Achilles Tendon 'Conditioning' Exercises

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Dear Colleagues,

I have a patient with Left plantar fasciitis and right non-insertional achilles tendinopathy (awaiting diagnostic ultrasound). I had issued prescription foot orthosis 3 weeks ago, as well as prescribed eccentric calf exercises amongst other things, with a significant improvement in pain levels noted today at his review.

In between our visits, his chiropractor had referred him to a local Sports Physician who also recommended calf exercises. However, the exercises prescribed by the Sports Physician involved standing on a step/ledge with heels below the forefoot. The patient was advised to slowly rise on to their toes and then rapidly drop their heels back below the step. If done correctly you should notice a 'bounce' as your ankle reaches end range of motion.

I had prescribed the more controlled eccentric exercises (Alfredson's protocol).

My question - is there any evidence that shows the more rapid, uncontrolled approach works better for achilles tendinopathy, plantar fasciitis?

I am aware of the research that has been posted here on the benefits of the Alfredson's approach. I am concerned that this forceful, uncontrolled method recommended by the sports physician may be damaging to the patient.

Any info would be much appreciated.

Regards,

Tim

 

Tim apart from asking the Sports physician which might be the way to go and then report back because I would like to know as well.

I´m guessing the Sports physician is thinking that Force on the tendon is the cause of the remodeling of the tendon and success with Alfredsons prescription therefore the more force the better results.

But......

Full text linked below.

http://rheumatology.oxfordjournals.org/content/47/10/1493.full.pdf+html

Taken from text

So if not the force but the fluctuations in force, what we don´t know to my knowledge if a higher fluctuation will have better results either.

Hope that Helps

Edit they then go onto conclude

 

So if not the force but the fluctuations in force, what we don´t know to my knowledge if a higher fluctuation will have better results either.

Hope that Helps

Edit they then go onto conclude[/QUOTE]


Thanks Michael!!

The patient mentioned an article that the physician referred to so I will have to get onto the physician and found out what he knows.

Only speculating here but the part I highlighted in bold, maybe force has something to do with it? Greater acceleration resulting in greater force on the achilles tendon. The patient has also been advised in coming weeks to increase the load by adding 10kg dumbells..again, greater force.

Anyway, will have to go to the source and find out and report back. Thanks again.

Cheers,
Tim

 

Tim

so if we take Force = mass * acceleration

So we can increase the force 2 ways add speed or add weight, Which is important part of the eccentric training program, but in my understanding the patients pain response to training to the key to adding force not by the week and generally not until the 1st stage has been completed.

But it would be good to look at the paper.

, or maybe I should add when to increase these fluctuations in force.

I tend to agree with your 1st thoughts that it maybe too much too soon - but in everything Ive read on eccentric training patient pain response is the key to when to increase loads - Ive not read anything about speed.

 

Just some brief thoughts on the speed of the exercises before my afternoon list starts:

Viscoelastic tissues (such as the achilles tendon) are strain-rate sensitive. My understanding is that the rate of deformation will affect the tissue stiffness, (quicker = stiffer) and consequently its yield point (i.e. when the tissue enters the plastic region of its load deformation curve).

With this in mind, high velocity eccentric drops as part of a tendinopathy rehab programme sounds intuitively bad. Be interested to hear what the docs rationale is and to get a squizz at the paper he is referring to.

Ian

 

Absolulu(for those fans of How Not To Live Your Life)

It would strike me that the rehab exercise being advised would be similar to the method by which that type of injury would occur in a visco-elastic tissue?

Robin

 

Is it possible that he prescribes the Alfredson type exercises wrongly and is unaware of it? Probably not the case given that hes a sports physician but not impossible. I have come across people doing what they thought were these exercises but were not doing correctly.
Just a thought
Nick

 

hiya,
personally with these patients i have found that slow controlled eccentric exercises work well (although in fairness i havent tried it with the increased velocity). Like Ian i think that dropping quickly sounds like something that would do more harm than good and cause more damage. The angle of the joint and stretch on the TA in this kind of exercise can easily go beyond what would normally be required.
but willing to be proved wrong on that.

cheers
JB

 

Timm we strictly adhere to eccentric exercises for acute PF/tendinopathy and passive care until 6-8 weeks out (possibly longer if this were insertional or a confirmed high grade tear).

Subacute and chronic cases can begin concentric, controlled, supervised exercise. I don't care for the mindset that studies tell the whole story when common sense (and good clinical evidence and outcomes) tells us that standing on a step and loading the Achilles with the full body weight is a very bad idea in acute PF/tendinopathy. Especially in equine, heavy or poorly conditioned patients .

 

Thanks for your comments. It seems that everyone is in agreement that this technique of high velocity, uncontrolled loading of the Achilles tendon (and other structures) would be a bad idea in patients with current injury.

I am still trying to get hold of the physician who recommended these exercises - I advised the patient against this technique and recommended to more controlled eccentric exercises that you are familiar with. As you suggested Ian, using pain as a guide re reps. However, patient wanted to continue doing the exercises as the 'sports doctor' recommended them :bang:

I did find this article that described the technique that the physician recommended so seems he is not the only one out there advising this technique.

http://www.fiba.com/asp_includes/download.asp?file_id=499

"After an injury, the Achilles does need some rest. What seems to help the healing process once the pain lessens is an exercise called the calf drop, an aggressive strength-building exercise that lengthens and strengthens the tendon."
"Flex the knees and drop so the heels are lower than the toes. Rise as high as possible on the balls of the feet, hold for a few seconds, and then quickly drop to stretch the tendon again. Perform three sets of 10 repetitions. Depending on pain,
repeat the exercise daily."
Bove, T. (2005). The Achilles Tendonitis. FIBA Assist Magazine

It does mention to do the exercises without pain. I still wouldn't recommend this due to the risk of furter damage, tear, rupture of the tendon..

