Article Summary: Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial.

Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial.

Population: 58 patients with chronic (> 3 months) mid-portion achilles tendinopathy.  Randomized to one of two loading programs for a total of 12 weeks with a 52 week follow up.

Eccentric Loading Program:

Exercise	Sets	Reps	Rest	Pace
Straight Leg Heel Raises on Step	3	15	2 minutes	3” per rep
Rest 5 minutes
Bent Knee Heel Raises on Step	3	15	2 minutes	3” per rep

Perform 2x/day, 7 days per week for 12 weeks

As exercises become easier you can progress by adding a loaded backpack

• Start with approximately 10% body weight (BW) and increase by 10% BW as tolerated, no more than 1x/week

Heavy Slow Resistance Program:

Exercise	Week 1	Week 2-3	Week 4-5	Week 6-8	Week 9-12	Pace
Seated Bent Knee Heel raises	3x15 RM	3x12 RM	4x10 RM	4x8 RM	4x6 RM	3” concentric / 3” eccentric 2-3 minutes rest between exercises
5’ Rest
Seated Leg Press Heel Raises (knees straight)	3x15 RM	3x12 RM	4x10 RM	4x8 RM	4x6 RM
5’ Rest
Standing Smith Machine Heel Raises (knees straight)	3x15 RM	3x12 RM	4x10 RM	4x8 RM	4x6 RM

Results:

HSR Showed slightly better improvements in 

• VAS - Running
• 54 -> 5 compared to 49 -> 12
• VAS - Heel rise (less significant difference compared to running)
• 29 -> 5 compared to 19 -> 6
• 10 point difference at baseline may be significant
• VISA-A: 
• 54 -> 89 compared to 58 -> 84
• A-P diameter
• 8.6mm -> 6.9 mm compared to 8.3mm -> 7.3mm
• Doppler % (higher doppler signals correlated with poorer clinical outcomes, though reliability of doppler is questionable and exercise tends to decrease accuracy. Subjects were instructed not to exercise for 24 hours before doppler was performed)
• 4.0% -> 1.0% compared to 2.8% -> 1.6%
• No change at 12 weeks in ECC, 4.0 -> 2.0 in HSR.
• Patient satisfaction: 
• 100% compared to 80% at 12 weeks (p = .052)
• 96% compared to 76% at 52 weeks (p = .01)

Author’s Conclusion: “The results of this study show that both traditional ECC and HSR yield positive, equally good, lasting clinical results in patients with Achilles tendinopathy and that the latter tends to be associated with greater patient satisfaction after 12 weeks but not after 52 weeks.”

My Conclusion: Though statistically speaking, there is little difference between the groups, there was a consistent trend for the HSR group to show greater improvement on all measures. Even if the results were not considered significant, the fact that better improvements were able to be achieved with HSR is enough for me to make that my first line of defense in patients with chronic mid-portion achilles tendinopathy.

Citation:

Beyer, Rikke, et al. "Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial." The American journal of sports medicine 43.7 (2015): 1704-1711.