Page 1 of 3 1 2 3 LastLast
Results 1 to 10 of 28

Thread: Achilles tendinopathy

  1. #1

    Achilles tendinopathy

    Since my achilles tendinopathy has recently flaired up again, I've been doing some more research on this condition and thought I'd share some of my findings in case they can be of benefit to others.

    For the last decade, daily progressive eccentric loading has been the gold standard therapy for achilles tendinopathy: 3x15 eccentric heel drops with straight knee plus 3x15 reps with bent knee done twice daily for every day over a 12 week period. That's 180 reps per day or 1260 reps per week!

    Similar results were achieved in one study with a high volume of static stretching twice a day. However, I believe this can have deleterious effects on the functioning of the muscle tendon complex, as static stretching reduces muscle strength and makes tendons more compliant (stretchy), while a sprinter needs them to be stiff.

    A recent paper, however, has shown that "heavy slow resistance" (HSR) training provides the same or even better results. The study used three different soleus and gastroc exercises (standing and seated calf raise and calf raise in a leg press machine) with weights increasing and reps decreasing (from 3x15 in the beginning to 4x8 towards the end) every couple of weeks or so. Each rep takes 6s, whith 3s used for the eccentric and 3s for the concentric phase. They only trained 3x per week (instead of 14x), which resulted in better compliance of the participants to the training protocol. After twelve weeks, the HSR group had equal or better results than the eccentric group, despite a significantly lower total training volume (405 reps per week). Both groups resumed their normal exercise routines 3 weeks into the study, so the last 9 weeks of the program took place while the subjects were engaged in sports. Anything that didn't cause more than mild pain right after or the day following exercise was allowed.

    Training only three times per week makes sense to me, as intense eccentric loading of tendons results in net collagen loss for the first 36-48 hours, after which there is net collagen synthesis until about 72h post exercise. This also suggests to me that people who are prone to achilles problems should ideally only subject their achilles tendons to intense loading once every 72h.

    Others have researched optimal training protocols to strengthen/stiffen/thicken the achilles tendon. A protocol involving 5x4 near-maximal 3s isometric contractions of the calf muscles 4x per week (i.e. 80 reps per week) was found to be most effective. Longer or shorter (including plyometric) loading was less effective. Only the duration, type (isometric and plyometric) and intensity (moderate or high) of the contractions were modified to find the optimal protocol, so whether the frequency and volume of training they used is ideal remains to be seen. I would have gone for fewer sessions per week, due to the reasons described above.

    Another paper looked at how long it takes for structural changes to occur in the achilles tendon in response to training. Significant changes were seen after two months. It only took one month to lose all the gains made in 3 months of achilles tendon strengthening, which suggests to me that athletes with achilles issues should train them all year round.

    Interestingly, a study conducted on soccer players showed that eccentric exercise resulted in increased collagen synthesis in diseased but not in healthy tendons. This suggests to me that the tendon strengthening effect of purely eccentric contractions may plateau once the tendon is healed. Isometric loading, on the other hand, results in strengthening and thickening of healthy tendons, which may make it more useful as an ongoing preventative exercise.

    To ensure I get the best of all worlds, I am thus now using a combination of eccentric, HSR and isometric exercises 3x a week, with a total volume of about 300 reps per week (120 eccentric reps, 120 HSR reps and 60 isometric reps). I do these exercises immediately after sprint training or at least 48h after and 48h before sprint training to avoid a state of continuing net collagen loss.

    On a positive note, my plantar fasciitis has improved to a point were it is not affecting my training anymore. I get some pressure discomfort in my heel which starts a few hours after a sprint session, but am perfectly fine again the next day.

    Some references:

    Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial.
    Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP.
    Am J Sports Med. 2015 Jul;43(7):1704-11. doi: 10.1177/0363546515584760. Epub 2015 May 27.

    Human Achilles tendon plasticity in response to cyclic strain: effect of rate and duration.
    Bohm S1, Mersmann F1, Tettke M2, Kraft M2, Arampatzis A3.

    Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis.
    Langberg H1, Ellingsgaard H, Madsen T, Jansson J, Magnusson SP, Aagaard P, Kjaer M.

  2. #2
    Moderator X-Man's Avatar
    Join Date
    May 2003
    Posts
    1,707

    Re: Achilles tendinopathy

    excellent post
    X-Man
    CF.com Moderator

  3. #3
    Administrator Angela Coon's Avatar
    Join Date
    Apr 2005
    Posts
    1,464

    Re: Achilles tendinopathy

    Quote Originally Posted by robin1 View Post
    Since my achilles tendinopathy has recently flaired up again, I've been doing some more research on this condition and thought I'd share some of my findings in case they can be of benefit to others.

