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Eccentric vs. Concentric and achilles tendinopathy

Discussion in 'Biomechanics, Sports and Foot orthoses' started by TDC, Sep 29, 2012.

  1. TDC

    TDC Member

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    Is it a common consideration that a lack of eccentric load through the gastroc-soleal complex and achilles tendon may be partly to blame for some achilles overuse injuries in runners?

    In runners that are heel strikers there is a larger proportion of concentric stress as compared to the runner landing on the mid to forefoot who has a extra eccentric load following initial contact.

    Now if the gold standard exercise for mid-portion achilles tendinopathy is high rep eccentric heel drops (Alfredson protocol) then this begs the question;

    Is a more mid foot/forefoot landing strategy that has a higher ratio of eccentric vs. concentric contraction if done within tissue stress limits better for overall tendon health and prevention of achilles tendon injuries in the future?

    I was just thinking about this as i have heard reports from runners in my clinic that since they have switched to running in shoes with a lower heel height differential they have gotten less achilles problems. At first i was confused as this would only put MORE stress through their achilles tendon but maybe its about getting more eccentric load through it which has been shown on micro dialysis to increase peri-tendon collagen production.
  2. Admin2

    Admin2 Administrator Staff Member

  3. phil

    phil Active Member

    Makes sense to me. This is plausible from a theoretical basis. It also matches my personal experience.

    The key would be adequate transition to lower drop shoes. I.e. not too much too soon.
  4. Nat

    Nat Active Member

    Your finding matches my observations too.
  5. Interesting. I have seen a number of runners develop Achilles tendinitis/tendinopathy from switching over to running in shoes with a low heel height differential over the last quarter century. I wouldn't be so sure that we should tell runners to all switch to running shoes less heel height differential any more than you should treat Achilles tendinitis/tendinopathy by putting people in flat soled shoes without heel lifts.

    Maybe those of you who claim that low heeled shoes prevent Achilles tendinitis can explain to me why we still treat Achilles tendinitis with heel lifts?:confused:
  6. Nat

    Nat Active Member

    I do not.
  7. I recommend small 1/8" heel lifts initially in runners with Achilles tendinitis along with eccentric stretching, gastroc-soleus strengthening, icing and a reduction in running mileage and speed. I have never tried having runners with Achilles tendinitis use a lower heeled running shoe. Does anyone else tell runners with Achilles tendinitis to run in shoes with lower heel height differential?
  8. Nope. And I'm initially far more aggressive with my heel-lifts than you- typically 8mm or more.
  9. phil

    phil Active Member

    I definitely use heel raises in the acute/ reactive stage.

    But I would consider lower heel height differential footwear for those chronic rumbling degenerative tendons, as a means of eccentricly loading this tendon.
  10. Somewhere between 30 % and 70 % of patients with midshaft Achilles tendonopathy ( AT) will get improvement in symptoms depending who you believe.

    The Umea research people here in Sweden claim 70% Jill Cook wrote 30 % in one her papers.

    1st I think needs to be broken down into sub-groupings

    1. Compression described by Cook

    2. reduced torsion of the Achilles tendon and Gastroc/Sol complex

    3. breakdown in the collagen fibers and scar tissue development

    there are more

    of the 3 above, eccentric training and a lower heel will generally according to my understanding have positive results in those with a reduction in torsion - those that have long term results are probably the one that go through a genetic change - there was a thread about mice on her a few weeks ago.

    The others will get greater symptoms through eccentric training and a lower heel in running shoes as part of a rehab program - and as I said somewhere between 30 - 70 % depending on who you believe.

    But only in those who have a reduction in torsion

    and a further but a reduction in elongation of the Achilles tendon ie a heel lift will have a positive effect in all 3 causes that I wrote about above - again according to my reading especially in the acute phase
  11. All these "minimalist shoes" with "low heel drop" (i.e. reduced heel height differential) are just fine for some runners, but I see plenty of runners developing Achilles tendon pathologies due to running in these shoes, especially if they have never run in these types of shoes before.

    So much for the notion that wearing "low drop" shoes is better for your Achilles tendon....:cool::craig::boxing:
  12. will be for some - problem is no one has a way of working out who before hand :D, yet
  13. phil

    phil Active Member

    Acute mid portion Achilles tendinitis can be from many causes, including changing to lower heeled running shoes if you've never run in them before. I would thing this would be a factor of increased tissue stress.

