VOLUME 12.

1, 2016

D.O.I: http: doi.org/10.4127/jbe.2016.0097

Stasinopoulos Dimitrios (PhD)1, Peter Malliaras2

1
Vice-Chairperson / Assistant Professor, Physiotherapy, Coordinator of MSc in
Sports Physiotherapy
Coordinator of Physiotherapy Program, Director of Cyprus Musculoskeletal and
It is time to abandon the myth that eccentric

Sports Trauma Research Centre (CYMUSTR EC) Physiotherapy Program, Dep. of

Health Sciences, School of Sciences, Nicosia, Cyprus
1
Research Fellow, Musculoskeletal Research Centre, La Trobe University, Aus-
tralia
Visiting Senior Lecturer, Centre for Sport and Exercise Medicine, Queen Mary,
University of London, UK

Achilles and patellar tendinopathy are the most common

tendinopathies of the lower limb. The main complaints of
patients with tendinopathy are pain and decreased function
both of which may affect daily activities. Diagnosis is based
on defining pain features (e.g. localized pain) as well as
training is best practice.

reproducing pain with specific clinical tests and palpation.

Although the signs and symptoms of tendinopathy are relatively
clear, to date, no ideal treatment has emerged. Many clinicians
advocate a conservative approach as the treatment of choice for
tendinopathy. For example, many physical therapy strategies
have been proposed for the rehabilitation of tendon disorders.
These include electrotherapy such as therapeutic ultrasound,
extracorporeal shockwave therapy, low level laser, iontophoresis
and non-electrotherapeutic modalities such as exercise, soft
tissue techniques, taping and dry needling or acupuncture.
These treatments aim to reduce pain and improve function in
tendinopathy via different mechanism of action. There is no
evidence that any treatment is able to reverse the pathology of
the tendinopathy. Such a variety of treatment options suggests
that the optimal treatment strategy is not known, and more
research is needed to discover the most effective treatment in
patients with tendinopathy.
16 JBE – VOL. 12.1, 2016

Nowadays, eccentric training of the “injured” tendon is the most commonly

used conservative approach in the treatment of tendinopathy. It was first proposed
by Alfredson et al. (1) who advocate 3 sets of 15 repetitions of eccentric exercises
at a slow speed twice daily, 7 days/week, for 12 weeks. The patients are advised
that tendon soreness during the first weeks of training is to be expected. In the
beginning, only body weight is used to load the tendon, isolating the eccentric
component by using the non-injured leg to return to the start position. Patients
are advised to continue even if they experience pain, unless the pain becomes
disabling. If the subjects could perform the eccentric loading exercise without
experiencing any minor pain or discomfort, they are instructed to increase the
load by adding weight.
Previous systematic reviews have evaluated the evidence for eccentric loading
of the injured tendon in tendinopathy, concluding that outcomes are promising
but high-quality evidence is lacking (10, 20, 24). Furthermore, eccentric training
of the injured tendon alone is not effective for many patients with tendinopathies
(6). Therefore, eccentric training of the injured tendon is combined with static
stretching exercises of the injured tendon in the treatment of tendinopathies as
it was first proposed by Stanish et al (28). In the Stanish exercise program, the
patients perform a program consisting of five steps. The first step is a general,
whole-body warm up exercise. The second step is static stretching exercises for
the «injured» tendon. Next, 3 sets of 10 repetitions of the eccentric exercises are
carried out once daily for six weeks and after six weeks, the patients are instructed
to carry out 3 sets of 10 repetitions, three times per week for six more weeks. The
intensity of the exercise should be such that pain, or discomfort, is experienced
in the last set of 10 repetitions. The progression of eccentric training is shown in
Table 1. Every session ends with the same static stretch exercise as in the step 2.
The patients are also instructed to use ice on the «injured» tendon for 5 - 10 min
after the program. There is lack of evidence to investigate the effectiveness of the
Stanish exercise protocol in the management of tendinopathy.
Only one pilot trial compared the above two reported protocols in Achilles
tendinopathy in recreational athletes who were between 35 and 55 years old
(29). The Alfredson exercise program was superior to Stanish exercise program
reduced pain and improved function at the end of the treatment and at six month
follow-up. The superiority of Alfredson exercise program can be explained by two
mainly reasons: Firstly, the load of eccentric exercises in the Alfredson exercise
protocol was increased according to the patients’ symptoms otherwise the results
are poor (11) and secondly eccentric exercises in the Alfredson exercise protocol
were performed at a low speed in every treatment session because this allows
tissue healing (15).
Studies have shown positive results in the treatment of tendon injuries of
upper limb (Lateral elbow Tendinopathy) using eccentric training as described
It is time to abandon the myth that eccentric training is best practice 17

