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Eccentric Training for the Treatment
of Tendinopathies
Bryan Murtaugh, MD and Joseph M. Ihm, MD

Overuse injuries, including tendinopathies, represent approximately 7% of
all primary care physician visits in the
United States (18,88). Tendinopathies
are a common source of pain encountered in the sports medicine setting
(40,63,93). More than 30% of injuries
related to sports activity arise from or
have an element of tendinopathy (33).
In particular, the prevalence of patellar
tendinopathy is 45% in volleyball players
and 32% in basketball players (40,42).
The prevalence of Achilles tendinopathy
in runners is approximately 11% to
29% (27,51), and up to 40% of all
elbow injuries in tennis players are due
to tendinopathy (40). Tendinopathies
also have been described at the rotator cuff, hamstring, hip
adductor, and posterior tibialis tendons (74).
Tendinopathy is not limited to those participating in
sports activities as it occurs in individuals who are inactive
(19,48). A large cross-sectional study showed that the overall
incidence of symptomatic midportion Achilles tendinopathy
in the general population was 1.85 per 1,000 registered persons in primary care practices, with the incidence rate of 2.35
per 1,000 in those between 21 and 60 years old (9). Lateral
elbow tendinopathy affects as many as 15% of workers in
jobs that require repetitive movements of the hand and upper
limb (5,26).

Tendinopathy can result from overuse and is experienced in the affected
tendon as pain with activity, focal tenderness to palpation, and decreased
ability to tolerate tension, which results in decreased functional strength.
While tendinopathy often occurs in those who are active, it can occur in
those who are inactive. Research has shown that an eccentric exercise
program can be effective in the treatment of tendinopathies. The earliest
studied was the Achilles tendon, and subsequent studies have shown
benefits using eccentric exercises on other body regions including the
patellar tendon, proximal lateral elbow, and rotator cuff. In this article, we
review the research on using an eccentric exercise program in the treatment of painful tendinopathy and proposed mechanisms for why eccentric exercises are effective in treating this and then finish by providing a
general framework for prescribing an eccentric exercise program to those
with a symptomatic tendinopathy.

Tendinopathy is a term used commonly to describe any
painful condition occurring within or around a tendon. It can
result from overuse and is experienced as pain with activity,
focal tenderness to palpation, and decreased ability to tolerate
tension, which results in decreased functional strength (88).
While some define tendinopathy and tendinosis differently,
for simplicity, tendinopathy will be used in this article for
both entities, and the treatment of symptomatic tendinopathy
will focus on those with our macroscopic tendon tears, partial or complete. We will review the evidence for treating
tendinopathy using an eccentric exercise program, address
possible mechanisms by which eccentric exercises positively
affect the tendon in the treatment of tendinopathies, and
provide a framework for the implementation of an eccentric
training program.

Department of Physical Medicine and Rehabilitation, Rehabilitation
Institute of Chicago, Chicago, IL
Address for correspondence: Joseph M. Ihm, MD, Rehabilitation Institute
of Chicago, 345 E. Superior Street, Chicago, IL; E-mail:

Current Sports Medicine Reports
Copyright * 2013 by the American College of Sports Medicine

Risk Factors for Tendinopathy
Risk factors for tendinopathy include intrinsic or extrinsic factors. Systemic intrinsic risk factors include older age
(91,97), obesity (15,23,103), increased waist circumference
(52), diabetes (14), hypertension (23), dyslipidemia (20),
and genetic predisposition (48). The aging process may result in histologic findings similar or identical to those seen in
tendinopathy, predisposing patients to partial tears and the
development of pain (23). Obesity, increased waist circumference, diabetes, hypertension, and dyslipidemia all affect
microvascularity, and this may play a key role in the development of tendinopathy. The lipid profile of some with
Achilles tendinopathy is very similar to the lipid profile that
Current Sports Medicine Reports

Copyright © 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.


. such as fluoroquinolones (96). Some proposed mechanisms include hypoxia. Tendon degeneration with mechanical breakdown of collagen could theoretically generate pain. Some of these treatment options may be considered sooner rather than later or in combination with an eccentric exercise program.. excessive apoptosis.76). especially those with systemic intrinsic risk factors. Extrinsic risk factors include excessive mechanical load (76. or platelet-rich plasma (57). Theories on the causes of pain in tendinopathy suggest that a combination of mechanical and biochemical factors may play a role. Nonsystemic intrinsic risk factors include abnormal biomechanics (3. If the patient is active but unable to participate in usual fitness activities due to a symptomatic tendinopathy.48. Furthermore lipid accumulation has been found in biopsies from tendinopathy subjects (19. in most cases.58. hypercellularity. It is unclear how risk factors may affect one’s response to eccentric training. and substance P. The affected tendon also shows an increased infiltration of new blood vessels. and matrix metalloproteinase imbalance (84). and seat height).g. Current and former smoking has been associated with lateral elbow tendinopathy (85). physical therapy should address any biomechanical issues that may have caused or contributed to the patient’s problem. if any. and disorganized collagen (84). inflammation.67. ice. and work tasks with repetitive movements (85). Bracing should be considered and may allow individuals to remain more active. percutaneous tenotomy (25). 