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JSM Foot and Ankle
Case Report *Corresponding author
Stasinopoulos Dimitrios, Department of Health Sciences,

The Effectiveness of Eccentric- School of Sciences, Diogenes Str. Engomi, Nicosia,

Cyprus, Email:

Concentric Training and Isometric

Submitted: 25 August 2017
Accepted: 06 September 2017
Published: 08 September 2017

Contractions on Pain and Disability ISSN: 2475-9112

Copyright

in Achilles Tendinopathy: A Case

© 2017 Dimitrios

OPEN ACCESS

Report Keywords
• Isometric contractions
• Pain
Stasinopoulos Dimitrios* • Disability
Department of Health Sciences, School of Sciences, Cyprus • Achilles tendinopathy

Abstract
Purpose: Many patients with Achilles Tendinopathy do not respond to eccentric training. The aim of the present case report is to find out the effect of
eccentric - concentric training of gastrocnemius and soleus combined with isometric contraction of gastrocnemius and static stretching exercises of gastrocnemius
and soleus on pain and disability in a patient experiencing Achilles Tendinopathy.
Methods: A patient with unilateral Achilles Tendinopathy for 6 months was included in the present study. The patient followed a supervised exercise five
times per week for 6 weeks consisting of, isometric gastrocnemius exercise, and slow progressive eccentric - concentric training of gastrocnemius and soleus and
static stretching exercises of gastrocnemius and soleus. The programme was individualized on the basis of the patient’s description of pain experienced during
the procedure. The VICTORIAN INSTITUTE OF SPORTS ASSESSMENT – ACHILLES QUESTIONNAIRE was used to evaluate the patient at baseline, at the end of
treatment (week 6), and 1 month (week 10) after the end of treatment.
Results: At the end of the treatment and at the follow – up there was a decrease in pain and an increase in function.
Conclusions: The results of the present study suggest that the combination of isometric gastrocnemius exercise, slow progressive eccentric - concentric
training of gastrocnemius and soleus and static stretching exercises of gastrocnemius and soleus can produce significant improvements in terms of pain and
disability in Achilles Tendinopathy.

INTRODUCTION
Achilles Tendinopathy (AT) is one of the two most common
tendinopathies of the lower limb. It is appeared not only among
athletes but also in non-athletes. AT is characterized by an
increased presence of fibroblasts and disorganized collagen
and the absence of prostaglandins and inflammatory cells [1].
Therefore, this condition is a degenerative and not inflammatory
as originally thought. Therefore, the term Achilles tendonitis
is incorrect for diagnosis [2]. The term Achilles tendinosis is
suitable for diagnosis [2]. However, the best clinical diagnostic
term is the term AT [3].
Intrinsic factors such as misalignment, inflexibility and/or
muscle weakness and extrinsic factors such as training errors,
sport technique, inappropriate footwear, are the main factors
that lead to AT [4]. Diagnosis is based on reproducing pain with
palpation specific and clinical tests as well as defining pain
features (e.g. localized pain) [5]. Mid – portion AT presents with
pain 2-6 cm proximal to the tendon insertion, whereas insertion
AT, which is less common than mid – portion AT, presents with
pain at the insertion of the Achilles tendon [3]. Pain occurs
after exercise [6]. As the process progresses, pain occurs at the
beginning of the exercise and disappears during the exercise [6].
Later pain may occur during exercise [6]. Pain interferes with
activities of daily living in severe cases [6].
However, the ideal treatment for the management of AT
does not exist. A conservative approach is advocated by many
clinicians [3]. Therefore, physiotherapy is usually recommended.
A wide array of physiotherapy approaches has been proposed
for the management of AT such as exercise programmes, manual
techniques, electrotherapeutic/physical modalities and soft
tissue manipulation [3]. The theoretical mechanisms of action
of the above treatment is different, but all have the same aim,
improve function and to reduce pain. Such a variety of treatment
techniques suggests that the optimal management strategy is not
known, and further research is required to find the most effective
treatment in patients with AT.
One of the most common physiotherapy treatments for
AT is an exercise training. Eccentric exercise has shown good
clinical results in AT [7] as well as in conditions similar to AT
in histopathological appearance and clinical behaviour, such as
rotator cuff [8], patellar [9] and lateral elbow tendinopathy [10].