by Alfredson and static stretching exercises as described by Stanish (19, 30, 31).
Well – designed trials are needed for lower limb tendinopathies to investigate
whether the results can be better when the patients who undergo the Alfredson
eccentric exercise protocol also undertake static stretching exercises as described
by Stanish before and after the eccentric exercise program.
Malliaras and his colleagues (17) performed a systematic review of studies
comparing two or more loading programs in Achilles and patellar tendinopathy.
They concluded that clinicians should consider eccentric-concentric loading
alongside or instead of eccentric loading. A Heavy Slow Resistance (HSR) program
is recommended in the management of lower limb tendinopathy (4, 13). The HSR
program is performed 3 times per week using resistance equipment in a fitness
center. Each session consists of three 2-legged loaded quadriceps and lower limb
kinetic chain exercises. The patients complete 3 or 4 sets in each exercise with a 2-
to 3-minute rest between sets and a 5-minute rest period between the 3 exercises.
The number of repetitions decreases, and load gradually increases, every week.
The repetitions and loads are as follows: 3 times, 15-repetition maximum (15RM), in
week 1; 3 times, 12RM, in weeks 2 to 3; 4 times, 10RM, in weeks 4 to 5; 4 times, 8RM,
in weeks 6 to 8; and 4 times, 6RM, in weeks 9 to 12. All exercises are performed in
the full range of motion of ankle joint for Achilles midportion? tendinopathy and until
90o of flexion for patellar tendinopathy. Patients are instructed to spend 3 seconds
completing each eccentric and concentric phase (ie, 6 seconds per repetition).
The HSR program was produced equivalent pain and function improvement (VISA)
than the Alfredson eccentric program, but significantly better patient satisfaction
at six month follow–up. This clinical improvement was accompanied by increased
collagen turnover in the HSR group. In the Achilles tendon, eccentric and HSR
have recently been shown to yield similar clinical outcomes (VISA and patient
satisfaction) at 1 year follow up. Based on the above findings, the HSR program
can be recommended as an alternative to the Alfredson eccentric program lower
limb tendinopathy rehabilitation.
The question that arises is whether HSR program is effective for all patients with
lower limb tendinopathy and for all sites of Achilles and Patellar tendinopathy? It
is seems that HSR program is recommend for young active people. In addition,
research has shown that different sites of Achilles tendinopathy are managed
with different protocols of eccentric exercises. For example, eccentric training
with dorsiflexion is effective for patients with mid-portion Achilles tendinopathy
(1, 16, 21, 23, 25) but eccentric training without dorsiflexion has positive effects
on patients with insertional Achilles tendinopathy (12). As mentioned above, all
exercises in HSR are performed in the full range of motion of ankle joint for Achilles
tendinopathy. Therefore, HSR may not to be an effective approach for insertional
Achilles tendinopathy unless range of motion is modified. Squat is an effective
treatment approach when the patellar tendinopathy is at the inferior pole of the
18 JBE – VOL. 12.1, 2016

patella; however, no studies have investigated the effectiveness of training on

other sites of patellar tendinopathy. Thus, studies determining the effectiveness of
exercises at other sites of patellar tendinopathy are needed.
Recently, isometric exercises have been recommended to reduce and manage
patellar tendon pain (2) and initiate muscle-tendon unit loading when pain limits
the ability to perform isotonic exercises (7). Five repetitions of 45-second isometric
mid-range quadriceps exercise at 70% of maximal voluntary contraction have
been shown to reduce patellar tendon pain for 45 minutes post exercise and this
was also associated with a reduction in motor cortex inhibition of the quadriceps
that was associated with patellar tendinopathy (22). It is our belief that isometric
contraction is more effective with the knee near extension unless the patient has
fat pad syndrome. The dosage will depend upon individual factors but evidence
and clinical experience suggests performing 5 repetitions of 45 seconds hold, 2-3
times per day, with 2 minutes rest between holds to allow recovery (18). Isometric
evidence is currently limited to the patellar tendon.
Thus, rehabilitation of lower limb tendinopathy is changing and now eccentric
training is not the only exercise option. Isometric, concentric-eccentric, stretching
- eccentric and isolated eccentric loading may be indicated depending on factors
multiple factors such as pain, function, age, site of tendinopathy, access to
equipment, etc.
A component lacking from evidence-based programs is adequate consideration
of the kinetic chain. Poor lumbopelvic control has the potential to alter load
distribution on the lower limb kinetic chain and increase the risk of lower limb
tendinopathy. It is our belief that the improvement of lumbo-pelvic control can be
achieved by performing simple exercises such as single leg bridging in supine and
four point prone bridging exercises[8,14]. Future research is needed to confirm
this suggestion.
In addition, hip extensor weakness has been associated with patellar tendinopathy
(26). Exercises to strengthen these muscle groups should be considered in exercise
protocols and patellar tendinopathy. Functional activities such as jumping, cutting
and sprinting should also be included in lower limb tendinopoathy rehabilitation
programs among athletes, but have so far not been included in popular programs
in the literature (18, 26).
According to previous reported issues, it is time to stop strengthening the tendon
only eccentrically. The tendinopathy management should be based on a progressive
loading of the lower extremity (kinetic chain), muscle-tendon unit, and tendon itself.
However, the optimal protocol of exercise training needs to be investigated.
Finally, electrotherapeutic modalities, manual therapy techniques, bracing/
taping and acupuncture have also been recommended in the management of
tendinopathy. There is minimal experimental evidence to support the efficacy of
the use of the above approaches for the management of tendinopathy (3, 5, 9, 27).
It is time to abandon the myth that eccentric training is best practice 19

The above recommended therapies should not be substitute but instead an adjunct
to an exercise program. Further research is needed to find out which treatment
strategy, if exists a treatment strategy, combined with progressive exercise training
will provide the best results in the rehabilitation of tendinopathy.
Writing this article it is not our intention to increase the knowledge of physiothera­
pists but to generate questions about why they do not use the same treatment
protocol for the management of all lower limb tendinopathies. It is believed that
even if an exercise program is found for the management of all tendinopathies of the
lower limb, this program will not be used as a sole treatment.

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Address for correspondence:

Stasinopoulos Dimitrios (PhD)
Vice-Chairperson/ Assistant Professor, Physiotherapy
Physiotherapy Program,
Dep. of Health Sciences, School of Sciences
Coordinator of MSc in Sports Physiotherapy
Coordinator of Physiotherapy Program
6, Diogenes Str. Engomi, P.O.Box 22006, 1516, Nicosia, Cyprus
Τel. +35722713044 [f] +35722713013
D.Stassinopoulos@euc.ac.cy [w] www.euc.ac.cy
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