Tendinitis Research Summaries

Study Diagnosis Outcome When assessed Subjects Protocol Other Activity Other factors/Comments
A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. van der Plas A, de Jonge S, de Vos RJ, van der Heide HJ, Verhaar JA, Weir A, Tol JL. Br J Sports Med. 2011 Nov 10. [Epub ahead of print] Mid portion Achilles tendinitis (2-6 cm above insertion) VISA-A at 1 year and 5 year. Average score improved from 49.2 to 65 following 12 week trial, increased to 75 at one year and 83.4 at 5 years. 39.7% were completely pain free at 5 years, rest has some degree of residual symptoms. 1 year and 5 years 46 subjects at follow up, ave age 51, 35 of which were recreational athletes. After completing Alfredson’s 12 week protocol, 67% never performed eccentric exercise again, but no correlation in pain status was found between patients who continued the exercises and those who did not. No mention of other activity during or after protocol. Perhaps in their earlier short term study with same subjects this is mentioned, older study on order. Interesting to me was that most did not continue with the exercise after the 12 week trail, and that there was no correlation towards further improvement in those that did and didn’t. I suspect this might be a limitation of Alfredson’s protocol as there is no work to increase concentric strength at any point, perhaps holding them back with regards to further functional gains, also that eccentric exercises do become unwieldy and perhaps needlessly complex that might decrease compliance compared to continuing with more conventional progressive resistance exercise program.
Prospective evaluation of the effectiveness of a home-based program of isometric strengthening exercises: 12-month follow-up. Park JY, Park HK, Choi JH, Moon ES, Kim BS, Kim WS, Oh KS. Clin Orthop Surg. 2010 Sep;2(3):173-8. Epub 2010 Aug 3. Lateral Epicondylitis VAS dropped from 53.1 at start to 29.7 at 1 month, 10.6 at 3 months, 8.5 at 6 months, 7.8 at 12 months for the immediate group, the delayed group was similar but with delayed results ~4 weeks, catching up with immediate group by 6 months. By 12 months 88% of participants were performing all daily activities without pain. 1, 3, 6 and 12 months 31 subjects, 15 in the immediate therapy group, 16 delayed exercise 4 week. No control group. Average age 50 years. 13 men and 19 women. Isometric holds, 4 sets of 50 repetitions performed daily, with each rep held 10 seconds. Participants were instructed to perform the exercises gently, without pain. Elbow held in full extension in demo photo. Does not say if the 4 sets were done all at once or divided throughout the day. Not told to stop the exercises but compliance ~80% after 1 month, and dropped steadily to ~40% as 12 months. No mention of other activities. This one is interesting because it showed isometric exercise to be effective, rather than the more frequent use of eccentric exercise. Also no equipment was required and they trained without pain. I would expect, over time the isometric contractions without pain would become stronger, but there was no mention of this. No control group, the the 4 week delay in treatment group served as a kind of control, with no meaningful improvement in that group until after they started the exercises, while the immediate group was well ahead by this time. The authors theorized isometric exercise might be better for epicondylitis because forearm contractions during ADLs were more isometric in nature than calf or quadriceps contractions, but it would be interesting to see if results are generalizable.
Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, Magnusson SP. Scand J Med Sci Sports. 2009 Dec;19(6):790-802. Epub 2009 May 28. Patellar Tendinitis VAS during sports and VISA-P Cortisone group VISA-P increased from 64 to 82 at 12 weeks but returned to 64 at 6 months, VAS during preferred sporting activity decreased from 58 to 18 at 12 weeks, but back up to 31 at 6 months. The eccentric group VISA-P increased from 53 to 75 at 12 weeks and 76 at 6 months, VAS during preferred sporting activity decreased from 59 to 31 at 12 weeks, and 22 at 6 months. The concentric group VISA-P increased from 56 to 78 at 12 weeks and 86 at 6 months, VAS during preferred sporting activity decreased from 61 to 19 at 12 weeks, and 13 at 6 months. 12 weeks and 6 months 52 male recreational athletes, age 18-50, average 31-34 years, 12 in CORT group, 12 in ECC group, 13 in HSR group. Cortisone group had 2 shots in patellar tendon, one at week zero and one at 4 weeks. The Eccentric group did eccentric decline squats 3×15 twice per day 7 days per week for 12 weeks. The concentric group did 15 RM worked down to 6 RM by week 12, 4 sets per exercise on squats, leg press and hack squats 3 times per week. 3 second concentric and 3 second eccentric phases on each. Pain was OK during both eccentric and concentric exercises so long as pain was not increased following the exercise. Sporting activities were allowed in all groups so long as pain did not rise above 30 on VAS, and they said other studies had gone as high as 50 on VAS in recreational activities and still been successful. Most interesting new study to me, found combined concentric/eccentric training better than both cortisone and and eccentric training alone, with benefits being greater as time went on. “HSR proved to be more effective than ECC with retard to tendon tissue normalization and collagen turnover/production, and tended to improve clinical outcomes more than ECC.”
