Sports Injuries & Medicine (ISSN: 2576-9596)

review article

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Physical Therapy Treatment for Chronic Achilles Tendinopathy

Emilio Balado*, Gustavo Rodriguez

Faculty of Physical Therapy, University of Vigo, Spain

*Corresponding author: Emilio Balado, Faculty of Physical Therapy, University of Vigo, Spain, Tel: + 667064040; E-mail: miliobalado@gmail.com

Received Date: 23 April, 2017; Accepted Date: 20 May, 2017; Published Date: 06 June, 2017

Citation: Balado E, Rodriguez G (2017) Physical Therapy Treatment for Chronic Achilles Tendinopathy. Sports Injr Med 1: 114. DOI: 10.29011/2576-9596.100014

1.      Abstract

Objective: To analyze the clinical effectiveness of Physical Therapy treatment for chronic Achilles tendinopathy.

Search strategy: Search in Medline, WoS, CINAHL, Pub Med Central and Science Direct based on the keywords.

Study selection: 203 studies were identified, 18 being selected on the basis of the inclusion criteria: from 2006 to November 2011, focused on the objective of the study and with pretest and posttest.

Synthesis of Results: Eccentric exercises singly or combined with other therapeutic modalities, especially shock waves are the most used option. The best results are obtained in insertional tendinopathies.

Conclusions: More studies are needed to confirm the clinical effectiveness of the different physical agents used for physical therapy treatment for chronic Achilles tendinopathy, and to determine the importance of the lesional location in the recovery process tendon.

Keywords: Achilles tendon; Tendinopathy; Chronic Disease; Physical Therapy

1.      Introduction

Tendinopathy is a frequent alteration of the musculoskeletal system, With several pathological manifestations. In the acute phase, the Component of inflammation, which associates an increase of neutrophils, edema Peritendinosus, local inflammation and stiffness. In subacute and chronic cases, Inflammation seems to play a less important role, predominating degeneration Of the structure of collagen tissue (which being thinner and less durable Disables the tendon to support loads), neovascularization Intratendinous (occurring both at the intra-tendinous and paratendinous levels) and the Increased neuropeptide concentration and cellular apoptosis [1-3].

Traditionally, chronic pain of the Achilles tendon has been referred to as Tendinitis is caused by pain, swelling, and vascular enlargement. Nevertheless, recently, it has been confirmed that this inflammation is very small or nonexistent [3]. And although sometimes the terms tendinitis and tendinosis are used as Synonyms [4], Achilles tendinosis involves pathological changes for the tendon with absence of inflammatory cells and, therefore, is the term related to Chronic processes [2].

Achilles tendinopathies can be classified into insertional ones (those that Occur in the tendon-bone junction) and non-insertional (more proximal, and localized, At least 2 cm above the insertion of the tendon in the calcaneus). The first Tend to occur in older, less athletic or overweight individuals [5]. These injuries, caused by tendon overuse, prevail in Activities that involve career or leap, and, consequently, a high demand of the Tendon (an estimated percentage of sports injuries of 30-50% are related to the tendon). However, it is not always associated with activity Physics, and may also occur in sedentary individuals and in the population General, especially in people who are overweight [5-7] and older than 35 Years [7,8]. In this way, Achilles tendinopathy does not only cause discomfort Sports, but can lead to a general deterioration of health and a Increased morbidity [8].

The multifactoriality (see figure 1) explains that the results obtained with Unique and simple treatments are not always effective [9], especially if other diseases that correlate with an increase in risk of tendinopathy, such as diabetes mellitus, kidney disease or Rheumatological diseases [5]. It is often stated that treatment Conservative is more effective, in principle, than the surgical one, but the Is varied. Traditional conservative treatment maintained little Activities that supposed to modify the structure of tendons and their capacity to withstand the tensions that arose to him, which often implied a Recurrence of the problem [6]. The eccentric exercises of the triceps muscles Sural intervention are an emerging therapeutic intervention for the treatment of Tendinopathy, especially in the Achilles tendon [8]. In a similar way, Resulting in the treatment of extracorporeal shock waves, popular in the Last decade for the treatment of soft tissue disorders [3]. In this review we aim to explore the effectiveness of treatment of physiotherapy on chronic Achilles tendinopathy, investigating a possible Consensus among studies that makes us think of a therapy or treatment Common and effective to alleviate the clinic of this pathology.