68. Medications. and NSAIDs may have deleterious effects on long-term tendon healing (47). see the review by Sharma and Maffulli (84). and poor technique (76. hormone replacement therapy (23). Eccentric Training for Treating Tendinopathies Copyright © 2013 by the American College of Sports Medicine. In fact.51. Chemical irritants and neurotransmitters also have been proposed as causing pain. may be considered if the patient does not respond to the mentioned treatments and remains limited significantly in function or activity due to pain. Genetic risk factors for tendinopathy also have been described in several studies (31.95).32. Many of the studies included patients diagnosed with tendinopathy by history and physical examination alone. corticosteroid (21).43. one study gives dimensions of the Achilles tendon that can be used as a screening tool to diagnose those with familial hypercholesterolemia (10). and injection of substances such as autologous blood (65). malalignment (76).79). However smoking was not found to be associated with chronic rotator cuff tendinopathy in a crosssectional study of Finnish subjects (72). General Approach to Treatment of Symptomatic Tendinopathy Conservative care for managing tendinopathy includes modification of activity. then either the eccentric program needs to be progressed more slowly or the clinician should consider other options (e. In summary. overtraining. However. footwear. In addition to instruction on an eccentric exercise program.104).71. which suggests that tendinopathy has a similar appearance at different body regions. Given that many of the studies involving use of an eccentric training program do not include those with tears of the involved tendon. glyceryl trinitrate patch (60). hyperthermia. the nonneuronal cholinergic system has been implicated as a factor in chronic tendinopathy with evidence of both acetylcholine and a marked increase 176 Volume 12 & Number 3 & May/June 2013 of muscarinic receptors. running surface. the tendon involved shows no signs of inflammation but instead shows fibroblasts. improper equipment (e. until recently. decreased muscle strength (20.62. . In one study. injections or surgery) with the patient’s level of pain and weakness helping to guide this decision. oral contraceptives (23). Some avoid use of NSAIDs since there usually is no inflammation. but the etiology has not yet been elucidated fully. rapid progression. Eccentric Exercises in the Treatment of Tendinopathy The current most common therapeutic exercise regimen for treatment of tendinopathy involves mechanically loading the painful or abnormal tissue with the use of eccentric exercises. Imaging with either a magnetic resonance imaging (MRI) study or ultrasound should be considered prior to initiating an eccentric exercise program if there is concern for a macroscopic partial or complete tendon tear. While eccentric muscle strengthening has been used for some time. Further research may clarify this. which is known as neovascularization (88). These include lactate. steroids (23). Unauthorized reproduction of this article is prohibited. The source of pain in tendinopathy is unknown. histopathologic findings were similar when comparing patellar and Achilles tendinopathy (44).78). Pathophysiology Many causes of tendinopathy have been proposed.g.37. training errors (e.85). particularly in the patient with severe pain or in the elite level athlete where time to return to play may be critical.. and analgesics. muscle inflexibility (105). including extracorporeal shock wave therapy (77. but some studies used imaging to confirm the diagnosis and/or rule out other causes of pain. however its role in pain mechanisms is unclear (13).49. glutamate.102). if a tear is present. Other treatments. though evidence is mixed on its effectiveness (5.50.104)). Furthermore studies using NSAIDs in the treatment of tendinopathy show minimal. tendinopathy has been accepted as a more appropriate term. With these changes identified. also have been associated with tendon pathology. the clinician should be aware of the potential risk factors when managing patients with tendinopathy. then alternatives for maintenance of fitness need to be discussed. More recently.g.94. Eccentric exercises involve lengthening of the musculotendinous unit while a load is applied to it. all of which have been found to be elevated in tendinopathy (84).is associated with increased insulin resistance (19). oxidative stress. nonsteroidal anti-inflammatory drugs (NSAIDs) (12. and joint laxity (76). In the past.59. racquets.82). Surgery is needed rarely and usually reserved for only the most refractory cases (41). vascular hyperplasia. little was known about how eccentric exercises result in decreased pain and normalization of the tendon in those with tendinopathy. An interaction between other risk factors and one’s genetic make-up may further increase the likelihood of developing tendinopathy (48). prolotherapy (106). For a detailed review of the potential causes of tendinopathy and pain related to it. the term tendinitis was used widely because the etiology of this condition was thought to be associated with an inflammatory process. and retinoids (22). difference in recovery time or long-term management of pain (88).

patients loaded the Achilles tendon into full ankle dorsiflexion. However this study did not include a control group (29). There have been several other studies on eccentric exercises in the treatment of Achilles tendinopathy using Alfredson’s protocol. Their study demonstrated that an eccentric exercise program. (2) was the first to perform a controlled study using eccentric exercises in patients with midportion Achilles tendinopathy. and they hypothesized that microtrauma of the tendon occurs during an eccentric load. In contrast to the Ohberg study.61. While most of the studies on eccentric exercises have concentrated on pathology of the midportion of the tendon. Ohberg and Alfredson (64) also found a decrease in tendon thickness and normalized tendon structure measured by ultrasound in most patients with chronic Achilles tendinopathy who were treated using eccentric exercises. this protocol has been less studied in the treatment of insertional Achilles tendinopathy. Unauthorized reproduction of this article is prohibited. Stanish and Curwin understood that more force can be generated on the musculotendinous unit using maximum eccentric contractions than with concentric and isometric contractions. an optimal regimen could not be determined. This study showed a high success rate for Achilles tendinopathy using this protocol. incorporating progressively faster drop squat eccentric exercises. which all showed positive effects of the eccentric exercise protocols. Eccentric training resulted in decreased tendon volume and decreased intratendinous signal on MRI. Current Sports Medicine Reports Copyright © 2013 by the American College of Sports Medicine. compared to 36% of the patients who were treated with the concentric training regimen. Based on the research of Komi and Buskirk (36) and other investigators. Shalabi et al. 8. they postulated that the treatment program should include eccentric exercises in order to train the tendon to withstand loads that could have caused the initial damage. in 200 patients with Achilles tendinopathy with a mean duration of symptoms for 18 months. One study used a protocol similar to that used by Stanish and Curwin. as with a number of studies using eccentric training.acsm-csmr. specifically the Achilles tendon. Alfredson et al. In one study. every day for 12 wk. 89% of patients with midportion tendinopathy had a good response. This was compared to a control group performing leg extension or leg curl concentric exercises (6). Producing patients’ tendon pain