Eccentric loading versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy: a randomized controlled trial. Rompe JD, Furia J, Maffulli N. Am J Sports Med. 2009 Mar;37(3):463-70. Epub 2008 Dec 15. Mid portion Achilles tendinitis (2-6 cm above insertion) VISA-A score improved from 50 to 73 in eccentric group, while combined eccentric exercise and shock-wave treatment group improved from 50 to 86.5. Combined group had slightly less women in it 53% vs. 59% but were on average older 53 years vs. 46 years. Only 26% in group eccentric and 35% in combined groups performed some sort of sporting activity at least once per week. 4 months, treatment was 12 weeks. 34 patients per group, average age 46 in eccentric, and 53 in combined. 59% women in eccentric and 53% in combined. Eccentric group: 2 exercises (one with knee straight and one with knee bent) 3×15 each, 2 x per day, 7 days per week for 12 weeks, starting with full body weight on one leg, train with pain unless “disabling”, no indication of varied speed. Combination group also had SWT 3 times, at weekly intervals. Exercises were demonstrated once by author and subjects were instructed to add 5kg of books at a time to their backpacks. “After 6 weeks, the patients were told to slowly return to their previous sports/recreational activity.” Subjects were told to increase resistance by putting books in a backpack at home, which I think might have decreased compliance regarding increasing resistance levels as eventually it will be difficult to keep adding books to a backpack, thus patients might max out before optimal strength levels are reached. Also no recording of BMI, such that less fit individuals might be starting off with higher resistance levels and less strength than more fit counterparts. Only 9/34 in group 1 and 12/34 performed some sort of sporting activity at least once per week. Appears to less athletic than the Scandinavian studies. I think that though differences between groups were statistically significant, but relatively minor and may be due to the increased females and lesser number of athletes of eccentric group, so it is hard to say how much effect the SWT had on outcomes.
Eccentric exercises for the management of tendinopathy of the main body of the !Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation. Knobloch K, Schreibmueller L, Longo UG, Vogt PM. Disabil Rehabil. 2008;30(20-22):1685-91. Achilles Tendinitis FAOS improved significantly in both groups that did eccentric exercise but did not differ with use of the brace. VAS (but did say if at rest or during activity. VAS decreased from 5.1 to 2.9 in one group and 5.4 to 3.6 both eccentric groups (a 43.1% and 34.6% improvement respectively) while use of heal brace did not have a significant effect on pain or function. 12 weeks 63 males and 34 females average age 47 Eccentric training 3 sets of 15 reps twice daily. “All groups performed their regular sport activity throughout the study period for at least 12 weeks.” Study showing beneficial changes in pain, function, and quality of life with eccentric exercise while allowing subjects to continue with regular sport activity.
Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain–a pilot study. Chester R, Costa ML, Shepstone L, Cooper A, Donell ST. Man Ther. 2008 Dec;13(6):484-91. Epub 2007 Jul 26. Achilles Tendinitis FILLA and VAS “during rest, walking, and if appropriate during recreational sport” Graphs of VAS not significantly different between exercise or ultrasound and not different from what I would expect from natural course without treatment. 2, 4, 6 and 12 weeks, TREATMENT WAS ONLY 6 WEEKS 4 male and 4 female in exercise group with average age of 59, while ultrasound group had 7 male and 1 female average age of 48. Exercise was eccentric, slow of UP TO 3 x 15 reps with a TEN SECOND REST at bottom of each rep, with both straight knee and bent knee, once per day 7 days per week for 6 WEEKS. Instructed to continue unless pain is disabling. “only one subject progressed to using a backpack with weights and a number of subjects were unable to progress to performing the exercise with a bent knee.” Group was largely sedentary. “It is reasonable to suggest that the sedentary or relatively sedentary lifestyle in our study in comparison with the majority of the subjects in the studies above is a likely contributing factor to our results.” I think this study is difficult to assess in relation to others. The subjects did not progress on exercises very well, the treatment weeks was only 6 weeks compared to 12 in others, the exercise protocol included a 10 second stretch on every rep while no others did so, and the randomization procedure led to non-random and unequal treatment groups for which they admit “the subjects in the eccentric loading group were older, had a greater proportion of women to men, had a longer duration of symptoms and had a greater number of additional pathologies than the subjects allocated to the ultrasound group.”
Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic Achilles tendinopathy. Stergioulas A, Stergioula M, Aarskog R, Lopes-Martins RA, Bjordal JM. Am J Sports Med. 2008 May;36(5):881-7. Epub 2008 Feb 13. Mid portion Achilles tendinitis (2-6 cm above insertion) VAS during physical activity. Eccentric only group was 81.8 at baseline, 71.5 at 4 weeks, 62.8 at 8 weeks, and 53.0 at 12 weeks. Combined laser and eccentric group was 79.8 at baseline, 53.6 at 4 weeks, 37.3 at 8 weeks, and 33.0 at 12 weeks. 4, 8 and 12 weeks 20 patients per group, 37.5% female, average age ~30 years old. All were active in athletics. Eccentric exercise was 4 x per week for 8 weeks. Athletes started with 1 set of 5 reps and worked up to 12 sets of 12 reps by 4th week. Started with body weight, adding 4 kg at a time in backpack with lead weights, when exercises could be performed without pain. Exercises were done with knee straight and with knee bent. Exercisers told to work through pain up to 5/10, but stop if it became disabling or they hurt worse the next day. “All patients were recreational athletes attending various sporting activities 1 to 5 times (mean 2.1) per week. Interesting because both groups made steady improvements in spite of the fact that they all continued with their sporting activities throughout the trial. The addition of laser treatment did help (and was placebo controlled) and authors noted that different parameters have been shown to work or not work in prior research so I think it’s worth further investigation and follow up in literature. Subjects were younger than in any other study, but exercise frequency and volume was different than in other studies.