Mean age. GE: Experimental group. GC: Control group. EE: Eccentric exercise. EVA: Visual Analog Scale. VISA-A: Victorian Institute of Sports Assessment-Achilles Questionnaire. FAOS: Foot and Ankle Outcome Score. SatO2: Saturation of oxygen. AF: Physical activity. EMG: Electromyographic. AOFAS: American Orthopedic Foot and Ankle Society Score. SF-36: Health Survey Questionnaire Short-Form 36. US: Ultrasound. FILLA: Functional Index of the Leg and Lower Limb. EP: Exercises Proprioceptive. PDI: Pain Disability Index. OCR: Radial shock waves. OCE: Extracorporeal shock waves.

2.      Material and Methods

From October 2010 to November 2011 a review was carried out Systematic review of scientific articles related to the treatment of physical therapy in Chronic Achilles tendinopathy. The bibliographic search was done in the bases Medline, WoS and CINAHL, being complemented with the base search engine Pub Med Central and the Science Direct portal. For the choice of the articles the keywords "Physical Therapy "," Achilles Tendon "," Chronic Disease "," Tendinopathy "and the following inclusion criteria: - Scientific articles published from 2006 to the present-Articles dealing with chronic Achilles tendinopathy and Effect of different conservative therapeutic modalities on the same. - Accessible articles available in full text. - Articles written in English, Spanish or Portuguese. Figure 2 reports the search strategy followed in each case, as well as Such as the results obtained and the exclusion criteria used for the disposal of unused items.

3.      Results

After the bibliographic search, 18 studies were analyzed (of the total 19 articles found) for this review that met the criteria of inclusion. One of them corresponds to a study protocol, in which they still specified the results of the investigation, so it was not analyzed. The articles analyzed investigate the effect of different modalities Therapies that can be managed by physiotherapists in case of tendinopathy Chronic Achilles tendon. The modalities used in the different Articles were as follows:

o    Eccentric exercise program only (in 5 articles).

o    Eccentric exercise program combined or compared to other exercises

Therapeutic modalities: shock waves, ultrasound (US), night splints, AirHeel ankle brace, combined conservative therapies (US, transverse massage Deep, ice ...) and laser (in 10 articles)

o    Treatment with extracorporal shock waves (in 2 articles, one

Which compares this therapy with other conservative therapies, and the other, which focuses only in shock waves).

o    Approach with a set of combined and specific mobilizations Of soft tissue (in 1 article). Table 1 shows the main characteristics of the studies Included in the present study. In relation to the eccentric work developed, Indicate that most of the work applies a training regime Eccentric with a similar protocol consisting of 12 weeks of exercises Eccentrics with daily work (usually 3 sets of 15 repetitions, performed One, two or three times daily depending on the study). The exercises were performed On a platform or ladder, supporting the forefoot of the affected member and Maintaining maximum plantar flexion. Once in this position, and leaving as Sole support of the affected limb's foot, it slowly descended to a Maximal dorsiflexion, with consequent stretching of the tendon. The climb, Concentric contraction, was developed with the healthy limb (in the Cases of unilateral tendinopathy) and with the help of the arms (in cases Bilateral). This exercise was performed with the stretched knee (for contraction of both twins) and folded (to center the work on the soleus). In all it was noticed To patients experiencing possible pain or discomfort from mild to Moderate, which was permitted, as long as it was not an incapacitating pain. Progressive eccentric training was applied, both in repetitions and in Load, placing a backpack with 5 kg of weight once the patients did not They will experience pain when performing the exercises with the own weight of the body.