    For the last decade, daily progressive eccentric loading has been the gold standard therapy for achilles tendinopathy: 3x15 eccentric heel drops with straight knee plus 3x15 reps with bent knee done twice daily for every day over a 12 week period. That's 180 reps per day or 1260 reps per week!

    Similar results were achieved in one study with a high volume of static stretching twice a day. However, I believe this can have deleterious effects on the functioning of the muscle tendon complex, as static stretching reduces muscle strength and makes tendons more compliant (stretchy), while a sprinter needs them to be stiff.

    A recent paper, however, has shown that "heavy slow resistance" (HSR) training provides the same or even better results. The study used three different soleus and gastroc exercises (standing and seated calf raise and calf raise in a leg press machine) with weights increasing and reps decreasing (from 3x15 in the beginning to 4x8 towards the end) every couple of weeks or so. Each rep takes 6s, whith 3s used for the eccentric and 3s for the concentric phase. They only trained 3x per week (instead of 14x), which resulted in better compliance of the participants to the training protocol. After twelve weeks, the HSR group had equal or better results than the eccentric group, despite a significantly lower total training volume (405 reps per week). Both groups resumed their normal exercise routines 3 weeks into the study, so the last 9 weeks of the program took place while the subjects were engaged in sports. Anything that didn't cause more than mild pain right after or the day following exercise was allowed.

    Training only three times per week makes sense to me, as intense eccentric loading of tendons results in net collagen loss for the first 36-48 hours, after which there is net collagen synthesis until about 72h post exercise. This also suggests to me that people who are prone to achilles problems should ideally only subject their achilles tendons to intense loading once every 72h.

    Others have researched optimal training protocols to strengthen/stiffen/thicken the achilles tendon. A protocol involving 5x4 near-maximal 3s isometric contractions of the calf muscles 4x per week (i.e. 80 reps per week) was found to be most effective. Longer or shorter (including plyometric) loading was less effective. Only the duration, type (isometric and plyometric) and intensity (moderate or high) of the contractions were modified to find the optimal protocol, so whether the frequency and volume of training they used is ideal remains to be seen. I would have gone for fewer sessions per week, due to the reasons described above.

    Another paper looked at how long it takes for structural changes to occur in the achilles tendon in response to training. Significant changes were seen after two months. It only took one month to lose all the gains made in 3 months of achilles tendon strengthening, which suggests to me that athletes with achilles issues should train them all year round.

    Interestingly, a study conducted on soccer players showed that eccentric exercise resulted in increased collagen synthesis in diseased but not in healthy tendons. This suggests to me that the tendon strengthening effect of purely eccentric contractions may plateau once the tendon is healed. Isometric loading, on the other hand, results in strengthening and thickening of healthy tendons, which may make it more useful as an ongoing preventative exercise.

    To ensure I get the best of all worlds, I am thus now using a combination of eccentric, HSR and isometric exercises 3x a week, with a total volume of about 300 reps per week (120 eccentric reps, 120 HSR reps and 60 isometric reps). I do these exercises immediately after sprint training or at least 48h after and 48h before sprint training to avoid a state of continuing net collagen loss.

    On a positive note, my plantar fasciitis has improved to a point were it is not affecting my training anymore. I get some pressure discomfort in my heel which starts a few hours after a sprint session, but am perfectly fine again the next day.

    Some references:

    Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial.
    Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP.
    Am J Sports Med. 2015 Jul;43(7):1704-11. doi: 10.1177/0363546515584760. Epub 2015 May 27.

    Human Achilles tendon plasticity in response to cyclic strain: effect of rate and duration.
    Bohm S1, Mersmann F1, Tettke M2, Kraft M2, Arampatzis A3.

    Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis.
    Langberg H1, Ellingsgaard H, Madsen T, Jansson J, Magnusson SP, Aagaard P, Kjaer M.

    I was just reading this and I wondered if you had seen it or remembered it.

    "Soviet Research has shown that EMS can increase blood Flow to tendons by up to 45%" ( Page 165 Charlie Francis Training System)

    That number is not only mind blowing but too amazing to ignore.

    Have you tried any EMS at all?

  4. #4

    Re: Achilles tendinopathy

    Is that EMS applied directly to the tendon or to the muscle it attaches to? I'm sure any type of exercise involving the muscles a tendon attaches to will increase blood flow to that tendon. There have been some papers showing that nitroglycerin patches (the types that are used for people suffering from angina pectoris to increase blood flow to the heart) placed over the sore spot of a diseased tendon can improve the results of a standard rehab protocol, although some other studies have found no such effect. I have used them in the past, although I'm not sure if results would have been different without them.