Cite this article: Dimitrios S (2017) The Effectiveness of Eccentric-Concentric Training and Isometric Contractions on Pain and Disability in Achilles Tendi-
nopathy: A Case Report. JSM Foot Ankle 2(4): 1037.

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Eccentric training is not enough for all patients with AT
[11]. 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 [12]. Furthermore, Malliaras and his colleagues [13]
concluded that clinicians should consider eccentric-concentric
loading alongside or instead of eccentric loading in lower limb
tendinopathy. Recently, isometric exercises are indicated to
reduce and manage tendon pain [14-16]. Perhaps if the eccentric-
concentric training combines to isometric contractions and static
stretching exercises of the injured tendon the success rate in the
treatment of tendinopathy will be higher.
To our knowledge, there have been no studies to investigate
the effectiveness of these kinds of contractions (concentric,
eccentric and isometric) and static stretching exercises of the
injured tendon for the management of AT. Therefore, the aim
of the present case report is to present the effect of eccentric-
concentric training combined with isometric contraction and
static stretching exercises of the injured tendon on pain and
disability in a patient experiencing AT.
CASE PRESENTATION
History
The subject was a 26-year-old male basketball player with
a six- month history of Achilles tendon pain, in his left leg.
A specialist (orthopaedic) diagnosed the AT. He has played
basketball for about ten years. The site of pain was about 4 cm
above of Achilles tendon and he complained of pain after his
training only. The pain subsided within 20 or 40 minutes after his
training. He did not complain of pain in other activities. He did not
have any problems with the other joints. He did not complain of
other symptoms such as locking, giving away, stiffness, swelling
or crepitus. He took no drugs at the time of assessment; he had no
history of trauma in the ankle before, only one hamstring strains
in the other leg. He had followed a physiotherapy rehabilitation
program following the hamstring strains. He had no prior
physiotherapy treatment for the problem in his Achilles tendon.
He did not have a history of epilepsy, cancer or diabetes and none
in his family did. He did not have any illness or operation in the
past.
Examination findings
Although the condition was diagnosed by a specialist,
the physiotherapist D. S. assessed his ankle to rule out other
conditions and confirm the diagnosis. No pain was mentioned
during posture and gait. Color changes, muscle wasting,
swelling or body deformity were not noted. In palpation, signs
of inflammation like swelling, synovial thickening and heat were
not found.
On physical examination, the low back, hip and knee
movements were pain free, with full power and full range of
motion. The active and passive movements of the ankle and
subtalar joints were normal. Muscle strength tests were normal
and no capsular pattern was found. The heel raise test also known
as calf raise or toe raise test (the patient carries out plantar
flexion from the standing position) was positive. The Thompson’s
(Simmonds) test (examiner squeeze the calf musculature
JSM Foot Ankle 2(4): 1037 (2017)
Dimitrios (2017)
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while observing for ankle plantar flexion) was negative. The
painful arc sign (thickened portion of tendon moves with active
plantar flexion and dorsiflexion of the ankle) was positive. The
compression test (examiner compress Achilles tendon and the
pain diminishes during plantar flexion and dorsiflexion) was
positive. Tenderness with palpation about 4 cm above of Achilles
tendon was found, confirming the diagnosis.
Procedure
The patient followed a supervised exercise programme
consisting of, isometric gastrocnemius exercise, slow progressive
eccentric - concentric training of gastrocnemius and soleus and
static stretching exercises of gastrocnemius and soleus. Firstly,
the patient performed the isometric gastrocnemius exercise with
the ankle in maximum plantar flexion and knee in full extension.
Each repetition was painless and lasted 45 seconds. The patient
performed 3 sets of five repetitions of isometric contraction with
1-min rest interval between each set. Later, the patient carried
out the eccentric–concentric training. The calf muscle was loaded
both with the knee straight (gastrocnemius) and to maximize
the activation of the soleus muscle also with the knee bent. Each
of the two exercises included 15 repetitions done in three sets.
Between each set there was 2-minute rest. In the beginning, the
loading consisted of the body weight, with the patient standing
with 100% body weight on the affected leg. From an upright body
position, the calf muscle was loaded by having the patient lower
the heel beneath the forefoot.
The patient counted to 6 during the exercise. As the subject
moved from the standing to the new position, the calf muscle and
Achilles tendon by inference were loaded eccentrically; followed
by concentric loading, as the injured leg was used to get back to
the start position. Each exercise was performed at a slow speed