4.      Discussion

After the results found in the review, the first thing we can To point out is that the most used therapeutic option is the exercise Eccentric, since they are a treatment regimen in 15 of the 18 articles analyzed, Which, to a certain extent, indicates its importance in the management of tendinopathy Chronicle of Achilles. Second, we encounter shock waves. However, as we can see throughout the analysis of the results, Not all articles analyze the same treatment regimen, do not follow the Same Achilles involvement, nor to the same area of ​​the tendon. Thus, we find ourselves With a majority that focuses on the pathology of the middle and proximal area of ​​the Tendon, discarding insertional pathology [1,6,9-15] Another group, not so numerous, that It treats pathology of the insertion and the middle portion indistinctly, or that It simply does not specify the exact location of the affection [2-4,7,16,17] two that They exclusively treat the pathology of tendon insertion [5,18]; And, finally, one whose Sample are healthy subjects [19]. If we talk about the type of pathology, we can that the articles generally analyze tendinopathy in general, without Clarify what type of concrete injury persists in the tendon. However, there are Exceptions. The first, the article published by Henriksen et al [19] Healthy subjects (although we focus on the effectiveness of eccentric treatment at the Tendinopathy of the middle portion of the Achilles). And, in the same way, led them to By Boesen ET al [4], Christenson [2] and Langberg et al [10], in the three cases are Tendinosis, and that of Saxena et al [7], whose specimens show paratendinosis or Tendinosis. Likewise, not all patients have the same characteristics. The subjects that make up the different samples are from physically Active and practicing sports on a regular basis, to subjects practicing sports Occasionally, people with a sedentary life without sports practice or even, elite athletes. These differences make it difficult to compare results Obtained, since the patients will evolve differently depending on their state of form, their activity and their age. In addition to these differences, we can observe that the sample size Used by the authors is not broad enough to extrapolate the results to the population and generalize the results obtained in them. In spite of all these limitations, Positive results obtained in most of the studies, which, although it is necessary to continue with the research in this field, it allows to show the Benefits of a conservative treatment from the physiotherapy of tendinopathy Chronicle of Achilles. Thus, the eccentric work in this pathology shows a Beneficial in the regeneration of the collagen tissue [10], in the microcirculation of the Tendon [16] and in its vascular response [4], besides an improvement in the functionality [1-3,5- 7,9,11-16,18], in pain [1-3,5-7,9-11,11,12,14-18] and in the quality of life of the patients Patients [1,5,7,9,13-16,18]. In addition, if the eccentric exercises are added the waves of shock, as reflected in the works of Rompe ET al [14] and Rasmussen et al.

Al [3], it appears that the results on chronic Achilles tendinopathy improve. InIn any case, it would be necessary to continue investigating on which therapeutic modality is more In the work of Rompe et al [18], better results are obtained in the Group treated only with shock waves than in the group treated only with exercises Eccentric, although in the other of this same first author [15] are not observed Significant differences between both, although yes with respect to the control group. That it seems clear is that the shock waves also appear to conform A valid therapeutic option [5, 7]. Despite what was said in the previous paragraph, Physiotherapy in the treatment of the chronic tendinopathy of the Achilles tendon still has a way to go. So, of the three works that used an orthosis, the results with a night splint were not positive [12] and with an Air Heel ankle brace they did not improve those obtained to the group that followed a work with eccentric exercises [9], while the use of Semi-rigid splints did offer better results than a physiotherapeutic treatment [17]. No better results were obtained with the use of ultrasound [13] or Ultrasounds and Cyriax [6] than with eccentric exercises. The same we can think of If using laser [1], although its use offered similar benefits to the treated group Only with eccentric exercises, the authors modified the habitual protocol followed In case for the use of these. All this, together with the limitations indicated at the beginning of this section, allows us to suggest that the effects of the various therapeutic modalities related to the treatment of tendinopathy to use common protocols of action and valuation in order to be able to and use larger samples to facilitate the generalization of Results.

5.      Conclusions

Eccentric exercises are the most standardized therapy at the time of Treating, through physiotherapy, chronic tendinopathy of the Achilles tendon, following most articles a common protocol lasting 12 weeks Where 3 sets of 15 repetitions are performed, usually once or twice a day. The annexation of other therapeutics different from the exercise program Eccentric is shown favorable with US and deep transverse massage, with laser or with shock waves. In the latter case, even its use offers better Results than with the eccentric exercise program. On the contrary, the addition A night-time splint or an Air Heel ankle bracelet does not produce this synergistic effect. There are authors who do not investigate this synergistic effect, but rather Effectiveness of eccentric exercises with other therapeutic alternatives. From this Form different treatments valid and alternative to the exercises Eccentrics, such as shock waves or the use of Semi-rigid orthopedic insoles. Within the generic pathology of chronic Kolesin tendinopathy, The articles focus on some areas or other tendon, or on a type of involvement Concrete or other, so the results are not comparable, although the most Favorable results are obtained in tendinopathies that affect insertion rather than Middle or proximal tendon We can also conclude that sedentary patients evolve worse and More slowly than active patients or with involvement in the sport. Of the same In this way, the longer the evolution affects, the worse the evolution. Finally, the work should consist of a larger sample for the Extrapolation and generalization of results. This systematic review Offers a possible pathway for chronic tendonopathy of the tendon of Achilles, but its effectiveness still has yet to be proven and the data. Conflict of interests. The authors state that there is no conflict of interest when writing the article.


