekly basis. Subjects who performed at
least 75% of the recommended exercises were defined
as demonstrating good compliance; in the first week,
about 95% reached that level. From week 2–7, it
remained around 80% and then declined gradually
to about 50% in week 13. No other differences in
compliance were reported and these authors concluded
that the number of participating subjects was too small
to calculate any association between compliance and
outcome. The third included study (Rompe et al.,
2007) stated that each treatment session was documen-
ted on standardized forms; however, no information
was reported on the compliance.
Overall, the systematic review identified three high-
quality RCTs that all used very similar eccentric
exercise protocols and highlighted the effectiveness of
eccentric exercises for chronic non-insertional AT.
However, only sparse data are reported about the
subjects’ compliance with eccentric exercise protocols.
Discussion
This systematic review revealed no definitive evi-
dence on the efficacy of various dosages of eccentric
exercises for chronic non-insertional AT. However,
we identified a possible trend in favor of eccentric
exercise protocols with less stringent criteria than the
often proposed Alfredson protocol (Alfredson et al.,
1998). Therefore, future RCTs that compare different
doses of eccentric exercises for chronic non-inser-
tional AT are much needed.
In the current study, only three RCTs that
used eccentric exercises for the treatment of AT
were selected. All of these referred to previous studies
(Stanish et al., 1986; Niesen-Vertommen et al., 1992;
Alfredson et al., 1998; Mafi et al., 2001; Silbernagel
et al., 2001; Fahlstro
¨m et al., 2003; Sayana &
Maffulli, 2007) as sources of their eccentric exercise
protocol; however, due to the strict exclusion and
inclusion criteria of this review, none of these
previous studies were eligible for inclusion. With a
broader search strategy and less stringent article
selection, more studies would have been included
and a greater variety of dosages of eccentric exercises
might have been identified. However, our aim was to
identify only RCTs with high methodological quality
and a well-defined population to ensure that our
results were robust.
Still, the three included high-quality RCTs (Roos
et al., 2004; Herrington & McCulloch, 2007; Rompe
et al., 2007) provide additional evidence to support
the belief that eccentric exercises in the treatment of
chronic non-insertional AT are effective. Further-
more, the significant improvements over time of each
eccentric exercise group in all included studies leave
no doubt that they should be included in conserva-
tive rehabilitation of this disorder. Strikingly, in
comparison with a wait-and-see policy and in addi-
tion to deep friction massage, stretching and ultra-
sound, they were very effective. However, night splint
or shock-wave treatment, respectively, have similar
positive effects, albeit with a slightly lower improve-
ment in pain or VISA-A. While Roos et al. (2004)
already evaluated the effect of combining their two
treatment modalities (eccentric exercises and night
splint) for chronic non-insertional AT and found
no additional effect, Rompe et al. (2007) failed to
establish such an approach.
The inclusion in this review of the study by Her-
rington and McCulloch (2007) caused some debate.
The aim of their study was to compare two different
types of treatment for AT; however, their experi-
mental design failed to provide an answer to that
question. The control groups was treated with a
standard package of deep friction massage, stretch-
ing and ultrasound; the experimental group received
the standard package plus eccentric exercises. Thus,
as all participants received the standard package of
care but only one group had the additional eccentric
exercises, then any differences at the final assessment
point can be attributed to the difference, i.e. additive
benefit, of eccentric exercises. The addition of a third
group who performed eccentric exercises alone would
have made their work more robust and enabled a
comparison of the different elements of treatment to be
made. As it stands, they could only make conclusions
about the effects of eccentric exercise in addition to
the standard package of care and failed to separate
out the effects of eccentric exercise alone, something to
be aware of! However, their research design is often
used in clinical studies and for this reason, plus the fact
of reporting of compliance data (albeit sparsely),
which strengthened our evidence toward the second
Eccentric exercises for Achilles tendinopathy
613
part of our question ‘‘is there an optimum dose?’’, it
was decided to include Herrington & McCulloch’s
work. The knowledge that other treatment modalities
have similar positive effects and that not all patients
completely recover with only eccentric exercises for
treatment leaves room for further improvement to
develop an optimal rehabilitation approach. Further-
more, another variable in rehabilitation programs
might be the eccentric exercise protocol itself.
The three included studies used similar eccentric
exercise protocols that recommend an intensive train-
ing with two sessions each day for at least 11 weeks of
a 12-week treatment period. All studies reported
positive results with this approach, although compli-
ance in the three studies varied. Herrington and
McCulloch (2007) reported that all subjects carried
out their exercises at least once a day and had no
periods where they did fewer than two sessions for
more than 2 consecutive days. Roos et al. (2004), on
the other hand, reported that only for the first 7 weeks
more than 70% of the subjects performed more than
75% of the recommended exercises, which suggests a
significantly lower mean amount of training than in
the study of Herrington and McCulloch (2007).
Although the studies included reported compliance
data collection, they neither provided detailed data
nor analyzed the collected data. This precludes any
conclusion about the effectiveness of various
amounts of eccentric exercises for chronic non-inser-
tional AT. Unfortunately, due to lack of time, we
had no opportunity to contact the authors of the
included studies to ask whether they would provide
compliance data of their studies for such an analysis.
Furthermore, the risk of muscle injuries associated
with eccentric exercises cannot be overlooked (Roig
Pull & Ranson, 2007). This risk may increase in
subjects who are unaccustomed to exercises and if
sufficient recovery periods are not allowed (Clarkson
& Hubal, 2002). Muscle injuries often occur when
athletes are fatigued (Roig Pull & Ranson, 2007) and
strength recovery may take up to 24 hours post-
exercise (Clarkson & Hubal, 2002). In contrast to
these findings, most clinical trials for AT use a
protocol with two exercise sessions per day. How-
ever, the included studies that used this approach did
not report any adverse effects in their publications
(Roos et al., 2004; Herrington & McCulloch, 2007;
Rompe et al., 2007). Slow speeds may lessen the risk
of tendon injury; often, the movement velocity of
eccentric rehabilitation exercises is much lower than
say running or jumping activities or even during
studies investigating resistance training where velo-
cities of 60, 120 or 1801/s are routinely used and are
occasionally as high as 3001/s (Pereira & Gomes,
2003) without, to our knowledge, any reports of
injury. Still, it seems logical that if fewer exercise
sessions have similar positive effects in terms of
outcome, lower intensity eccentric exercise protocols
should be used to reduce the potential risk of injuries.
Perspectives
The present review suggests that similar positive
outcome results can be achieved with eccentric ex-
ercises for chronic non-insertional AT, despite widely
varying compliance with the same prescribed dose.
However, a definitive conclusion regarding the effec-
tiveness of different dosages of eccentric exercises for
chronic non-insertional AT cannot yet be drawn. We
recommend that future clinical studies of eccentric
exercises for chronic non-insertional AT should
publish or preferably analyze their compliance
data. Moreover, an RCT that specifically investigates
this aspect should be conducted to determine the
potential relevance to clinical outcomes of dosages of
eccentric exercises for chronic non-insertional AT.
Key words: achillodynia, achilles tendinosis, training,
volume, intensity, adherence.
Acknowledgement
The research was not supported by any grants. None of the
authors had any conflicts of interest.
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