Eccentric calf muscle training in athletic patients with Achilles tendinopathy. Maffulli N, Walley G, Sayana MK, Longo UG, Denaro V. Disabil Rehabil. 2008;30(20-22):1677-84. Mid portion Achilles tendinitis (2-6 cm above insertion) VISA-A. Average score increased from 36 to 52. 60% were considered successful, unsuccessful was judged if pain still interfered with normal activities and if VISA-A score did not improved less than 10 points. 12 weeks 45 athletic patients, 29 men average age 26, and 16 women average age 26 Subjects worked up 3 sets of 15 reps with knee bent and with knee straight, twice per day, 7 days a week. Allowed to work through mild to moderate pain, starting with body weight (1 set of 10 reps) and adding 5 kg at a time if 3rd set painless. They did work from a slow to fast pace then increased weights, working a slow to fast pace again in later weeks of the study. No mention of other activity during or after protocol. This is an interesting study in that they did not find the same results as did Alfredson (60% effective vs better than 80% effective. Differences I see, is that they worked to increase rep speed rather than just resistance levels while keeping speed constant like Alfredson. Could be the increased rep speed lessens time of tension on eccentric exercise and thus lessens adaptation. Also there is no mention about return to running, or sports during the course of treatment. It has been my experience that patients do better with relative rest (less duration) but not complete rest from the offending activity, and that with complete rest the pain just returns as they start the activity again, regardless exercise intervention. Another difference is the use of ice massage after treatment, but other studies have found ice to have no effect on outcomes rather than deleterious effect.
Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Am J Sports Med. 2007 Jun;35(6):897-906. Achilles Tendinopathy VISA-A, VAS, and a variety of functional tests. 6 weeks, 3 months, 6 months, and 1 year 19 subjects per group, ~half men and women, average age 46 Both groups did same rehab exercise protocol including concentric, eccentric, and plyometric calf muscle exercises 12 to 15 total sets of 10-15 reps increasing intensity over 12 weeks, then at 12 weeks reducing exercise frequency to 2-3x per week. The “exercise group” was instructed to continue normal running and jumping activities keeping pain <5/10, while the “active rest group” was instructed to stop all running and jumping type exercises for 6 weeks. Active rest group only did exercise program as per protocol for the first 6 week, while the exercise group was instructed to continue running and jumping activities over the course of treatment so long as pain did not rise above 5/10 on VAS and pain did not rise from week to week. There is a lot to be learned from this study. Both groups had an rapid increase in function in first 6 weeks and more steady improvements thereafter. Both groups improved statistically equal in regard to both pain and function, but absolute gains in the resting group were a little higher with VISA-A score increasing from 57 to 75 at 6 weeks and 91 at 1 year. The exercise group improved from 57 to 70 at 6 weeks and 85 at 1 year. One could ague the rest helped a little but the continued exercise group improved nearly as much in spite of continued exercise and would otherwise be better able to maintain and or further improve fitness/sports performance rather than a decline in health/function from lesser activity. Downside of this study is it did not state how active either group was before or after the 6 week differential period, so it is hard to say how this adapts to various activity levels. In light of the in season elite level volleyball players it does seem improvements can be seen in pain and function even with intense and prolonged additional exercise. Also this study used both concentric, eccentric, and plyometric types of exercises in their program indicating that the combination of contractions types is effective in treating Achilles tendinopathy.
Anatomic factors related to the cause of tennis elbow. Bunata RE, Brown DS, Capelo R. J Bone Joint Surg Am. 2007 Sep;89(9):1955-63. Lateral epicondyle. “As the elbow is extended, the undersurface of the extensor carpi radialis brevis rubbed against the lateral edge of the capitellum while the extensor carpi radialis longus compressed the brevis against the underlying bone.” “Dramatic bowing and stretching of the tendons over the epicondyle and the capitellum occur with the elbow in full extension.” “…we believe this wear leads to tendon abrasion and is the initial step in the cause of tennis elbow.” 85 cadaver elbows.