Figure 1:  Representation and classification of the different risk factors of Atherosclerotic tendinopathy.




Figure 2: Scheme with the search strategy carried out and the results obtained in each case, as well as the excluded articles and the

 

Author

 

Shows

Affectation

Treatment

Duration of Treatment

Results

Langberg et al10

12football players of Elite

(MS: 26)

GE: 6 with tendinosis

Unilateral chronic

half.

GC: 6 healthy

EE

12 weeks

2 sessions / day

GE: ↑ synthesis of collagen in the

Injured tendons (measured with

Technique of microdiálisis) and ↓ pain

(Measured with EVA scale)

Sayana et al.

34 patients

Sedentary

(MS: 44)

Tendinopathy

Unilateral chronic

half

EE

12 weeks

2 sessions / day

19 improved (use of the questionnaire

VISA-A, with an average increase of

11.5 points on its scale)

15 showed no improvement

Knobloch16

59 patients

64 tendons

Affections

(MS: 49)

Tendinopathy

Chronic instillation

(10 tendons) and

Mean (54 tendons)

EE

12 weeks

1 session / day

Pain and improvement of quality of life

(Use of the FAOS questionnaire)

↓ the capillary blood flow of the tendon

(Measured with Doppler and

Blood flow spectroscopy)

SatO2 invariable

Knobloch16

21 sujetos

(realizaban

AF)

(EM:

GC: 28

GE: 34)

GE: 11 con

tendinosis unilateral

insercional y media

GC: 10 sanos (pero

sin entrenar al

menos en los 2 años

anteriores)

EE (GE)

5 km de

carrera (GC)

series

3 x15 rpt

GC: Doppler activity in 6

Tendons of 5 patients before

exercise; After the race in 8

Patients.

GE: Doppler activity before and

After EE in all

Patients.

Henriksen et

al19

16 subjects

Healthy

(MS:)

Any

EE

5 x 3 dorsiflexions

Complete

↓ EMG activity and ↑ forces

Three-dimensional reaction in

Leg muscles in phase

Eccentric

Your and al12

58 patients

70 tendons

They performed

AF)

GE1: 34

(MS: 44.1)

GE2: 36

(MS: 45.1)

Tendinopathy

Chronic portion

half

GE1: EE

GE2: EE +

Splint

Nocturnal

12 weeks

1 session / day

GE1: ↑ significant in 78% of the

Tendons in the

Questionnaire VISA-A + 63% of

Excellent or good satisfaction

(Measured by questionnaire)

GE2: ↑ significant in the 71% in the

VISA-A and 48% in satisfaction

Petersen and

Al9

100

Patients

GE1: 37

GE2: 35

GE3: 28

(MS: 42.5)

Tendinopathy

Chronic portion

half

GE1: IN

GE2:

tobillera

AirHeel

GE3: IN +

AirHeel

12 weeks

3 sessions / day

Satisfactory results in the 3

Groups (in EVA scale, scale of

AOFAS and SF-36 questionnaire) without

Significant differences between them

Chester and

Al13

16 patients

Sedentary

(MS: 53)

Tendinopathy

Chronic portion

half

GE1: EE

GE2: US

GE1:

12 weeks

1 session / day

(6 weeks

Supervised and 6

Weeks no)

GE2:

6 weeks

2 sessions / sem

At 6 weeks: both groups

Improved in terms of pain

EVA), but not at 12 weeks.