    I have tried EMS applied to the muscle with an adductor tendon injury, but not for achilles tendinopathy. Again. It's difficult to tell whether it did anything for me, as I have nothing to compare it to. The standard duration for a tendinopathy rehab program is 12 weeks, so anything you try you will have to do for a long time before expecting results.

    EMS (or TENS) applied directly to an injured achilles tendon of rats has been shown to disrupt healing. Electroacupucture, however, had a positive effect in two studies. Overall, a number of reviews have concluded that there is insufficient evidence for the effectiveness of electrostimulation modalities in the treatment of tendon injuries.

  5. #5
    Administrator Angela Coon's Avatar
    Join Date
    Apr 2005
    Posts
    1,464

    Re: Achilles tendinopathy

    Quote Originally Posted by robin1 View Post
    Is that EMS applied directly to the tendon or to the muscle it attaches to? I'm sure any type of exercise involving the muscles a tendon attaches to will increase blood flow to that tendon. There have been some papers showing that nitroglycerin patches (the types that are used for people suffering from angina pectoris to increase blood flow to the heart) placed over the sore spot of a diseased tendon can improve the results of a standard rehab protocol, although some other studies have found no such effect. I have used them in the past, although I'm not sure if results would have been different without them.

    I have tried EMS applied to the muscle with an adductor tendon injury, but not for achilles tendinopathy. Again. It's difficult to tell whether it did anything for me, as I have nothing to compare it to. The standard duration for a tendinopathy rehab program is 12 weeks, so anything you try you will have to do for a long time before expecting results.

    EMS (or TENS) applied directly to an injured achilles tendon of rats has been shown to disrupt healing. Electroacupucture, however, had a positive effect in two studies. Overall, a number of reviews have concluded that there is insufficient evidence for the effectiveness of electrostimulation modalities in the treatment of tendon injuries.
    I'd do both and I would do it as routinely with as much method as training. You need to see the papers and understand what the methods are before you are able to judge for yourself. Anyone can perform a study.

    How long and for what kind of duration did you use EMS for your other tendon injury.

    Why is standard rehab 12 weeks? According to whom? I'd advise anyone to do as many things as possible and keep doing them for as long as possible.

    TENS is a pain blocker. How would TENS have anything to do with healing?

  6. #6

    Re: Achilles tendinopathy

    I couldn't find studies using EMS on diseased tendons, so I looked at TENS which was the most similar technology I could find studies on. TENS still applies an electric current to the tissues, although the characteristics of that current may differ.

    I used EMS in massage mode on my adductors for a few weeks in an effort to accelerate healing of a partial tear to adductor longus and brevis tendons sustained during powerlifting training. I don't know if it helped.

    Twelve weeks is used as a standard duration for tendon rehab programs in many studies because you should be able to see evidence of effectiveness at this point. Tendons heal slowly, so any shorter and you may miss a positive effect of an intervention. A successful intervention should have the majority of study participants with chronic tendinopathy back to or near pre-injury activity levels within twelve weeks.

  7. #7

    Re: Achilles tendinopathy

    I don't have time to elaborate, but two important points, firstly skipping is more specific rehab v eccentrics and use sports tapping.

  8. #8

    Re: Achilles tendinopathy

    Can you elaborate on the basis for your opinion regarding skipping? I haven't seen any studies comparing eccentrics to skipping, but 3s isometrics were a lot more effective than skipping/plyometrics in building achilles strength in the cyclic strain study I cited above. The research seems to suggest that plyometric type contractions are too short to stretch tenocytes sufficiently to stimulate a lot of collagen synthesis and that high intensity loading for about 3s at a time is ideal. I personally haven't seen much benefit from skipping. I have usually continued my sprint training to some degree while rehabbing achilles flare ups, so I guess that's giving me enough plyometric type foot contacts (around 200 per foot per session including warm-up) to not derive further benefit from skipping.

  9. #9
    Administrator Angela Coon's Avatar
    Join Date
    Apr 2005
    Posts
    1,464

    Re: Achilles tendinopathy

    Robin, how did you get tendonitis?

    What therapies and or modalities are you currently using to treat your tendonitis?

  10. #10

    Re: Achilles tendinopathy

    I've been having bouts of achilles tendinopathy for six years now. The first time was from sled pulling, but there are probably many factors that contributed to it including age and genetics. As soon as I hit 30, I started getting tendon problems (achilles, adductor, hamstring) and my dad gets it whenever he engages in any kind of running training. Flare ups usually happen when I'm not taking enough rest between workouts that load the tendon. 6-12 weeks of rehab usually takes care of it.

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •