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Eccentric training for the achilles tendon post surgery

Discussion in 'Biomechanics, Sports and Foot orthoses' started by mike weber, Jan 21, 2011.

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    Not sure if this should be in the surg forum or not. Hopefully Bob,Steve and other scalpel types may see it as well as the Biomex folks.

    Anyway - has a 19 year old who was born with a club foot on his left side.

    Began serial casting at 23 hours and and 4 months had his Achilles tendon lengthened. Results were very good.

    Without going into any other biomechanical info My question focuses on the achilles tendon post surgery and eccentric training .

    Patient is very active now runs, plays Squash

    He has developed mid shaft tendinopathy - which normally I would treat including Alfredsons prescription training program.

    I wonder whats are peoples thoughts - I personally don´t think its a good idea to eccentrically train a post surgery lengthen achilles tendon ( even 18 years later).

    anyone else got an option ?
  2. bob

    bob Active Member

    Hello Michael,
    Midshaft tendinopathy? Do you have any imaging? Given the time between surgery and now and the fact that he plays squash, I would not worry too much about offering eccentric exercises to this patient. Do you know what type of surgery he had and what state it left the tendon in? Realistically, he's playing squash which will put far greater eccentric force on the tendon than Alfredson's prescription, so I would not worry too much about potential ruptures. If you are cautious, you could try a brace? See:

    Chronic Achilles Tendinopathy: Prospective Randomized Study Comparing the Therapeutic Effect of Eccentric Training, the AirHeel Brace, and a Combination of Both
    Wolf Petersen, Robert Welp, and Dieter Rosenbaum,
    The American Journal of Sports Medicine 35:1659-1667 (2007)

    Background: Previous studies have shown that eccentric training has a positive effect on chronic Achilles tendinopathy. A new strategy for the treatment of chronic Achilles tendinopathy is the AirHeel brace.

    Hypothesis: AirHeel brace treatment improves the clinical outcome of patients with chronic Achilles tendinopathy. The combination of the AirHeel brace and an eccentric training program has a synergistic effect.

    Study Design: Randomized controlled clinical trial; Level of evidence, 1.

    Methods: One hundred patients were randomly assigned to 1 of 3 treatment groups: (1) eccentric training, (2) AirHeel brace, and (3) combination of eccentric training and AirHeel brace. Patients were evaluated at 6, 12, and 54 weeks after the beginning of the treatment protocol with ultrasonography, visual analog scale (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, and Short Form-36 (SF-36).

    Results: The VAS score for pain, AOFAS score, and SF-36 improved significantly in all 3 groups at all 3 follow-up examinations. At the 3 time points (6 weeks, 12 weeks, and 54 weeks) of follow-up, there was no significant difference between all 3 treatment groups. In all 3 groups, there was no significant difference in tendon thickness after treatment.

    Conclusions: The AirHeel brace is as effective as eccentric training in the treatment of chronic Achilles tendinopathy. There is no synergistic effect when both treatment strategies are combined.
  3. Thanks Bob , no ultrasound. Just diagnosis from patient assessment.

    The mum only knows that the tendon was made longer. So no idea of the operation.

    When looking at the achielles many years after an op how does the tendon make up compair to a normal tendon andor and tendon after chronic issues and developed scar tissue from overuse ?

    Ie many years after op would the tendon fibers look similar to those from a thickened scared tendon from overuse -classic tendinopathy ?
  4. Admin2

    Admin2 Administrator Staff Member

  5. bob

    bob Active Member

    Hello Michael,

    The few tendons that I have seen many years following the original surgery appear fibrosed, white and relatively 'shiny' with loss of the usual apparent continuity of bundles of tendon fibres. When debriding achilles tendons that have failed conservative care, I see areas of focal tendinosis deep within the centre of the tendon that sometimes contain calcification and usually a yellowish hue to areas of degeneration. The tendon often has the classic 'onion bulb' appearance where the external bundles of fibres have reasonable continuity, but bulge out around the inner core of pathologic tendon fibres and calcification. The overlying paratenon and soft tissue is usually very different due to previous surgical trauma.

    So, in short, no they look quite different. ;)
  6. Thanks Bob, thats great I have skin in the way and santas not dropped off the ultrasound machine yet.

    Now all i need is a study which has compaired the 3 types of tendons for the differences in elastic properties.

    I look when back on a computer next week.

    Thanks again Bob.

    Have a great weekend

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