↑ values of functionality in GE2

(As measured by the FILLA index), but not

Are significant in relation to GE1

Herrington y

McCulloch

25 patients

They performed

AF with

Load for

The tendon)

GE1: 12

(MS: 36.6)

GE2: 13

(MS: 37)

Tendinopathy

Chronic portion

half

GE1:

US + Cyriax

GE2:

US + Cyriax

+ EE

GE1:

6 weeks

1 session / sem +

program of

Stretching 12

Weeks

GE2:

Same as GE1 + EE

12 weeks

2 sessions / day

Both groups improved from

The 12th week, but the improvement was

Significant difference in GE2, where

Reached the maximum score

(Measured with VISA-A questionnaire)

Mayer et al17

28

halls

(More than 32

Km / week)

GE1: 11

(MS: 41)

GE2: 9

(MS: 35)

GC: 8

(MS: 38)

Tendinopathy

Unilateral chronic

GE1:

US + Cyriax

+ Ice + EE

+ EP

GE2:

templates

Orthopedic

Semi-rigid

GC: sin

treatment

GE1:

8 weeks

4 sessions / sem

GE2:

Same GE1 + 12

Laser sessions

total

Pain in 6 of GE1 and 8 of GE2 without

Significant differences between the two

GE (through index POI)

↑ eccentric force in both GE

Stergioulas

And al1

40 patients

They performed

AF)

GE1: 20

(MS: 28.8)

GE2: 20

(MS: 30.1)

Tendinopathy

Chronic portion

half

GE1: EE

GE2: EE +

Low laser

intensity

GE1:

12 weeks

2 sessions / day

GE2:

Same GE1 + 3

OCR sessions

In total (weeks

4th, 5th and 6th)

After follow-up control on the 12th

Week ↓ pain was greater and

Reached faster in the GE2

(Measured with VISA-A scale).

Also less symptomatology

Secondary in GE2.

Rompe et

Al14

68 patients

They performed

AF)

GE1: 34

(MS: 46.2)

GE2: 34

(MS: 53.1)

Tendinopathy

Chronic

unilateral

GE1: EE

GE2: EE +

OCR

GE1:

4 weeks

1 session / without

GE2:

Same GE1 + 1

Sitting / without

OCE (4 sessions

total)

At the beginning of the

Treatment groups, both groups

The EVA and VISA-A scales and

Its FA (56% of GE1 and 82% of GE2)

Rasmussen

It is

48 patients

GE1: 24

(MS: 46)

GE2: 24

(MS: 49)

Tendinopathy

chronicle

GE1: EE

GE2: EE +

OCE

GE1:

12 weeks

2 sessions / day

GE2:

3 sessions of

OCR in total

(Weeks 2 nd, 3 rd and

4ª)

After the 4th, 8th and 12th week of

Follow-up, both groups improved

Level of pain (EVA scale), but the

GE2 achieved better results in

Functionality according to the AOFAS scale

Rompe et

Al18

50 patients

GE1: 25

(MS: 39.2)

GE2: 25

(MS: 40.4)

Tendinopathy

Chronic instillation

GE1: EE

GE2: OCR

GE1:

12 weeks

2 sessions / day

GE2:

3 sessions of

OCR in total

(Range of 1

week)

At the beginning of the

Treatment, both groups improved

Significantly on the EVA scales

And VISA-A, especially in GE2 (16

Patients of GE2 versus 7 of GE1

They get a complete improvement)

Rompe et

Al15

75 patients

GE1: 25

GE2: 25

GC: 25

(MS: 48.6)

Tendinopathy

Chronic portion

half

GE1: EE

GE2: OCR

GC: sin

treatment

GE1:

1 session only

GE2:

1 session only

GC:

repose,

Modification of

Footwear, baths

contrast,

Iontophoresis, ice,

US, massage,

Stretching ...