at every treatment session. The subject was told to go ahead with
the exercise even if she experienced mild pain. However, she
was told to stop the exercise if the pain became disabling. When
the exercises were pain-free the load was increased by using a
backpack that was successively loaded with weight. Finally, static
stretching exercises of gastrocnemius and soleus were performed
as described by Stanish et al. [12], before and after the eccentric -
concentric training. Each stretch lasted 30 seconds and there was
a one-minute rest between each stretch.
The recommended programme was followed five times
a week for 6 weeks. It was individualized on the basis of the
patient’s description of pain experienced during the procedure.
The patient was instructed to avoid activities that irritated pain
such as jumping, hopping and running [11,15,17] but to use his
ankle during the course of the study He was also told to refrain
from taking anti-inflammatory drugs throughout the course of
the study. A treatment diary monitored the patient compliance.
Communication and interaction (verbal and non-verbal)
between the therapist and patient was kept to a minimum, and
behaviors sometimes used by therapists to facilitate positive
treatment outcomes were purposefully avoided. For example,
patient was given no indication of the potentially beneficial
effects of the treatment or any feedback on his performance in
the pre-application and post application measurements [18].
In the present study function and pain measured. The patient
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was evaluated at the baseline (week 0), at the end of treatment
(week 6) and at 1 month (week 10) after the end of treatment.
The Victorian Institute Of Sports Assessment – Achilles
Questionnaire (VISA-A) questionnaire was used to monitor
the pain and function of patients. The instrument is a simple
questionnaire, consisted of eight questions that takes less than
five minutes to complete and once patients are familiar with it
they will be able to complete most of it themselves. It is a valid
and reliable outcome measure for patients with AT [19].
RESULTS
VISA-A score was 39 at the initial evaluation. At the end of the
treatment (week 6), there was a rise in VISA - A score of 35 units.
At week 10, the VISA - A score was 81 (Table 1).
DISCUSSION
The present case report examined the effect of isometric
gastrocnemius exercise, slow progressive eccentric - concentric
training of gastrocnemius and static stretching exercises of
gastrocnemius and soleus in a patient experiencing AT. The
findings of the study have shown significant improvements in
terms of pain and disability. The results obtained from this case
study are novel; as to date, similar studies have not been carried
out.
Τhe eccentric training is the most commonly used conservative
treatment in the management of AT. Clinicians should consider
eccentric-concentric loading alongside or instead of eccentric
loading in Achilles tendinopathy [13]. The management of AT
can be obtained by a Heavy Slow Resistance (HSR) program
[20]. The HSR program was produced significantly better patient
satisfaction at six-month follow–up than the conventional
eccentric program. Therefore, the HSR program can be proposed
as an alternative to the conventional eccentric program AT
rehabilitation.
Recently, isometric exercises have been recommended
to manage and reduce tendon pain. These exercises increase
the strength at the angle of contraction without producing
inflammatory signs [14,16,21]. Five repetitions of 45-second
isometric mid-range quadriceps exercise at 70% of maximal
voluntary contraction have shown to reduce patellar
tendinopathy pain for 45 minutes post exercise. This was also
associated with a reduction in motor cortex inhibition of the
quadriceps that was associated with patellar tendinopathy [21].
The dosage of isometric contractions in the present was based on
clinical experience [14-16,21] and their effect on pain in patients
with AT requires further study. Therefore, it was hypothesized
that the simultaneous use of these two kinds of contractions
(isotonic and isometric) will further enhance the analgesic effect
of contractions in the management of AT, increasing the lower
limb function.
Table 1: VISA - A score before each evaluation.
VISA - A
Week 0 39
Week 6 74
Week 10 81
JSM Foot Ankle 2(4): 1037 (2017)
Dimitrios (2017)
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It has also been proposed that the positive effects of exercise
programmes for tendon injuries may also be attributable to
the effect of stretching. Τhe aim of stretching is to lengthen
the muscle-tendon unit, orientate the new collagen fibers and
experience consequently less strain during joint motion [22].
Stretching may increase the range of motion of the relevant joint
and strengthen the tendon or make it more resistant to strain
[12,23].
Adequate consideration of the kinetic chain is a component
lacking from evidence-based programs. Poor lumbopelvic control
has the potential to increase the risk of lower limb tendinopathy
and alter load distribution on the lower limb kinetic chain
[3,16,24]. It is believed that the improvement of lumbo-pelvic
