Håkan Alfredson

Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis

We prospectively studied the effect of heavy-load eccentric calf muscle training in 15 recreational athletes (12 men and 3 women; mean age, 44.3 7.0 years) who had the diagnosis of chronic Achilles tendinosis (degenerative changes) with a long duration of symptoms despite conventional nonsurgical treatment. Calf muscle strength and the amount of pain during activity (recorded on a visual analog scale) were measured before onset of training and after 12 weeks of eccentric training. At week 0, all patients had Achilles tendon pain not allowing running activity, and there was significantly lower eccentric and concentric calf muscle strength on the injured compared with the noninjured side. After the 12-week training period, all 15 patients were back at their preinjury levels with full running activity. There was a significant decrease in pain during activity, and the calf muscle strength on the injured side had increased significantly and did not differ significantly from that of the noninjured side. A comparison group of 15 recreational athletes with the same diagnosis and a long duration of symptoms had been treated conventionally, i.e., rest, nonsteroidal antiinflammatory drugs, changes of shoes or orthoses, physical therapy, and in all cases also with ordinary training programs. In no case was the conventional treatment successful, and all patients were ultimately treated surgically. Our treatment model with heavy-load eccentric calf muscle training has a very good short-term effect on athletes in their early forties.

Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up

Objective: To prospectively investigate tendon thickness and tendon structure by ultrasonography in patients treated with eccentric calf muscle training for painful chronic Achilles tendinosis located at the 2–6 cm level in the tendon. Methods: The patients were examined with grey scale ultrasonography before and 3.8 years (mean) after the 12 week eccentric training regimen. At follow up, a questionnaire assessed present activity level and satisfaction with treatment. Results: Twenty six tendons in twenty five patients (19 men and six women) with a mean age of 50 years were followed for a mean of 3.8 years (range 1.6–7.75). All patients had a long duration of painful symptoms (mean 17.1 months) from chronic Achilles tendinosis before treatment. At follow up, 22 of 25 patients were satisfied with treatment and active in Achilles tendon loading activities at the desired level. Ultrasonography showed that tendon thickness (at the widest part) had decreased significantly (p<0.005) after treatment (7.6 (2.3) v 8.8 (3) mm; mean (SD)). In untreated normal tendons, there was no significant difference in thickness after treatment (5.3 (1.3) mm before and 5.9 (0.8) mm after). All tendons with tendinosis had structural abnormalities (hypoechoic areas and irregular structure) before the start of treatment. After treatment, the structure was normal in 19 of the 26 tendons. Six of the seven patients with remaining structural abnormalities experienced pain in the tendon during loading. Conclusions: Ultrasonographic follow up of patients with mid-portion painful chronic Achilles tendinosis treated with eccentric calf muscle training showed a localised decrease in tendon thickness and a normalised tendon structure in most patients. Remaining structural tendon abnormalities seemed to be associated with residual pain in the tendon.

Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment

Background: The mechanism that causes pain in chronic Achilles tendinosis is not known. However, high resolution colour Doppler ultrasound has shown that neovascularisation may be involved. Objective: To investigate if sclerosing the neovessels would affect the level of tendon pain. Methods: The effect of colour Doppler ultrasound guided injection of a sclerosing agent, polidocanol, against neovessels was studied in 10 patients (seven men and three women, mean age 55 years) with painful chronic mid-portion Achilles tendinosis. Results: Eight patients were satisfied with the results of treatment. There was significantly reduced pain during activity (reported on a visual analogue scale (VAS)) and no remaining neovascularisation after an average of two injections. Two patients were not satisfied, and neovascularisation remained. At the six month follow up, the same eight patients remained satisfied and could perform Achilles tendon loading activities as desired. Their VAS score had decreased from 74 before treatment to 8 (p<0.01). Conclusions: Sclerosing neovessels appears to be an effective treatment for painful chronic Achilles tendinosis, suggesting that neovessels play a key part in causing chronic tendon pain.

Chronic Achilles tendinosis: recommendations for treatment and prevention.

Chronic Achilles tendinosis is a condition with an unknown aetiology and pathogenesis that is often, but not always, associated with pain during loading of the Achilles tendon. Histologically, there are no inflammatory cells, but increased amounts of interfibrillar glycosaminoglycans and changes in the collagen fibre structure and arrangement are seen. In situ microdialysis has confirmed the absence of inflammation. It is a condition that is most often seen among recreational male runners aged between 35 and 45 years, and it is most often considered to be associated with overuse. However, this condition is also seen in patients with a sedentary lifestyle.Chronic Achilles tendinosis is considered a troublesome injury to treat. Nonsurgical treatment most often includes a combination of rest, NSAIDs, correction of malalignments, and stretching and strengthening exercises, but there is sparse scientific evidence supporting the use of most proposed treatment regimens. It has been stated that, in general, nonsurgical treatment is not successful and surgical treatment is required in about 25% of patients. However, in a recent prospective study, treatment with heavy load eccentric calf muscle training showed very promising results and may possibly reduce the need for surgical treatment of tendinosis located in the midportion of the Achilles tendon.The short term results after surgical treatment are frequently very good, but in the few studies with long term follow-up there are signs of a possible deterioration with time. Calf muscle strength takes a long time to recover and, furthermore, a prolonged progressive calcaneal bone loss has been shown on the operated side up to 1 year after surgical treatment.

Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players

Background: Conservative treatment of patellar tendinopathy has been minimally investigated. Effective validated treatment protocols are required. Objectives: To investigate the immediate (12 weeks) and long term (12 months) efficacy of two eccentric exercise programmes for the treatment of patellar tendinopathy. Methods: This was a prospective randomised controlled trial of 17 elite volleyball players with clinically diagnosed and imaging confirmed patellar tendinopathy. Participants were randomly assigned to one of two treatment groups: a decline group and a step group. The decline group were required to perform single leg squats on a 25° decline board, exercising into tendon pain and progressing their exercises with load. The step group performed single leg squats on a 10 cm step, exercising without tendon pain and progressing their exercises with speed then load. All participants completed a 12 week intervention programme during their preseason. Outcome measures used were the Victorian Institute of Sport Assessment (VISA) score for knee function and 100 mm visual analogue scale (VAS) for tendon pain with activity. Measures were taken throughout the intervention period and at 12 months. Results: Both groups had improved significantly from baseline at 12 weeks and 12 months. Analysis of the likelihood of a 20 point improvement in VISA score at 12 months revealed a greater likelihood of clinical improvements in the decline group than the step group. VAS scores at 12 months did not differ between the groups. Conclusions: Both exercise protocols improved pain and sporting function in volleyball players over 12 months. This study indicates that the decline squat protocol offers greater clinical gains during a rehabilitation programme for patellar tendinopathy in athletes who continue to train and play with pain.

Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis?

The background to the good clinical results reported using painful eccentric calf-muscle training as treatment for chronic painful mid-portion Achilles tendinosis is not known. Recently, using ultrasound and colour Doppler technique, we showed that painful tendinosis was associated with a local neovascularisation. Furthermore, in a pilot study, destroying these neovessels by sclerosing therapy cured the pain in most patients. Dynamic ultrasound and colour Doppler examination has shown that the flow in the neovessels stops during dorsiflexion in the ankle joint. Therefore, it was of interest to study the occurrence of neovascularisation before and after eccentric training. Forty-one tendons in 30 patients (22 men and 8 women, mean age 48 years) with chronic painful mid-portion Achilles tendinosis were examined with ultrasonography and colour Doppler, before and after 12 weeks of eccentric calf-muscle training. Before treatment, there was a local neovascularisation in the area with tendon changes (hypo-echoic areas, irregular fibre structure) in all tendons. 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. In conclusion, in patients with chronic painful mid-portion Achilles tendinosis, a good clinical result after eccentric training seems to be associated with a more normal tendon structure and no remaining neovascularisation. Action on the area with neovessels during the eccentric training regimen might possibly be responsible for the good clinical results.

In situ microdialysis in tendon tissue : high levels of glutamate, but not prostaglandin E2 in chronic Achilles tendon pain

Abstract This investigation was to our knowledge the first to use the microdialysis technique to study concentrations of substances in a human tendon. In four patients (mean age 40.7 years) with a painful nodule in the Achilles tendon (chronic Achilles tendinosis) and in five controls (mean age 37.2 years) with normal Achilles tendons (confirmed by ultrasonography) the local concentrations of glutamate and prostaglandin E2 were measured under resting conditions. A standard microdialysis catheter was inserted into the Achilles tendon under local anesthesia. Sampling was performed every 15 min over a 4-h period. The results showed significantly higher concentrations of glutamate in tendons with tendinosis than in normal tendons (196 ± 59 vs. 48 ± 27 μmol/l, P < 0.05), and there were no significant changes in glutamate concentration over the period of investigation. There were no significant differences in the mean concentrations of prostaglandin E2 (83 ± 22 vs. 54 ± 24 pg/ml) between tendons with tendinosis and normal tendons. In conclusion, in situ microdialysis appears a useful method to study certain metabolic events in tendon tissue. The higher concentrations of the excitatory neurotransmitter glutamate in Achilles tendons with a painful nodule may possibly be involved in the pain mechanism in this chronic condition. Furthermore, there were no signs of inflammation in the tendons with painful nodules, as indicated by the normal prostaglandin E2 levels.