during the exercises was expected. His eccentric calf muscle exercise protocol involved using 3 sets of 15 repetitions with the knee fully extended and 3 sets of 15 repetitions with the knee partially flexed. (83) evaluated 25 patients with chronic Achilles tendinopathy before and after an eccentric exercise program using the Alfredson’s protocol. The results showed that after the eccentric training regimen. However one study reported significant improvements in patients treated with 12 wk of eccentric exercises as well as those treated with a heel brace alone. Positive changes in tissue structure and mechanical properties as a result of eccentric training also have been investigated. However. in addition.87). improved their calf strength. One systematic review of RCTs was completed to try to resolve this issue (55). all 15 patients returned to their preinjury running activity and. symptoms improved significantly. due to insufficient data and a similar number of repetitions and sets among all three protocols. Interestingly Alfredson (1) began using eccentric exercises in the treatment of tendinopathy out of necessity as a result of having a painful Achilles tendinopathy himself. However. 177 . and most of these have confirmed his initial findings (45.78Y80. 65% had no symptoms at 5-year follow-up (86). led to complete relief in 44% of patients and marked improvement in an additional 43% with a mean follow-up period of 16 months (89). When comparing eccentric exercises and concentric exercises in midportion Achilles tendinopathy. The protocol involved once-daily exercises. 82% of the patients were satisfied and had www. Patellar Tendinopathy There have been a few studies on eccentric exercises in the treatment of patellar tendinopathy. Three sets of 15 repetitions were performed twice daily for 12 wk.. he compared an eccentric exercise program to conventional therapy followed by surgical intervention.05 mm at baseline to 7. Eccentric exercise also has been shown to be better than wait-and-see (78) or cryotherapy (35). and this normalization correlated with decreased pain. patients performing eccentric exercises improved more than the concentric group (45). with no significant difference between the two groups at 1 year (67).org resumed their previous activity level. stretching. A small pilot study of 27 patients with insertional tendinopathy examined a modified protocol where eccentric exercises were performed without loading into dorsiflexion. which correlated with improved pain and subjective performance. the positive changes seen within the tendon did not clearly correspond to improved symptoms. compared to only 32% in those with insertional tendinopathy (11). In this study. and 12 wk (61). Average tendon thickness decreased from 8. In a separate 5-year follow-up study of patients with Achilles tendinopathy that used Alfredson’s 3-month eccentric exercise program. The review included three RCTs. After the 12-wk training period. Nevertheless a recent systematic review of randomized controlled trials (RCTs) supports use of eccentric training as an integral component in the treatment of symptomatic Achilles tendinopathy (92). though the reason why these changes occur is unknown. In this study of patients that had a mean duration of symptoms for 18 months. In another group of patients who underwent a training regimen that included an eccentric exercise program for midportion Achilles tendinopathy. This program was repeated twice daily. although this did not reach statistical significance (100). Another study comparing eccentric exercises with concentric exercises showed significantly greater pain reduction in the eccentric exercise group at 4. which occurred over a 6-wk period. Greater satisfaction levels (67%) were reported with this regimen. Additional resistance was added (e.g. (89) were the first in the medical literature to propose an eccentric exercise program for the treatment of tendinopathy. and a progressive increase in the speed of movements.Achilles Tendinopathy Stanish et al. by wearing a back pack with weights) when the exercises became easier. The optimal protocol using eccentric exercises for midportion Achilles tendinopathy has to be established yet. this study did not include a placebo control group.50 mm at 5 years. but patients were told that pain should not be progressive or disabling. In order for the injured tendon to be adequately rehabilitated. where patients were directed to exercise daily with a warm-up and stretching.

(70) compared two different eccentric exercise regimens.. and 3 had a Type 3 shaped acromion. for 12 wk. However there is a poorer prognosis with use of an eccentric exercise program in those patients diagnosed with lateral elbow tendinopathy and found to have a large intrasubstance tear or lateral collateral ligament tear on ultrasound (7). consisting of 3 sets of 15 repetitions. compared to a passive rehabilitation program (ice. which consists of a barbell suspended from wires that could be moved vertically at a chosen distance and with speed that was controlled by a hydraulic machine. Therefore further research is needed. and exercises were performed with reproduction of tendon pain.e. and subjective disability. Rotator Cuff Tendon Disorders Only a few studies have examined the effect of eccentric exercises on shoulder pain. There was a significant pain reduction and return to sport in both groups. using an inexpensive flexible rubber bar. patients received 5 to 6 sessions of supervised physical therapy with home exercises once or twice per day over a 12-wk period. A pilot study by Purdam et al. All seven patients in the concentric exercise group were not satisfied and had undergone surgery or sclerosing injections. Another study showed that a supervised eccentric exercise and stretching program was found to be superior to a home-based eccentric exercise and stretching program to reduce pain and improve function in patients with lateral elbow tendinopathy (90). Eccentric exercises have been shown to result in increased function compared with therapeutic ultrasound 178 Volume 12 & Number 3 & May/June 2013 in the treatment of lateral elbow tendinopathy (81). (16) examined the efficacy of two different 12-wk eccentric rehabilitation protocols. Tyler et al. At the 52-wk follow-up. 5 patients were satisfied with treatment and had withdrawn from the waiting list for surgery. patients with patellar tendinopathy with a mean duration of pain of 17 months were randomized to use either an eccentric or concentric quadriceps exercise on a decline board and treated for 12 wk. Among the satisfied patients. massage. including rotator cuff disorders. However a limitation of this study is that there were only a total of 19 patients. for the treatment of chronic lateral elbow tendinopathy. and ice. A study by Young et al. A study by Bahr et al. with no difference between the groups. However this study was limited by a small number of patients. and different types of shoulder rehabilitation exercises. strength. A recent review of eccentric exercises in the treatment of lateral elbow tendinopathy concluded that eccentric training produced encouraging results. One study of elite volleyball players who continued to compete through the season during the treatment period found no benefit from eccentric exercises compared to a control group who continued to train as usual. NSAIDs. Also. muscle strength. 