Eccentric exercise in treatment of Achilles tendinopathy. Nørregaard J, Larsen CC, Bieler T, Langberg H. Scand J Med Sci Sports. 2007 Apr;17(2):133-8. Achilles tendinitis, both mid portion and insertional. Reported minimal improvement at 12 weeks in both groups, however at 1 year 21/23 tendons in eccentric group had “very significant improvement” or “completely cured” while only 12/19 were as improved in the stretching group. 3, 6, 9, and 12 weeks and 1 year 45 patients, ~half men and women, average age ~42. Eccentric Protocol: 1 increasing to 2 & 3 sets of 15 reps of body weight eccentric calf raises with knees straight and with knee bent. 5kg added at a time to backpack pain decreased. Performed twice daily for 12 weeks. Stretching group did 5x 30 seconds with straight knee and bent knee performed twice per day. No other details as to how stretches were performed. “They were allowed to continue ongoing pain free sporting activities, but were told not to take up new activities or increase the amount of training.” The authors noted their results were not as good or as fast as Alfredson 1998 and Fahlstom 2003, but used the same training protocol, however they noted their groups activity may be lower, they included insertional tendinitis. They also reported supervision of subjects was not as good and subjects were not encouraged to work through pain as with Alfredson and Fahlstom. They also suspect their subjects less athletic to start. They also noted women had a poorer prognosis then men.
Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achilles: a randomized controlled trial. Rompe JD, Nafe B, Furia JP, Maffulli N. Am J Sports Med. 2007 Mar;35(3):374-83. Epub 2007 Jan 23. Mid portion Achilles tendinitis (2-6 cm above insertion) VISA-A etc. Eccentric group improved from 50.6 to 75.6, shock-wave treatment from 50.3 to 70.4 and wait and see from 48.2 to 55. Eccentric and shock wave treatment were not significantly different but both were significantly better than the wait and see group. 16 week after start of treatment, intervention was for only 12 weeks. 75 patients, 25 per group, average age 48 in eccentric group, 51 in SWT group, and 46 in wait and see. Most ~2/3 were not athletic. Subjects worked up 3 sets of 15 reps with knee bent and with knee straight, twice per day, 7 days a week for 12 weeks. Allowed to work through mild to moderate pain, starting with body weight (1 set of 10 reps) and adding 5 kg at a time if 3rd set painless. Speed was not varied. “Patients were asked to avoid pain-provoking activities throughout the 12-week treatment period. Walking and bicycling was allowed if it could be performed with only mild discomfort or pain. Light jogging on flat ground and at a slow pace was allowed after 4 to 6 weeks, but only if it could be undertaken without pain. Thereafter, activities could be gradually increased if no severe tendon pain occurred.” Interesting in that it compares eccentric exercise to wait and see and found significantly better improvements, which is good as previous research looking at traditional physical therapy exercises were not noticeably better than wait and see. Still the results were not as good as the Scandinavian studies. This study had the fewer number of athletes stop running for first 6 weeks but Scandinavians had done that too in some studies, however the proportion who were runners was less in this study.
Full symptomatic recovery does not ensure full recovery of muscle-tendon function in patients with Achilles tendinopathy. Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Br J Sports Med. 2007 Apr;41(4):276-80; discussion 280. Epub 2007 Jan 29. Achilles Tendinitis VISA-A and various functional tests. At one year follow up 67% were classified as fully recovered, average VISA-A increased from 56 to 89. Of those fully recovered (VISA-A at or above 90) only 25% had functional tests 90% or greater than their contralateral side. 12 months 37 people, 17 women & 20 men, 30-58 years, ave age 46 Progressive battery of exercises including both eccentric and concentric calf raises slow and fast, progressed over 6 months. unclear, but these researches in other studies advocated continuing with recreational activities so long as pain (VAS) does not rise over 5/10. “In a recent study, we found that continued physical activity with use of a pain-monitorying model des not seem to hinder recovery (unpublished data). Study used both concentric and eccentric exercises successfully, but found functional status often continues to lag even if patients are asymptomatic.
Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. Sayana MK, Maffulli N. J Sci Med Sport. 2007 Feb;10(1):52-8. Epub 2006 Jul 7. Mid portion Achilles tendinitis (2-6 cm above insertion) VISA-A 56% improved VISA-A score at least 10 points and did not have pain that interfered with activity, 44% didn’t respond 12 weeks 34 sedentary adults, ave age 44 1x 10 to 3 sets of 15, 2x per day, 7 days per week, for 12 weeks, rep speed varied from slow to fast Sedentary 16 patients were smoked
Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper’s Knee). A randomized, controlled trial. Bahr R, Fossan B, Løken S, Engebretsen L. J Bone Joint Surg Am. 2006 Aug;88(8):1689-98. Patellar Tendinopathy VISA-P scores improved similarly in both groups from 30 at baseline to 49 at 3 months, to 58 at 6 months, and 70 at one year. Leg press strength improved statistically at 6 months and more at 12 months. Standing jump and countermovement jump height did not change significantly in either groups, but decreased slightly in the surgery group. 55% of eccentric group returned to prior level of sports with no pain or mild to moderate pain while only 45% of the surgery group did so. 3, 6, and 12 months Average age 30-31 years. Only 14% female. Majority of patients were recreational or sub-elite athletes. 3 sets of 15 reps of eccentric squats on a 25 degree decline board performed 2x per day for 12 weeks. Pain kept between 3-5/10 VAS, with resistance (5 kg) added when pain dropped below 3/10. Surgery group performed similar exercises protocol, though delayed 6 weeks after procedure, and they were instructed not to train with pain. 66% compliance with exercise in eccentric group and 72% in surgery group. “During the first 8 weeks of treatment, the patients were not allowed to take part in sports-specific training. After four weeks, they were allowed to cycle, to jog on a flat surface, or to exercise in water if these activities could be done without pain. After 8 weeks, the patients were allowed to gradually return to their sport if there was no or minimal pain.” “During the first 8 weeks of treatment, the patients were not allowed to take part in sports-specific training. After four weeks, they were allowed to cycle, to jog on a flat surface, or to exercise in water if these activities could be done without pain. After 8 weeks, the patients were allowed to gradually return to their sport if there was no or minimal pain.”