control can be achieved by performing simple exercises such as
four point prone bridging exercises and single leg bridging in
supine. Further research is required to confirm this suggestion.
In addition, weakness of hip extensors has also been
associated with AT [25]. Exercises to strengthen the previously
reported muscle groups should be considered in exercise
programs in the management of AT. However, hip extensors
were not strengthened in the present trial because the strength of
hip muscles in the assessment was normal. Functional activities
such as sprinting, cutting and jumping should also be included
in AT rehabilitation programs among athletes, but have so far
not been included in popular programs in the literature [25].
These activities were included in the present study. The athlete
carried out these activities in the court under the supervision of
the gymnast.
The load of exercises was increased according to the patients’
symptoms otherwise the results are poor [26]. Furthermore,
eccentric exercises were performed at a low speed in every
treatment session because this allows tissue healing [27]. Ice was
not recommended at the end of the treatment because research
has shown that ice as a supplement to an eccentric exercise
programme offers no benefit to patients with tendinopathy [28].
Finally, the avoidance of painful activities is crucial for tendon
healing, because training during the treatment period increases
patients’ symptoms and delays tendon healing [29].
Eccentric exercises appear to improve function and reduce
the pain. The way by which eccentric exercises achieves these
outcomes remains unknown, as there is not good quality evidence
relating to physiological effects. The clinical improvement of the
HSR group was accompanied by increased collagen turnover. It is
unknown if the isometric contractions can reverse the pathology
of the tendinopathy and in this case the pathology of CPT.
Although a home exercise programme can be performed
any time during the day without requiring supervision from
a therapist, our clinical experience has shown that patients
fail to comply with the regimen of home exercise programmes
[28]. Although many ways can be recommended to improve
the compliance of patients with the home exercise programme
such as better self-management education exercise monitors
and phone calls, it is believed that this problem can be solved
by the supervised exercise programmes performed in a clinical
setting under the supervision of a therapist. It is believed because
clinicians’ experience has shown that many patients stopped
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the home exercise programme without giving an explanation,
whereas patients completed the supervised programme. One
possible reason why they continue the supervised exercise
programme could be the cost. In the supervised exercise
programme, the patients visit the therapist more times than the
home exercise programme, and this is more expensive. A future
study will combine the both types of exercise programmes in
order to maximize the compliance of the patients.
Even though the positive effects of such an exercise
programme in AT have been reported in the present case report,
its study design limits the generalization of these findings. Future
well-designed clinical trials are needed to confirm the positive
results of this case study establishing the effectiveness of such an
exercise program in the management of AT. In addition, structural
changes in the tendons related to the treatment interventions
and the long-term effects (6 months or more after the end of
treatment) of these treatments are needed to investigate. Further
research is needed to establish the possible mechanism of action
of this treatment approach, and the cost effectiveness of such
treatment, because reduced cost is an important issue for the
recommendation of any given treatment.
CONCLUSION
The exercise programme, consisting of isometric
gastrocnemius exercise, slow progressive eccentric - concentric
training of gastrocnemius and soleus and static stretching
exercises of gastrocnemius and soleus, had reduced the pain
and improved the function in a patient with AT at the end of the
treatment and at one month follow-up. Further well-designed
trials are needed to confirm the results of the present case report.
WHAT THIS STUDY ADDS
This study has shown that an exercise programme, consisting
of isometric gastrocnemius exercise, slow progressive eccentric
- concentric training of gastrocnemius and soleus and static
stretching exercises of gastrocnemius and soleus, had reduced
the pain and improved the function in a patient with AT at the
end of the treatment and at one month follow-up. Further well-
designed trials are needed to confirm the results of the present
case report.
ACKNOWLEDGEMENTS
The authors would like to thank the patient who participated
in this case report.
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Cite this article

Dimitrios S (2017) The Effectiveness of Eccentric-Concentric Training and Isometric Contractions on Pain and Disability in Achilles Tendinopathy: A Case Report.
JSM Foot Ankle 2(4): 1037.

JSM Foot Ankle 2(4): 1037 (2017)

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