7 out of 8 patients in the eccentric exercise group still were satisfied subjectively and 6 patients returned to previous sports activities. Unauthorized reproduction of this article is prohibited. the addition of an isokinetic eccentric protocol using a dynamometer that maintains a preset speed showed significantly better pain reduction. while the other group performed squats on a level surface. while 1 patient did not return due to reasons other than patellar pain. Nine patients were used in the study. the addition of daily eccentric exercises using the flexible rubber bar resulted in superior results for pain reduction. though clearly the results have been mixed. and ultrasonographic tendon imaging. although there was a compliance of only 59% of the recommended volume of exercises in the eccentric treatment group (101). at the proximal attachment vs at midportion of tendon) within the patellar tendon and the effectiveness of eccentric exercises remains unclear (75). A study by Frohm et al.This protocol was followed for 12 wk and performed by patients with a mean duration of pain over 3 months. although the literature is limited and eccentric programs have been varied (53). In this study. (4) that compared eccentric exercises with open tenotomy surgery showed equal improvement in both groups. One group performed exercises using a decline board. disability questionnaire scores. The association between the location of pathology (i. (98) conducted a study to assess the efficacy of a novel eccentric wrist extensor exercise. with a mean duration of symptoms of 41 months. (107) also supported greater improvements in elite volleyball players with patellar tendinopathy who performed eccentric exercises using a decline board compared to those with a traditional eccentric protocol using a flat 10-cm step. cross-friction massage. Lateral Elbow Tendinopathy (aka Lateral Epicondylitis) There have been only a few studies that have investigated the use of eccentric exercises in the treatment of lateral elbow tendinopathy. Further research may eventually clarify this issue definitively. The study showed a prominent positive effect in the group using the decline board compared with the standard squat group. therapeutic ultrasound. ultrasound. One other study evaluated the effect of strengthening eccentric exercises of the rotator cuff and concentric or eccentric exercises of the scapula stabilizers on the need for surgery in patients with subacromial impingement syndrome (24). but no difference was observed between the two groups. heat. Both groups had improved pain and functional scores at 12 wk. In both groups. In comparison to a control therapy that included stretching. . patients were instructed to perform exercises slowly. At mean follow-up of 32 months. The patients completed a painful eccentric training program directed at the supraspinatus and deltoid musculotendinous units. Patients with arthrosis in the acromioclavicular joint or with large calcifications causing mechanical impingement were not included. All patients had tried different treatment regimens. twice daily with no stretching or warm-up. The control group performed an exercise program of nonspecific exercises for the neck and shoulder. twice per day. In a study by Jonsson and Alfredson (28). one with a daily eccentric exercise program on a decline board and one twice-per-week program using a Bromsman eccentric overload training device. 2 had a partial supraspinatus tendon tear. There was significantly greater improvement in pain and function in the exercise group that included use of eccentric exercises compared to Eccentric Training for Treating Tendinopathies Copyright © 2013 by the American College of Sports Medicine. and all patients were on the waiting list for surgery. including rest. and stretching). Since an isokinetic dynamometer is expensive and not widely available. Overall current research suggests that an eccentric exercise program with use of a decline board generally has been more effective when compared to other training regimens. steroid injections. One pilot study specifically evaluated eccentric training in chronic painful impingement syndrome of the shoulder (30). including decreased tendon thickness and a more homogenous tendon structure (8).

Furthermore 12 wk of eccentric training reduced the abnormal paratendinous capillary blood flow in Achilles tendinopathy by as much as 45% and also decreased pain levels (35). For example. It is clear that the exercise regimen for tendinopathy is a different stress to the musculotendinous unit than that for muscle strengthening since the recommended muscle strengthening protocol is to perform exercises one time per day with at least 1 d of rest between workouts (54). 12 wk of eccentric training reduces pathologically increased capillary blood flow without changes in tendon oxygen saturation (34). Since collagen synthesis following exercise has been shown to peak at 24 h and decrease toward baseline at 72 h. Unauthorized reproduction of this article is prohibited. Despite the research to date that supports this recommendation. 179 . and it is possible that patients with tendinopathy have impaired eccentric control causing even more prominent force fluctuations. Yet they did find that the tendon is subjected to repeated loading and unloading in a sinusoidal-type pattern during eccentric exercises. The study included 12 patients. it may be reasoned that the optimum frequency be less than that of the current twice-daily protocol (39. the therapeutic exercise program to treat painful tendinopathy should consist of eccentric exercises that target the affected area with 3 sets of 15 repetitions once to twice per day for at least 12 wk. One other difference between eccentric and concentric exercises is that force rises through the course of an eccentric loading movement and falls during a concentric loading movement (73).36). it has been suggested that the good results of eccentric exercises in Achilles tendinopathy may be due to this intermittent disruption of this blood flow. repetitions.56. There is some evidence that eccentric exercises can develop greater forces in muscle during dynamic movements (17. Given that Alfredson’s eccentric exercise protocol results in patients completing more than 15. and duration of treatment remain unknown.66. The speed of the eccentric movement