A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy. Manias P, Stasinopoulos D. Br J Sports Med. 2006 Jan;40(1):81-5. Lateral elbow tendinopathy VAS over the previous 24 hours. VAS dropped 6.9 points at 4 weeks and 7.1 points (out of a 10 point scale) at 16 weeks in both groups. 0, 4 and 16 weeks 40 subjects, mean age 40 years, Exercise group did 3 sets of 10 repetitions of slow (30 seconds) progressive eccentric reverse wrist curls with a 30 second rest interval between each repetition, increasing weight with free weights when they could do sets without pain. Performed static stretching in wrist flexion and ulnar deviation 3 times 30-45 seconds before and after eccentric exercise. Exercise performed 5 times per week for 4 weeks. The ICE group did the same exercise program above but applied a bag of ice to the lateral epicondyle for 10 minutes afterwards. “All patients were instructed to use their arm during the course of the study but to avoid activities that irritated the elbow such as shaking hands, grasping, lifting, knitting, handwriting, driving a car and using a screwdriver.” No mention of exercise or sporting activity before, during or after the study. Interesting in that this is the only study that has used ice as a variable and found it had zero effect, good or bad on outcomes. Pain dropped a lot in a short time period which could be due to effectiveness of the exercise protocol, which was novel (taking 30 seconds to lower the weight) or due to the avoidance of aggravating activities. The outcome measure (VAS over prior 24 hours) perhaps does not take into account pain during activity and there were no functional measures.
Superior results with eccentric compared to concentric quadriceps training in patients with jumper’s knee: a prospective randomized study. Jonsson P, Alfredson H. Br J Sports Med. 2005;39(11):847-850. Patellar Tendinitis VAS during sporting activity (72.7 to 22.5) for eccentric group, concentric (74.3 to 68 but 3 patients dropped out) 9/10 eccentric patients satisfied, while 0/9 concentric patients were satisfied 12 weeks 15 men, 2 women, athletes, ave age 25 Single leg squats on decline board to 70 degrees knee flexion, 3 sets of 15 reps, 2x per day 7 days per week Sport specific training allowed after 6 weeks if there was no “severe pain.”
No effect of eccentric training on jumper’s knee in volleyball players during the competitive season: a randomized clinical trial. Visnes H, Hoksrud A, Cook J, Bahr R. Clin J Sport Med. 2005 Jul;15(4):227-34. Patellar Tendinopathy VISA-P, static vertical jump, countermovement jump. No difference in pain level between eccentric group and controls. Small 1.2 cm change in countermovement jump for eccentric group, but no difference in control group and no difference in either group for static jump. No trend in either group towards increasing VISA-P in eccentric vs. control group. Both groups however had average VISA-P scores increase from low 60s during pretest to mid to low 70s on graph at week 12 and week 40. 3 months and 6 months 13 in eccentric group and 16 in control group, ~ half male half female. Subjects from clubs in elite and 1st divisions for men and women in Norway. Had to have initial VISA-P score less than 80 points. Initial VISA-P score averaged 61 in eccentric group and 65 in control. 25 degree decline squats, 3 sets of 15 reps, intended 2x per day for 12 weeks, subjects with continued pain after 12 weeks were encouraged to continue with exercise, starting with bodyweight taking 2 seconds to lower to 90 degrees of knee flexion. Pain recommended to be at 5/10 and increased 5 kg increments when pain at 3-4/10. Both experimental and control group did PRE with rest of team 1.6 hours per week for eccentric group and 2.0 hours for control group. Volleyball training was 5.1 hours in eccentric group and 6.1 hours in control group. Only 6/13 of the eccentric group increased their load with final load averaging 4.2 kg. Eccentric group completed 59% of recommended volume. In season elite competitive volleyball players. Eccentric 1.4 and control 1.9 hours of weight training per week. Eccentric 5.8 hours per week of volleyball training and control 6.4 hours per week. Cited 3 studies indicating patellar tendinopathy is present in 40-50% of high level volleyball players. This study is particularly interesting in that both groups did a little better over time even in the course of a competition season with VISA-P scores increasing from ~low 60s to 70s. There was certainly no increase in pain, nor a decline in function over time. Also both groups strength trained during the course of treatment, the control group more so, which while not detailed I would assume to include weight training to the lower extremities. With the 2009 Kongsgaard study indicating that more conventional PRE as good or better than eccentric exercise, one could explain the results of this study better as mild successs in both groups while training in season, rather than a failure of response of the eccentric group.
Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. Young MA, Cook JL, Purdam CR, Kiss ZS, Alfredson H. Br J Sports Med. 2005 Feb;39(2):102-5. Erratum in: Br J Sports Med. 2005 Apr;39(4):246. Patellar Tendinopathy VISA-P and VAS scores comparing eccentric single leg squat stepping down a block, vs. single leg squat on a 25 degree decline board to increase quadriceps recruitment. Scores on graph so approximate but step group VISA-P was 56 at baseline, 66 at 12 weeks and 68 at 12 months. Decline group was 62 at baseline, 78 at 12 weeks, and 84 at 12 months. VAS score improved over time in both groups but was not significantly different. 12 weeks and 12 months. 17 elite volleyball players 18-35 years old 3 sets of 15 reps of eccentric single leg squats performed twice per day in both groups starting with body weight. The step group (10 cm height) was instructed to train with “minimal pain” while the decline (25 degree) group were instructed to train into “moderate” pain. The decline group increased resistance when pain decreased, while the step group was instructed to progress speed from slow to fast before increasing resistance as per Stanish protocol. Sounds like exercise protocol was initiated and completed in the preseason and then the athletes were tracked for the full competitive season with no additional intervention. Interesting for several reasons. First it is impossible to say if decline board is better than the step down because the exercise protocol was different (more pain allowed in decline group, increasing speed in step down group). I think perhaps a leg extension machine might be best still as you know for sure you are getting 100% quadriceps involvement as both above interventions allow for at least some degree of substitution from other muscles. Both groups improved but not as well as Achilles tendinopathy studies, that Alfredson was also a part of. Noted that most competitive athletes training with pain and patellar tendinopathy have a VISA-P of 50-80 which perhaps indicates that if you are below 50 it might be wise to take a break from sports.
Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis? Ohberg L, Alfredson H. Knee Surg Sports Traumatol Arthrosc. 2004 Sep;12(5):465-70. Epub 2004 Apr 2. Mid portion Achilles tendinitis (2-6 cm above insertion) “At follow-up after treatment (mean 28 months), there was a good clinical result (no tendon pain during activity) in 36/41 tendons, and a poor result in 5/41 tendons. In 34/36 tendons with a good clinical result of treatment there was a more normal tendon structure, and in 32/36 tendons there was no remaining neovascularisation. In 5/5 tendons with a poor clinical result there was a remaining neovascularisation in the tendon, and in 2/5 tendons there were remaining structural abnormalities.” 28 months 41 tendons, 22 men 8 women, mean age 48 years 2 exercises (one with knee straight and one with knee bent) 3×15 each, 2 x per day, 7 days per week for 12 weeks, starting with full body weight on one leg, train with pain unless “disabling”, no indication of varied speed. After 12 weeks they were encouraged to keep up the exercises 1-2 times per week. “The patients were allowed to gradually go back to their previous (before injury) tendon loading activity during the last 4 weeks of the 12 week training regimen.”
Chronic Achilles tendon pain treated with eccentric calf-muscle training. Fahlström M, Jonsson P, Lorentzon R, Alfredson H. Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):327-33. Epub 2003 Aug 26. Mid portion Achilles tendinitis (2-6 cm above insertion) & patients with insertional tendinitis. VAS during activity. 90/101 good vs. poor result for mid-portion tendinitis, while 10/31 of insertional tendinitis had good vs. poor result. Good groups were able to return to preinjury activity level and had VAS drop from ~66 to 13 while poor groups only dropped 5-10/100 points on VAS. 0 and 12 weeks 101 mid portion tendons, 31 tendons with insertional pain. Average age in 40s. 2 exercises (one with knee straight and one with knee bent) 3×15 each, 2 x per day, 7 days per week for 12 weeks, starting with full body weight on one leg, train with pain unless “disabling”, no indication of varied speed “During the 12-week training regimen, walking and bicycling was allowed if it could be performed with only mild discomfort or pain. Light jogging on flat ground and a slow pace was allowed after four to six weeks, if it could be done without pain. Thereafter their activities could be gradually increased if not severe pain in the tendon was felt.” They found significantly more women and those with high BMI in the poor result group. In the poor result insertion group all were treated surgically and there were signs of retrocalcaneal and subcutaneous bursitis in all subjects and signs of impingement between the postero-superior part of the calcaneus and the Achilles tendon.