    However, considering that eccentric tendon loading is generally considered very important in tendon repair, and that lower heeled running shoes should theoretically increase the eccentric load of the Achilles tendon, is it logical to consider lower heeled running shoes as part of rehab of chronic achielles pathology?
  14. rikmellor

    rikmellor Member

    I don't believe you should be looking at changing a shoe to attempt to cure achilles problems. If running is the cause of the pathology, what would happen if the client changed shoe and continued doing what they were doing? To assume that using a lower gradient shoe structure will change their running so much is a notion quashed many times on other threads here. Further, if the running is the mechanism, why not consider tissue stress firstly and question whether this would change with swapping shoes?

    I have found a 'general consensus' to be a problem with respect to tendon rehab. Alfredson et al are still researching and becoming way more specific with their research. I believe the emphasis should be on tissue stress, many times in this forum have I read field leaders negate footwear to then focus on volume/intensity and recovery - direct links to tissue stress.

    I'd agree with Mr Kirby on a notion that is oft repeated in this forum - it doesn't matter what footwear you have, you can still get injury in similar tissues; and there is yet to be a clear link to say otherwise.

    Critically appraising a client's training/rehab/tissue stress levels in certain time periods should offer way more insight when then compared to the cycle of tissue turnover in tendon.

    Some interesting reading in a paper such as: Wang, J.H.C. (2006). Mechanobiology of tendon. Journal of Biomechanics, 39, 1563-1582
    And then also to look at the group led by Michael Kjaer in Denmark, way more focussed tendon biology and mechanobiology.

    On a clinical level I know of many who have had success with traditional calf stress exercises without too much other intervention, but they focus on a time and stress focussed progressive rehab plan over a period that attempts to match collagen turnover, say 50-100 days - relative rest only. This is dependant on initial and subsequent grading (use VISA-A for example) and symptoms, plenty advocate rehab through pain, dependant of course.

    I don't think eccentric alone is the key, however much it is generalised. If tension when lengthened is key, why not do isometrics?
  15. phil

    phil Active Member

    I don't just focus on eccentrics. It's much easier to teach eccentric and concentric together. Heel goes up, heel goes down. I know I'm not doing it by the book, but I don't care.

    I really think that lower heel height running shoes for chronic degenerative achielles tendon pathology may have a place. Probably for 2 reasons, 1. it mixes up the tissue loading pattern (increasing eccentric tendon loading due to forefoot strike and increased ankle dorsiflexion), and 2. it is part of a generalised reduction in training intensity and volume (or should be, if you've got any brains).

    Anyone who runs in a lower heel running shoe for the first time notices it. Usually in the posterior calf, or medial ankle if they've got a medial STJ. The sensible response is to back off a bit, and let the tissues adapt to this stress. Wouldn't this approach achieve the same as relative rest plus alfrdsons heel drop protocol?
  16. lucky_mf

    lucky_mf Welcome New Poster

    I've experienced improvements since spending more time barefoot and switching to very flexible, zero drop, barefoot-type shoes for my running. I have some theories on why.

    First, my achilles problems were not caused by running, but rather years of playing basketball and in particular jumping and forcefully pushing off of one foot. Even though my injuries were not caused by running I found it hard to run more than 10-12 miles per week and to run on consecutive days in stability shoes with custom orthotics, even years after quitting basketball.

    Secondly, lack of flexibility in of my achilles was not a factor in my injury. The reason my podiatrist did not prescribe heal lifts is because I showed so much flexibility in this area.

    Third, since spending more time barefoot and making the switch to running in thin flexible shoes my feet and lower legs and gotten much stronger and more stable. I can now balance on either foot for an extended period of time and can even maintain my balance on the ball and toes of either foot. Before in approach and footwear I couldn't even balance on foot for more than a few seconds. Where my wet footprint used to look flat, I now have an arch. Additionally, the large callouses that I used to have to saw-cut off the medial side of my big toe, while still there, are now much less pronounced.

    Lastly, I think the more flexible shoes allow my planter facia to absorb some of the forces that would be solely absorbed by the achilles in less flexible shoes.

    All this is not to say that my achilles problems are completely solved (or that my approach to dealing with my injuries is generalizable). I have visible and palpable scar tissue on both achilles that isn't ever going away. I wake up stiff and sore and remain so until I warm up, and while I can run 20-30 miles a week mostly pain free, my attempts to play soccer or basketball have left me too tender to run for weeks. I've given up on these sports.

  17. NewsBot

    NewsBot The Admin that posts the news.

    Effect of Eccentric Strengthening on Pain, Muscle Strength, Endurance, and Functional Fitness Factors in Male Patients with Achilles Tendinopathy
    Yu, JaeHo PhD, PT; Park, DaeSung PhD, PT; Lee, GyuChang PhD, PT
    American Journal of Physical Medicine & Rehabilitation; 5 October 2012

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