may be an area of further research. neuromuscular benefits through central adaptation of both agonist and antagonist muscles (73). and therefore provide a greater remodeling stimulus. Given the adaptations that take place with the eccentric training protocol described in this article compared to muscle strengthening recommendations. In those with Achilles tendinopathy. A program with faster eccentric movements may lead to more force fluctuations. Studies have shown better strength gains with training at least every other day compared to daily (54). This may be similar to how bone responds to high-frequency loading and mechanical signals. whereas this was unchanged in the healthy tendons. and function.000 repetitions over a 12-wk period. (73). may provide an important stimulus for tendon remodeling and be responsible for the therapeutic benefit in eccentric exercises (73). (38) investigated the effect of eccentric exercises on collagen synthesis. which is the main type of collagen in normal tendons. alone cannot be responsible for the therapeutic benefit seen in eccentric loading. 6 with healthy Achilles tendons and 6 with Achilles tendinopathy.acsm-csmr. and increases in tendon stiffness (69). (89) suggested that eccentric exercises expose the tendon to a greater load than concentric exercises and proposed an eccentric exercise program as the best mechanism for strengthening the tendon. Prescribing an Eccentric Training Program for Tendinopathy Based on research to date. This was largely absent during concentric exercises. who performed eccentric exercises over a 12-wk www. which therefore result in altered pain perception. frequency. there are many questions that still remain. (89). In addition. with its force fluctuations. leading to increases in bone density (73). Also a significantly lower proportion of patients in the treatment exercise group chose to undergo surgery.the control exercise group that did not. In a study by Komi and Buskirk (36). (73) found no significant difference in peak tendon force or tendon length change when comparing eccentric with concentric exercises. Alfredson originally hypothesized that eccentric exercises may cause changes in the metabolism of the period. These findings suggest that tendon force magnitude. The data in this study were collected in healthy subjects. including its effects on tendon histology. Since ankle dorsiflexion has been shown to limit the blood flow in neovessels (35). Although eccentric exercises have been shown to be effective in the treatment of tendinopathy. However this was not found when forces were measured during specific eccentric exercises. and few studies have compared his protocol to other regimens (39). Specifically there was increased peritendinous Type I collagen. with high-frequency oscillations in tendon force. an optimal dosage of exercise to provide the best results has yet to Current Sports Medicine Reports Copyright © 2013 by the American College of Sports Medicine. the success of an eccentric exercise program may be due to this repeated interruption of blood flow over time (73). Thus far.99). the original protocol developed by Alfredson remains the most commonly used. and this occurred without a corresponding increase in collagen degradation. as originally suggested by Stanish et al. as seen in the study by Rees et al. This could explain why twice-daily eccentric training sessions can be performed without overtraining muscles. such as those used in the Alfredson protocol for the Achilles. Furthermore the optimum load. however integrated electrical activity was less in eccentric group. a reduction of neovascularization was demonstrated with color Doppler sonography after 12 wk of eccentric training (64). Rather the pattern of tendon loading and unloading.46. In one study. Rees et al. one study found that eccentric training with very high loads twice weekly was an effective regimen in the treatment of patellar tendinopathy (16). He later noted that there was a temporary interruption of blood flow in the tendon neovessels during each eccentric exercise sequence (75). These changes corresponded with a decrease in pain levels. 7 wk of eccentric muscle conditioning produced greater measurements in muscle tension than with concentric muscle conditioning. Other proposed mechanisms for the effectiveness of eccentric exercises include pain habituation as a result of completing several weeks of pain-provoking eccentric exercises. Langberg et al. More research is needed regarding the proposed mechanisms behind the positive effects of eccentric exercises in tendinopathy. Why Are Eccentric Exercises Effective? Stanish et al. structure. eccentric training was found to increase collagen synthesis. the current eccentric training for tendinopathy could be thought of as a ‘‘tendon-strengthening’’ program.

ABO blood groups and musculoskeletal injuries. 28:996Y9. 17. A randomized. 29:880Y5. et al. Kannus P. 26:360Y6. Misko R. J. Etiologic factors associated with symptomatic Achilles tendinopathy. 21. van den Berg C. J. J. J. Arthrosc. Komi PV. Sports Med. 2009. Br. 9. Lin J. 14. Holmgren T. Connell DA. 45:1026Y8. Physiol. et al. 180 Volume 12 & Number 3 & May/June 2013 7. 1995. 2005. Am. 84:865Y70. 22. et al. et al. Am. Scott A. 41:e7. Alfredson H. 14:76Y81. Fox AJS. Patients should be asked if the exercises are being performed at the prescribed frequency and if the exercises are painful and difficult. 24. Curtis M. Sports Med. 2005. Sports Med. lateral elbow. 28. Br. et al. Atherosclerosis. as some therapists are not accustomed to producing patients’ pain during the exercise regimen. 1989. et al. Ahmad M. Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols. de Jonge S. Sports Med. Foidart-Dessalle M. Jonsson P. Patients may continue routine fitness activities if these provoke minimal or no pain at the affected tendon (11). Curr. Rheumatol. J. J. Sunding K. Sports Med. Natri A. Sports Med. 2001. 38:581Y5. Khan KM. 5. then these need to be addressed prior to returning to unrestricted athletic activity. Hallgren HB. 23. et al. 2009. Holmes GB. Dahners LE. Br. 2007. 2011. Tinant F. Fu SC. et al. 344:1Y9. 35:60Y4. Proximal wrist extensor tendinopathy. Afshari HM. Heller F. Fossan B. Appl. 32. 1992. 6:40Y50. In vivo Achilles tendon loading during jumping in humans. injections) should be considered. Deciphering the pathogenesis of tendinopathy: a three-stage process. Osternig LR. Fahlstrom M. 29:1187Y92. Alfredson H. 11:327Y33. 41:1194Y7. Conclusions This article has attempted to summarize up-to-date research regarding the mechanisms for eccentric training for tendinopathy as well as outline a specific eccentric program to follow in the treatment of painful tendinopathy. et al. Gaida JE. 42:746Y9. Ferry ST. 2007. J. Vaughan CL. Balint JB. Occup. Br. J. Musculoskelet Med. Bahr R. 2007. Van Leuven F. Beller E. Communication with both the patient and the physical therapist about this protocol may be needed. Jacobson JA. Eccentric Training for Treating Tendinopathies Copyright © 2013 by the American College of Sports Medicine. Eccentric calf muscle training V the story. The eccentric exercises should be performed slowly initially. 2010. 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.g. Wahlstrom P. 3. 2009. Alfredson H. Injuries to runners. J. 31. Cannell LJ. Br. 26. Kajula UM. Only after it is confirmed that the prescribed exercise regimen has been completed and failed should other options be considered. 2006. Sportverletz Sportschaden. et al. Am. 39:847Y50. Deng X. Br. Br. 43:247Y52. 22:2009Y10. Cheuk YC. Jonsson P. 2009. Am. J. New insight into the nonneuronal cholinergic system via studies on chronically painful tendons and inflammatory situations. Injury. Grimsholm O. The use of Achilles tendon ultrasonography for the diagnosis of familial hypercholesterolemia. Sports Med. 27:952Y9. 41:269Y75. Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Sports Traumatol. Biomechanical variables associated with Achilles tendinopathy in runners. . Sports Exerc. 2011. Knee Surg. 39:411Y22. Croisier JL. References 1. 2008. Ther. J. et al. 18. Sports Traumatol. 2006. 13. 12. Bone Joint Surg. 35:1326Y33. or muscle strength in elite female basketball players? Br. The effects of obesity on orthopaedic foot and ankle pathology. Vincenzio B. If a patient returns after performing the prescribed program for several weeks and reports no improvement in pain. 1:48Y52. Sports Med. Br. Physiol. 2001. Jonsson P. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. BMJ. Bedi A. Superior results with eccentric compared to concentric quadriceps training in patients with jumper’s knee: a prospective randomised study. Bisset L. Sports Med. Clarke AW. Sports Med. 2010. Rehabil. 88:1689Y98. J. 1995. 2012. then imaging or other treatments (e. et al. Jarvinen M. The authors declare no conflicts of interest and do not have any financial disclosures. 2:30. Bone Joint Surg. Alfredson L. Ultrasound Med. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomized controlled study. 43: 288Y92. Ohberg L. Jonsson P. 2. Eccentric exercises have been shown to be effective in the treatment of tendinopathies at various locations of the body. Bass S. Housner JA. 16. 24:188Y9. Patients should be encouraged to reproduce tendon pain during therapy sessions. Sports determined (55). Rolf C. body composition. Technol. Sport Med. 6. Foot Ankle Int. Halvorsen K. Further research is necessary to determine the optimal protocol for eccentric exercises in the treatment of tendinopathies. Foot Ankle Int. Life Sci. although benefits have been seen using eccentric exercises on other body regions including the patellar tendon. 71:272Y4. Arthrosc. Sports Med. Achilles and suprapatellar tendintis due to isotretinoin. controlled trial. Jonsson M. Are unilateral and bilateral patellar tendinopathy distinguished by differences in anthropometry. Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper’s knee). Jozsa L. Frey C. Sonographically guided percutaneous needle tenotomy for the treatment of chronic tendinosis. Gaida JE. J. Taunton JE. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Eur. J. A systematic review and metaanalysis of clinical trials on physical interventions for lateral epicondylalgia. Br. Sports Med. 2006. Knee Surg. 25. J. James SL. Jonsson P. et al. Fukashiro S. 8. Descamps O. 1998. 11. 23:131Y3. et al. Alleque F. Forsgren S. 2008. Arthrosc. et al. J. J. 15. Bates BT. Hernandez-Rodriguez I. 29. 19. J. 4. Orthop. 2010. with the affected limb performing the eccentric portion of the exercise independently. then a detailed assessment of the home exercise program is warranted. The area studied earliest was the Achilles. J. et al. Frohm A. Oberg B. Lambert MI. 2009. Unauthorized reproduction of this article is prohibited. Saartok T. Med. but pain should not be progressive or disabling. J. New regiment for eccentric calfmuscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. Clin. 5: 453Y8. 38:1209Y14. If there are weaknesses in the kinetic chain that contribute to the problem. Incidence of midportion Achilles tendinopathy in the general population. 30. 1978. Sci. with the speed of movement increased as the rehabilitation protocol progresses. Rev. The concentric portion of the exercise may be performed passively or with the assistance of the uninvolved limb during closed kinetic chain exercises. Cook JL. Br. 2003. Distribution of blood groups in patients with tendon rupture. Sports Med. Sports Med. Diabetes mellitus alters the mechanical properties of the native tendon in an experimental rat model. 2008. Ihm J. 2011. 27. 2004. Pietila T. The effects of common antiinflammatory drugs on the healing rat patellar tendon. Lorentzon R. et al. Res. Azevedo LB. 20. Dyslipidemia in Achilles tendinopathy is characteristic of insulin resistance. Renstrom P. Garrick J. 21:540Y1. Jarvinen M. 10. and rotator cuff. Clement DB. Lateral elbow tendinopathy: correlation of ultrasound findings with pain and disability. Kiss S.. Leysen X. Zamora J. If the program is too painful to perform. J. 33. de Vos RJ. Paungmali A. Loken S. Alfredson H. Corticosteroid and other injections in the management of tendinopathies: a review. Am. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Eccentric training in chronic painful impingement syndrome of the shoulder: results of a pilot study. et al. 157:514Y8.

Olesen JL. Miller BF. 2009. Magra M. 11:243Y7. et al. Norris C. 2005. Effect of eccentric training on the plantar flexor muscle-tendon unit properties. Ther. Kent P. 2007. Rheumatology. Sci. 567:1021Y33. Coordinated collagen and muscle protein synthesis in human patella tendon and quadriceps muscle after exercise. 2008. 58. 2001. 2010. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy V a randomized trial with 1-year follow-up. 51. Am. ABO blood groups and Achilles tendon rupture in the Grampian region of Scotland. J. 18:541Y2. Am. Highet R. J. 2004. 52. Biomech. Sci. 50. Eccentric training in tendinopathy V more questions than answers. et al. Med. Ahya R. 2000. Lorentzon R. Reaper JA. Central versus peripheral adaptations following eccentric resistance training. Nonsteroidal anti-inflammatory drugs in tendinopathy. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy. 59. 2006. Clin. 39. 65. 2009. 2004. 53. 79. Ther. Rowlands D. 42. 63. The pathogenesis of tendinopathy. J. Longo UG. Sports Med. J. 23:343Y8. 30: 1590Y6. The role of eccentric exercise in the functional re-education of lateral epicondylitis: a randomised controlled clinical trial. Vittorino T. Pensini M. Sport Rehabil. Rheumatology. 60. 29Y39. 16:1Y3. Sport Med. Med. Goubel F. & Human Performance. 48. Selvanetti A. 56. Med. or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Engebretsen L. 2005. www. 2008. 