A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. Purdam CR, Jonsson P, Alfredson H, Lorentzon R, Cook JL, Khan KM. Br J Sports Med. 2004 Aug;38(4):395-7. Patellar tendinopathy VAS score in eccentric decline squat group decreased from 74.2 to 28.5 at 12 weeks with pain scale at 26.2 in 15 months. In standard squat group VAS score decreased from 79 to 72.3 at 12 weeks with no follow up shown at 15 months. 6/8 subjects in decline group returned to preinjury levels of sports, while only 1/9 in standard group returned to preinjury level of pain. 12 weeks for both groups, 15 months for decline squat group only. 8 men 1 woman, average age 22, in standard eccentric squat group, and 5 men 3 women, average age 28, in decline eccentric squat group. Both groups did eccentric squats 3 sets of 15 reps twice per day, flexing the knee to 90 degrees. Standard squat group did their eccentric squats with foot flat on the ground while declined group had foot on 25 degree decline board intending to increase quadriceps activity and to lessen calf, glute and hamstring activity. Most subjects appeared to be athletic, participating in a variety of sports but study did not detail time off of protocol for return to activity in either group. Results would indicate that you do want to isolate the quadriceps to ensure other muscles are not doing all the work.
A randomised clinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper’s knee in athletes: pilot study. Cannell LJ, Taunton JE, Clement DB, Smith C, Khan KM. Br J Sports Med. 2001 Feb;35(1):60-4. Patellar tendinopathy VAS. Over 12 weeks pain dropped 2.3 points (36%) in the leg extension/curl group and 3.2 points (57%) in the squat group. 9/10 in the drop squat group returned to sports but 5 still had low level pain. 6/9 of the leg extension/curl group returned to sports 4 of which still had low level pain. 6 and 12 weeks 7 males and 3 females in the drop squat group, average age 26. 6 males and 3 females in the leg extension/curl group, average age 26. Squat group did 3 sets of 20 bilateral drop squats once a day 5 days per week for 12 weeks. Starting from a standing position they unlocked their knees and dropped rapidly until thighs were just short of parallel to the ground, starting with body weight and adding resistance when easy, appears they rose back to standing with concentric leg activity so not a pure eccentric program. Leg extension/curl group did 3 sets of 10 reps, once a day 5 days per week, instructed to lift slowly, hold weight 2 seconds at top, with entire rep to take 5 seconds. They started with 5 kg and increased resistance when they could do 3 sets of 10 with that weight. “Once the subject’s knee pain was completely absent, he/she began an alternate day running program beginning with 1 km in running athletes and increasing by 1 km every third run…” Both groups had improved function and decreased pain. The drop squats were intended to increase eccentric activity but both groups included concentric and eccentric action.
Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia. Svernlov B, Adolfsson L. Scand J Med Sci Sports. Dec 2001;11(6):328-334. Lateral Epicondylitis VAS at rest, palpation, resistance, middle finger, grip but data not given between groups. Slight edge given to eccentric group over stretching but results poorly reported and follow up so far out that difficult to determine if either group better off than if no treatment. Also eccentric protocol so low in resistance, reps, and slow of progression as to be of doubtful efficacy. 3 months, 6 months, 1 year Eccentric group 13 men & 2 women, ave age 42. Stretch group 9 women 6 men, ave age 43. Eccentric group did warm up, static stretches, 3 sets of 5 reps of eccentric reverse wrist curls starting with 1kg for men and 0.5kg women adding 10% per week, exercise performed once daily “No change in usual working or training activities was prescribed; instead all patients were encouraged to use the affected arm as much as pain allowed.” “Previous steroid injections associated with inferior results.”
Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Mafi N, Lorentzon R, Alfredson H. Knee Surg Sports Traumatol Arthrosc. 2001;9(1):42-47. Mid portion tendinitis (2-6 cm above insertion) VAS during running or walking, 82% of eccentric group returned to previous activity level (PAL) with VAS decreasing from 69 to 12, of those that did not return to PAL VAS decrease to 44. 36% of concentric group achieved PAL with VAS decreased from 63 to 9, while non-responders went to 60. 12 weeks Eccentric group 12 men & 10 women, ave age 48 . Concentric group 12 men 10 women, ave age 48. Eccentric: 2 exercises (one with knee straight and one with knee bent) 3×15 each, 2 x per day, 7 days per week for 12 weeks, starting with full body weight on one leg, train with pain unless “disabling”, no indication of varied speed. Concentric: 2 to 3 sets of 15-20 repetitions of concentric calf raises with theraband, seated calf raises without resistance, standing heel raises, step ups on a bench, jump rope and lateral hops. Higher impact/functional exercises added after 4 weeks. Running allowed to continue if “with only mild discomfort and no pain.” “The patients were instructed to start jogging or walking activity at a slow pace, on flat ground, and for a short distance. Thereafter their activity could be gradually increased if there was no severe pain in the tendon. Concentric group did not seem to be as steady or structured as program as the eccentric group. Not so sure about 48 year old patients jumping rope.
Eccentric overload training for patients with chronic Achilles tendon pain–a randomised controlled study with reliability testing of the evaluation methods. Silbernagel KG, Thomeé R, Thomeé P, Karlsson J. Scand J Med Sci Sports. 2001 Aug;11(4):197-206.