Anyway, waiting to hear back from sports physician.

 

But Tim Bové Does not give any references here, so we will not know until we can find a study that says Velocity is an important role in eccentric training.

3 groups
1 control
1alfredsons
1 increased velocity

So we have 1 persons option hound that Dr for the evidence.

 

Article in the post, watch this space

 

Hiya
Have we not dispensed with the tendinitis as a description in favour of tendinopathy? I just can't see how dropping with that velocity could be safe. Having said that don't athletes regularly do rapid hamstring stretches as part of a warm up by throwing their leg up to head height?
Cheers
JB

 

Some evidence just got published:

The effect of eccentric and concentric loading speed on the normal achilles tendon: an in vivo biomechanical study
E Sweeney, S Chaudhury, H Screen, R Woledge, D Bader, N Maffulli, D Morrissey
Br J Sports Med 2011;45:e1 doi:10.1136/bjsm.2010.081554.25

 

Interesting, anyone have access to the full article yet?

I received some info from the Sports Doc last week on the program he is using for patients with achilles tendonopathy. It was published in a conference proceedings in 1983 and is taken from a document by Dr Ken Maquire for the Australian Institute of Sport. This is the program that was recommended for my patient and the reason behind me starting this thread.

"The Eccentric Program

An eccentric exercise program can be applied in the management of Achilles tendonitis. The first step is warm-up, followed by flexibility exercises for the calf muscles.

The warm up may consist of any moderately vigorous activity such as sit-ups, push-ups, and so forth.

Next, three sets of 10 repetitions of the eccentric program are carried out. This is most easily done by having the patient stand on the edge of a step. The body weight is supported on the ball of the foot, so the heel is free. Then allow the heel to drop downward with gravity, below the level of the step.
Progression is made by increasing the speed of the movement or increasing the resistance. The program proceeds as follows:
- Weight is supported equally on both feet throught the exercise session.
- Increase shifting of weight to symptomatic leg.
- Weight is supported on symptomatic leg only.
- Increase speed of dropping.
- Add weight to shoulders.

The severity of the initial symptoms determines the the starting resistance. The indication for an increase in resistance is the absence of pain at the end of 30 repetitions. For eg, an athlete whose symptoms present during any activity, such as running on level ground, and who experienced pain when dropping over the edge of the step would start at slow speed with body weight supported on both feet. An athlete who experiences pain only during extreme exertion, such as sprinting uphill, may start the program with weight placed on the shoulders and supported by one leg. Generally, adding 10% of body weight is a suitable starting point for this phase of the program, although trial and error may change the rule.

Since each athlete varies in body weight and size and in the severity of symptoms experienced, it is recommended the program be monitored by the amount of discomfort the patient experiences. There should be discomfort in the last 10 of the 30 repetitions, but pain should not be present throughout the and the level of pain should not be extreme. Ignoring pain, the body's warning signal, means further damage may occur. Progression should not take place until discomfort is absent or minimal."

Here is the program ( I hope this works)

Eccentric exercise program for Achilles tendonitis Dr K Maquire - AIS Porgram

Week Days Exercise Activity level
1 1 to 3 Slow drop, bilateral weight support Cannot participate
3 to 5 Moderate speed, bilateral support
6, 7 Fast drop, bilateral support

2 1 to 3 Slow, increased weight on symptomatic leg Cannot participate in sports
3 to 5 Moderate speed, increased weight
6, 7 Fast, increased weight

3 1 to 3 Slow, weight supported on symptomatic leg Pain during rapid drops; active in sports, but
3 to 5 Moderate, weight on one leg limited
6, 7 Fast speed

4 1 to 3 Slow, add 10% off body weight Pain during vigorous activity
3 to 5 Moderate, same weight
6, 7 Fast speed

5 1 to 3 Slow, increase by 5 to 10 lb. Pain only during exertion
3 to 5 Moderate speed
6, 7 Fast speed

6 1 to 3 Slow, increase 5 to 10 lb. Rarely experience pain
3 to 5 Moderate speed
6, 7 Fast speed


What does everyone think??
To me, still all very subjective and risk for further tissue damage too great in those that perhaps would progress through the steps to quickly or may start at a level they are not ready for. Then there is the point - is faster drops better then slower, controlled drops anyway. Also, think it is important to mention this program is tailored for 'athletes' (again subjective) so need to consider the age and activity level of the patient prior to recommending something like this. For now, I'll stick with what I'm doing ..

 

Here is program in PDF

 

Hi

Had a patient in a few weeks ago that reminded me of this thread. She had been instructed by physio to perform an exercise similar to that described originally by Tim- a bit like the alfredson protocol but with a sharp drop. I queried if this was her interpretation of it but she had apparently repeatedly confirmed with the physio how she was to do them- he used the words "slam down" to describe it. Will try and get in touch to find out what the aim was. In any case she had no improvement in symptoms.