74. Cools A. 61. Chronic Achilles tendinopathy: a prospective randomized study comparing the therapeutic effect of eccentric training. J. 2008. Treatment of tendon and muscle using platelet-rich plasma. 38. J. Rees JD. Eccentric training of the gastrocnemiusYsoleus complex in chronic Achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by magnetic resonance imaging. 1994. 2006. Viikari-Juntura E. 1992. 2003. Med. 34:226Y35. Rompe JD. 19:1Y5. 54. 32:1286Y96. 2004. Med. 71. Clin. Am. Baltimore. Cook J. Br. Lagerquist A. 36(9):1470Y5. Sci. 586:71Y81. Collins M. Nigg BM. Sports Traumatol. Nutrition. et al. Eccentric exercises: why do they work. Mishra A. Murrell G. Bone Joint Surg. Minimally invasive stripping for chronic Achilles tendinopathy. Kvist M. 66. Anthropometric risk factors for patellar tendon injury among volleyball players. 83. 2005. 68. Karppinen J. 15:417Y34. Jonsson P. Martin A. 181 . Sports Med. J. Sports Med. in vivo. A prospective study. an in vivo study in humans. Sharma P. Varonen H. Gajjar M. 2004. Cook J. Sport Med. J. and a combination of both. Capasso G. 2011. Furia JP. et al. Genetics: does it play a role in tendinopathy? Clin. McNair P. 46. Magnusson SP. p. 77. Maffulli N. Br. 2004. Van der ML. 2007. Med. Med. 44. Unauthorized reproduction of this article is prohibited. 37:269Y76. 49:2090Y7. 2006. 85. 2007. Sports. et al. J. McArdle WD. J. Scand. Alfredson H. Sports Med. Sports Phys. Roos EM. Kraemer R. MD: Lippincott Williams & Wilkins. 1972. Sci. Sport. Clement DB. Ribbans WJ. Kongsgaard M. Sports. Current concepts in the management of tendon disorders. 35:374Y83. Langberg H. BMC Musculoskelet Disord. September AV. Effects of neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis? Knee Surg. Handley CJ. Sport. Med. Nafe B. 2009. Intrinsic risk factors for the development of Achilles tendon overuse injury. 62. Br. Sports. J. 40:117Y23. Rheumatology. J. Magra M. Rheumatology. Variants within the COL5A1 gene are associated with Achilles tendinopathy in two populations. Katch F. 2012. J. Maffulli N. J. Maganaris CN. J. Taunton JE. Knobloch K. 6:27Y44. Kristoffersen-Wilberg M. Maffulli N. J. Svensson L. Maffulli N. Engstrom M. Wolman RL. et al. Eccentric exercise protocols for chronic noninsertional Achilles tendinopathy: how much is enough? Scand. Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. 45:508Y21. et al. Katch V. Pearson J. 41:227Y31. Sports Med. Shalabi A. Am. 72. 2008. 2007. Philadelphia (PA): Butterworth Heinemann Publishers. Variants within the MMP3 gene are associated with Achilles tendinopathy: possible interaction with the COL5A1 gene. 47:1493Y7. 37:463Y70. Sports Exerc. 33:561Y7. Sci. Raleigh SM. Sports Exerc. Components of the transforming growth factor-A family and the pathogenesis of human Achilles tendon pathology V a genetic association study. Am. Narici MV. Sports. Disabil Rehabil. Shiri R. Clin. The role and implementation of eccentric training in athletic rehabilitation: tendinopathy. Purdam CR. Maffulli N. Baxter D. 2009. Am. Human tendon behavior and adaptation. Antonaci A. Prevalence and determinants of lateral and medial epicondylitis: a population study. Clin. 57. Lian OB. J. 2006. Sport Med. J. 64. Ergonomics. 43. J. Barrucci A. 1990. et al. 11:165. Tendon injury and tendinopathy: healing and repair. 2006. Sci. Sports Injuries: Diagnosis and Management. Epidemiol. Eccentric training decreases paratendon capillary blood flow and preserves paratendon oxygen saturation in chronic Achilles tendinopathy. 9:42Y7. Hansen M. 23: 567Y74. Buskirk ER. 37. 35:1659Y67. Petersen W. Posthumus M. Sports Med. Sports Med. 41:1Y5. et al. Madsen T. Sports Med. Ramamurthy C. 164:1065Y74. Langberg H. 75. 43:514Y20. Genetic aspects of tendinopathy. Br. 33:1016Y21. Eccentric training programs in the management of lateral elbow tendinopathy. Exercise Physiology: Exercise. J. Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. 2004. Physiol. J. Bahr R. 2008. Sports Med. Scand. Sports Med. Rechardt M. 12:465Y70. Achilles tendon overuse injuries in athletes. Eccentric loading. Jagodzinski M. The role of impact forces and foot pronation: a new paradigm. Woodall J Jr. Niessen-Vertommen SL. Lichtwark GA. 2009. Sports Traumatol. Pousson M. et al. Noakes TD. J. Maffulli N. J. Vieira A. Furia J. et al. et al. Schwllnus MP. 21:218Y24. Wilson A.acsm-csmr. Sci. Sports. Maffulli N. 2007. 43:514Y20. 41:259Y63. 49. 40. Mokone GG. Rahman S. 69. Rees JD. J. Sci. 17:61Y6. J. Sport. 2009. Welp R. 2007. September AV. Sports Med. shock-wave treatment. J. Scand. 84. 28:113Y25. Mokone GG. J. 11:2Y9. Maffulli N. 10:269Y71. Malliaras P. Tumilty S. Using nitric oxide to treat tendinopathy. 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. 36. Orthop. Sports Med. 2007. 18:173Y201. 87:187Y202. Rosenbaum D. Wilson AM. van Hoecke J. 55. Denaro V. et al. 2004. Mahieu NN. Current Sports Medicine Reports Copyright © 2013 by the American College of Sports Medicine. 1994. Sports Phys. Cook J. Autologous blood injection to treat Achilles tendinopathy? A randomized controlled trial. 2008. 67. Similar histopathological picture in males with Achilles and patellar tendinopathy. Wilson AM. J. 2:109Y13. Changes in elastic characteristics of human muscle induced by eccentric exercise. Sci. Arthrosc. Int. what are the problems and how can we improve them? Br. 2010. Sports Med. Rehabil. hamstring strains. J. Sports Med. Med. 16:19Y26. Scand. The COL5A1 gene and Achilles tendon pathology. Rees JD. et al. Mahieu NN. the AirHeel brace. J. Garau G. J. Sports Med. Wolman RL. Malliaras P. 78. Riley G. Am. Kjaer M. Knobloch K. 41. Reiman M. 47.34. 80. The guanineYthymine dinucleotide repeat polymorphism within the tenascin-C gene is associated with Achilles tendon injuries. Int. Ohberg L. Waterson SW. Eccentric training in Achilles tendinopathy: is it harmful to tendon microcirculation? Br. Witvrouw E. 81. Heliovaara M. 2005. 1:286Y95. Meyer A. Maffulli N. et al. 43:131Y42. Mafi N. 70. Maffulli N. J. 2006. et al. Am. 38:395Y7. 2007. Magra M. and ACL reconstruction. A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. 73. J. Sport Med. et al. 17:231Y3. Br. J. Lorenz D. Med. 35. A molecular perspective. 45. Ellingsgaard H. Sport Med. Sayana MK. Lifestyle and metabolic factors in relation to shoulder pain and rotator cuff tendinitis: a population-based study. Disabil. The effect of eccentric versus concentric exercise in the management of Achilles tendonitis. 2002. Alfredson H. Maffiuletti NA. Maffulli N. 6th ed. Komi PV. 43:242Y6. The mechanism for efficacy of eccentric loading in Achilles tendon injury. Arthrosc. 76. 19:609Y15. 2008. Effect of eccentric and concentric muscle conditioning on tension and electrical activity of human muscle. Wolman RL. Physiol. Alfredson H. Knee Surg. 82. Clin. 2007. Sports Med. Sports Med. Rompe JD. 10:52Y8. Prevalence of jumper’s knee among elite athletes from different sports: a cross-sectional study. Stevens V. 56:103Y13.