Mid portion tendinitis (2-6 cm above insertion) Tested ROM, functional tests, pain, yes or no follow up questions. Both groups improved over time but the experimental results were better. At one year 12/20 felt fully recovered while control group 4/17 were fully recovered. 12 week exercise program, assessed at 6 weeks, 3 months, 6 months, and follow up questions at 1 year. 30 tendons in experimental group, 27 in control group, average age 47 and 41 respectively. All groups included some stretch and body weight concentric and eccentric calf raises. Eccentric group was allowed to train though pain of up to 5/10, while control group avoided pain. Eccentric group ramped up repetitions as symptoms would allow but no additional resistance was added beyond body weight. Frequency varied from 3x per day to every other day, progressing to lesser frequency as time progressed. Control group did concentric and eccentric calf raises but only progressed to 3 sets of 5 reps. Largely active group, more than half were joggers, and several others were active in other sports. Both groups improved, but neither did so in a stunning manner. The eccentric group did do better but exercise intensity and duration was also more so one can not determine if changes are due to the eccentric nature of the exercise, or the amount of exercise. Exercising with pain up to 5/10 was clearly not detrimental in comparison to pain free exercise. Even eccentric exercise group intensity was relatively light as they never added external resistance beyond body weight
Treatment of recurrent tendinitis by isokinetic eccentric exercise. Croisier J-L, Forthomme B, Foidart-Dessalle M, Godon B, Crielaard J-M. Isokinetics and Exercise Science. 2001;9:133-141. 9 Achilles, 10 patellar, and 15 lateral epicondyllar 15/34 patients had complete relief of symptoms, 10/34 had marked decrease in symptoms, 5/34 had moderate decrease in symptoms, and 4/34 had no change in symptoms. After 20 to 30 sessions, which should be ~7-10 weeks. Follow up for return to sporting activities was “after 3 months of practice”. 34 patients, 9 Achilles, 10 patellar and 15 epicondyllar. No blinding and no control group. Isokinetic eccentric exercise 3x per week, 1-5 sets of 10-30 reps, increasing speed and intensity over time. 20-30 sessions. Comanaged with ice, TENS, ultrasound, massage and stretching. “Subjects were instructed to avoid provoking pain or discomfort in the course of activities between training sessions.” Reported they generally noted a significant decrease in pain by the 10th session. Did exercises just 3x per week to good effect. Found roughly the same effectiveness regardless of tendinitis type.
Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Alfredson H, Pietila T, Jonsson P, R. L. Am J Sports Med. 1998;26(3):360-366. Mid portion tendinitis (2-6 cm above insertion) VAS while running (81.2 to 18.0) Worked, 15/15 back to full running program 12 weeks 15 recreational athletes, ave age 44 2 exercises (one with knee straight and one with knee bent) 3×15 each, 2 x per day, 7 days per week for 12 weeks, starting with full body weight on one leg, train with pain unless “disabling”, no indication of varied speed Running allowed to continue if “with only mild discomfort and no pain.”
Evaluation of eccentric exercise in treatment of patellar tendinitis. Jensen K, Di Fabio RP.  Phys Ther. 1989 Mar;69(3):211-6. Patellar tendinopathy Strength tested with eccentric contractions on KIN/COM dynamometer and VAS scores both resting and during activity. Normal subjects gained more strength (23%) than tendinitis group also increased strength but it was not statistically significant, noting that while strength did increase, the pain may limit work loads, which thereby hinders strength increases. Though they tested pain levels they did not report how pain changed over the course of the treatment in any group. 8 weeks 31 subjects, 15 female, 16 male aged 21-45 years. 15 had patellar tendinopathy and 16 were normal controls. Subjects were divided into 4 groups, normal and tendinitis groups with home stretches only and normal and tendinitis groups with the addition of isokinetic eccentric exercises done 3 times per week on KIN/COM dynamometer for 8 weeks progressing from 30 degrees per second to 70 degrees per second. Six sets of 5 reps were done in week one, 8 sets of 5 week 2 and 12 sets of 5 week 3-8. No mention. Noted the Curwin and Stanish theory, suggesting that eccentric exercise would better prepare the patient to withstand the higher forces of eccentric contractions during sports or ADLs with the theory it was these contractions that cause the damage to the tendon, they cited the 1973 Komi study on force velocity curves which is not on Medline. Difficult to determine much from this study as the results were not given in very clear format, the protocol was only 8 weeks long and the exercises were done 3 times per week with sets of only 5 repetitions.
Eccentric exercise in chronic tendinitis. Stanish WD, Rubinovich RM, Curwin S.

Clin Orthop Relat Res. 1986 Jul;(208):65-8.

Nonspecific tendinitis “44% of patients had complete relief of pain and function impairment, 43% had a marked decrease in symptoms (complaining of mild pain after athletic activities), 9% had virtually no change in their clinical state, and 2% were worse after the exercise program.” 16 months 200 patients with tendinitis lasting 18 months, failed prior physical therapy and had at least 3 corticosteroid injections 6 week program, 3 sets of 10 reps, 1x per day, slow speed, medium speed, then fast speed, then add resistance. No mention. Oldest of the research. No control, not very well described. 6 week program, but mean follow up was not until 16 months after the initiation of treatment.