Eccentric Loading for Achilles Tendinopathy--Strengthening Or Stretching?(Editor's Choice) (Report‪)‬

In recent years the management of chronic Achilles tendinopathy (AT) has moved from addressing inflammatory responses (Achilles tendonitis) to exercise rehabilitation combined with pharmacological interventions. (1-4) The non-operative clinical rehabilitation programmes for chronic AT are predominantly focused on progressive eccentric loading. (1-5) Various studies have examined the impact of eccentric loading in comparison with other modalities including concentric exercises, splinting and stretching. A systematic review of the role of eccentric loading on AT shows it has some promise for the changes in pain. (2) Direct comparison of eccentric and concentric programmes (6) suggests that eccentric exercises are more likely to generate a positive outcome (mean VAS change 18 mm, CI -3.7 to 39.7) in pain reduction than concentric exercises. Another recent systematic review shows that rehabilitation with eccentric exercises results in a greater relative rate of return to sport at 12 weeks (relative risk (RR) 2.38, CI 1.36 to 4.18) when compared with individuals who performed concentric exercises. (4) Although it is acknowledged that further well controlled clinical trials are required, (24) these results have influenced clinical rehabilitation practice, with the prescription of eccentric loading for chronic AT being a mainstay of specific exercise therapy. Furthermore, certain prognostic factors are starting to be considered in the efficacy of the eccentric loading profiles with evidence that insertional pain and individuals who are more sedentary may not respond well to the standard eccentric loading protocol. That stated, there have been limited investigations of the training paradigm, i.e. frequency, dose and painful limits, with the majority of research reporting the specific exercise programme that follows the early work by Alfredson et al (7) and Mafi et al. (8) Representative programme parameters reported in comparative studies (7-9) are shown in table 1.