Sports. 23:91Y8. Thomee P. et al. J. 2002. Tuite D. 100. 28:487Y91. 2011. Crossley KM. J. J. 2012. Meininger AK. Foot Ankle Res. Sci. 46:214Y8. de Jonge S. Intrinsic risk factors for the development of patellar tendinitis in an athletic population. A retrospective case-control analysis of 2002 running injuries. Sci. The aging tendon. Lyftogt JA. de Vos RJ. Hoksrud A. 2011. Sports Med. 1997. Arterioscler. et al. et al. Clement DB. A two-year prospective study. 29:190Y5. Relat. Silbernagel KG. Sport Med. Collins N. Sussmilch-Leitch SP. 2001. von Bahr S. Res. The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. Papadogiannakis N. 1978. 98. Hsu CC. Cook J. -9. Stanish WD. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. 103. 2010. Chang HN. 107. Connect Tissue Res. et al. 19:917Y22. J. DePasquale V. Sweeting KR. Occup. Med. McHugh MP. 31:329Y50. 2010. Tsai WC. Witvrouw E. A longitudinal study of industrial and clerical workers: predictors of upper extremity tendonitis. 91. Br. Nicholas SJ. 90. Thromb. 2011. et al. Clin. Tipton CM. Yelland MJ. 39:102Y5. 2010. Curwin S. Thomee R. J. Sports Med. and -13 without affecting expressions of types I and III collagen in tendon cells. Bialocerrkowski A. Scand. Skjong CC. Foot Ankle. No effect of eccentric training on jumper’s knee in volleyball players during the competitive season: a randomised clinical trial. 5:1Y16 93. 96. Brorsson A. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. 104. Laughlin HL. Am. Effects of celecoxib on migration. et al. 15:227Y34. 1991. et al. 36:95Y101. Bellamans J. Tyler TF. Lysens R. Ibuprofen upregulates expressions of matrix metalloproteinase-1. Orthop. Young MA. A prospective study of gait related risk factors for exercise-related lower leg pain. . Bahr R. Shoulder Elbow Surg. 2005. Clin. Stasinopoulos D. Gait Posture. Ho S. 2007. 92. Ryan MB. Thomas GC. 7(2):72Y7. J. 48:46Y51. Br. Eccentric exercises for chronic tendinitis. 2012. 2001. 106. 94. J. van der Plas A. Karlsson J. Stasinopoulou K. 95. 88. Med. Fluoroquinolone-associated tendinopathy. J. Tsai WC. J. Stasinopoulos MP. Gell N. Unauthorized reproduction of this article is prohibited. J. Chang Gung Med. Br. Rehabil. Physical activity and hypophysectomy on the aerobic capacity of ligaments and tendons. Visnes H.86. 208:65Y8. Eccentric overload training for patients with chronic Achilles tendon pain V a randomised controlled study with reliability testing of the evaluation methods. Yang YM. J. et al. J. J. Chou SW. Comparison of effects of a home exercise programme and a supervised exercise programme for the management of lateral elbow tendinopathy. Strocchi R. Am. Sports Med. Br. Movin T. J. Mechanism of accumulation of cholesterol and cholestanol in tendons and the role of sterol 27-hydroxylase (CYP27A1). Sports. 2005. Res. 2002. De Clercq D. Purdam CR. Willems TM. Taunton JE. Tendinopathy treatment: where is the evidence? Clin. 39:607Y13. O’Brien M. Physical therapies for Achilles tendinopathy: systematic review and meta-analysis. Delbaere K. 2005. Physiol. Franzblau A. 45:421Y8. et al. et al. 15:37Y46. 44:542Y6. 22:1129Y35. 101. 2006. Vailas AC. Sports Med. 34:461Y6. 87. Sports Med. 97. Guizzadi S. J. Werner RA. Appl. J. Tsai WC. Lundberg M. Rubinovich RM. Vasc. 105. Biol. Renstrom P. -8. 44:579Y83. Warden S. 99. Human Achilles tendon: morphological and morphometric variations as a function of age. Br. et al. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. 12:100Y4. Silbernagel KG. 2012. 11:197Y206. Sports Med. Cook JL. proliferation and collagen expression of tendon cells. Sports Med. 1986. 102. et al. 89. Orthop. Scand. Hsu CC. Sports Med. A 5-year follow-up study of Alfredson’s heel-drop exercise porgramme in chronic midportion Achilles tendinopathy. 182 Volume 12 & Number 3 & May/June 2013 Eccentric Training for Treating Tendinopathies Copyright © 2013 by the American College of Sports Medicine.