In vivo microdialysis and immunohistochemical analyses of tendon tissue demonstrated high amounts of free glutamate and glutamate NMDAR1 receptors, but no signs of inflammation, in Jumper's knee.

This investigation describes, to our knowledge, the first experiment where the microdialysis technique was used to study certain metabolic events in human patellar tendons in combination with immunohistochemical analyses of tendon biopsies. In five patients (four men and one woman) with a long duration (range 12‐36 months) of pain symptoms from Jumpers knee (localized tenderness in the patellar tendon verified as tendon changes with ultrasonography or MRI), and in five controls (four men and one woman) with normal patellar tendons, a standard microdialysis catheter was inserted into the patellar tendon under local anestesia. The local concentrations of glutamate (excitatory neurotransmitter) and prostaglandin E2 (PGE2) were registered under resting conditions. Samplings were done every 15 min during a 2 h period. In all individuals (patients and controls) biopsies were taken for immunohistochemical analyses.

A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy

Objectives: This non-randomised pilot study investigated the effect of eccentric quadriceps training on 17 patients (22 tendons) with painful chronic patellar tendinopathy. Methods: Two different eccentric exercise regimens were used by subjects with a long duration of pain with activity (more than six months). (a) Nine consecutive patients (10 tendons; eight men, one woman; mean age 22 years) performed eccentric exercise with the ankle joint in a standard (foot flat) position. (b) Eight patients (12 tendons; five men, three women; mean age 28 years) performed eccentric training standing on a 25° decline board, designed to increase load on the knee extensor mechanism. The eccentric training was performed twice daily, with three sets of 15 repetitions, for 12 weeks. Primary outcome measures were (a) 100 mm visual analogue scale (VAS), where the subject recorded the amount of pain during activity, and (b) return to previous activity. Follow up was at 12 weeks, with a further limited follow up at 15 months. Results: Good clinical results were obtained in the group who trained on the decline board, with six patients (nine tendons) returning to sport and showing a significantly reduced amount of pain over the 12 week period. Mean VAS scores fell from 74.2 to 28.5 (p  =  0.004). At 15 months, four patients (five tendons) reported satisfactory results (mean VAS 26.2). In the standard squat group the results were poor, with only one athlete returning to previous activity. Mean VAS scores in this group were 79.0 at baseline and 72.3 at 12 weeks (p  =  0.144). Conclusion: In a small group of patients with patellar tendinopathy, eccentric squats on a decline board produced encouraging results in terms of pain reduction and return to function in the short term. Eccentric exercise using standard single leg squats in a similar sized group appeared to be a less effective form of rehabilitation in reducing pain and returning subjects to previous levels of activity.

The chronic painful Achilles and patellar tendon : research on basic biology and treatment.

The etiology and pathogenesis of chronic tendon pain are unknown. Even though tendon biopsies having shown an absence of inflammatory cell infiltration, anti‐inflammatory agents (non‐steroidal anti‐inflammatory drugs, corticosteroidal injections) are commonly used. We have demonstrated that it is possible to use intratendinous microdialysis to investigate human tendons, and found normal prostaglandin E2 (PGE2) levels in chronic painful tendinosis (Achilles and patellar) tendons. Furthermore, gene technological analyses of biopsies showed no upregulation of pro‐inflammatory cytokines. These findings show that there is no PGE2‐mediated intratendinous inflammation in the chronic stage of these conditions. The neurotransmitter glutamate (a potent modulator of pain in the central nervous system) was, for the first time, found in human tendons. Microdialysis showed significantly higher glutamate levels in chronic painful tendinosis (Achilles and patellar) tendons, compared with pain‐free normal control tendons. The importance of this finding is under evaluation. Treatment is considered to be difficult, and not seldom, surgery is needed. However, recent researches on non‐surgical methods have shown promising clinical results. Painful eccentric calf‐muscle training has been demonstrated to give good clinical short‐ and mid‐term results on patients with chronic painful mid‐portion Achilles tendinosis. Good clinical results were associated with decreased tendon thickness and a structurally more normal tendon with no remaining neovessels. Using ultrasonography (US)+color Doppler (CD), and immunhistochemical analyses of biopsies, we have recently demonstrated a vasculo/neural (Substance‐P and Calcitonin Gene‐Related Peptide nerves) ingrowth in the chronic painful tendinosis tendon, but not in the pain‐free normal tendon. A specially designed treatment, using US‐ and CD‐guided injections of the sclerosing agent Polidocanol, targeting the neovessels outside the tendon, has been shown to cure tendon pain in pilot studies, in a majority of the patients. A recent, randomized, double‐blind study verified the importance of injecting the sclerosing substance Polidocanol.