At the beginning of the

Treatment, both GE improve

Significantly on the EVA scales

And VISA-A

Furia5

68 patients

(42

They performed

AF)

GE1: 12

(MS: 52.2)

Ge2: 23

(MS: 49)

GC: 33

(MS: 52.6)

Tendinopathy

Chronic instillation

GE1: OCE +

anesthesia

local

GE2: OCE +

anesthesia

regional

GC:

treatment

conservative

3 sessions of

Spaced OCE

With each other 7 days (+/-

3), without anesthesia and

Restricting

Taking NSAIDs

After valuation at the month, 3 and 12 months

Of treatment, much greater improvement

In GE than in GC (measured with

Scale of Roles and Maudsley, and EVA) and

They resumed AF

Saxena et

al7

60 patients

74 tendons

(MS: 48.32)

Paratendinosis (in

32 tendons)

Proximal Tendinosis

(In 23)

Tendinosis

Insertional (in 19)

OCR

6 weeks

After one year of treatment, and according to

The Roles and Maudsley Scale, there were

Significant improvements in 75% of the

Paratendinosis, in 78.26% of the

Proximal tendinosis and 84.21% of

The insertions

Christenson2

Single case

(athlete)

(Age 39)

Chronic Tendinosis

bilateral

Cyriax +

work

Isometric and

Of load

Dynamics of

Triceps sural

 

At the end of the treatment program,

Maximum score on the VISAA scale,

Without pain (EVA scale) and increased

Of the length of twins and soleus,

Confirming this improvement in the

Follow up 3 months later


Table 1: Characteristics of included studies.

  1. Stergioulas A, Stergioula M, Aarskog R, Lopes-Martins RAB, Bjordal JM (2008) Effects of Low-Level Laser Therapy and Eccentric Exercises in the Treatment of Recreational Athletes With Chronic Achilles Tendinopathy. Are J Sports Med 36: 881-888.
  2. Christenson RE (2007) Effectiveness of specific soft tissue mobilizations for the management of Achilles tendinosis: Single case study - Experimental design. Man There 12:63-71.
  3. Rasmussen S, Christensen M, Mathiesen I, Simonsen O (2008) Shockwave therapy for chronic Achilles tendinopathy. A double-blind, randomized clinical trial of efficacy. Acta Orthop 79: 249-256.
  4. Boesen MI, Koenig MJ, Torp-Pedersen S, Bliddal H, Langberg H (2006) Tendinopathy and Doppler activity: the vascular response of the Achilles tendon to exercise. Scand J Med Sci Sports 16: 463-469.
  5. Furia JP (2006) High-Energy Extracorporeal Shock Wave Therapy as a Treatment for Insertional Achilles Tendinopathy. Am J Sports Med 34: 733-40.
  6. Herrington L, McCulloch R. (2007) The role of eccentric training in the management of Achilles tendinopathy: A pilot study. Phys Ther Sport 8: 191-6.
  7. Saxena A, Ramdath SJr, Halloran OP, Gerdesmeyer L, Gollwitzer H (2011) Extra-corporeal Pulsed-activated Therapy («EPAT» Sound Wave) for Achilles Tendinopathy: A Prospective Study. J Foot Ankle Surg 50: 315-319.
  8. Munteanu SE, Landorf KB, Menz HB, Cook JL, Pizzari T, et al (2009) Efficacy of customised foot orthoses in the treatment of Achilles tendinopathy: study protocol for a randomised trial. J Foot Ankle Res 2: 27-40.
  9. Petersen W, Welp R, Rosenbaum D (2007) A Prospective Randomized Study Comparing theTherapeutic Effect of Eccentric Training,the AirHeel Brace, and a Combination of Both. Am J Sports Med 35: 1659-1667.
  10. Langberg H, Ellingsgaard H, Madsen T, Jansson J, Magnusson SP, et al. (2007) Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports 17: 61-66.
  11. Sayana MK, Maffulli N (2007) Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. J Sci Med Sport 10: 52-58.
  12. de Vos RJ, Weir A, Visser RJ, de Winter T, Tol JL (2007) The additional value of a night splint to eccentric exercises in chronic miportion Achilles tendinopathy: a randomised controlled trial. Br J Sports Med 41: e5-e11.
  13. Chester R, Costa ML, Shepstone L, Cooper A, Donell ST (2006) Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain - A pilot study. Man There 13: 484-491.
  14. Rompe JD, Furia JP, Maffulli N (2009) Eccentric Loading Versus Eccentric Loading Plus Shock-Wave Treatment for Midportion Achilles Tendinopathy. Am J Sports Med 37: 463-472.
  15. Rompe JD, Nafe B, Furia JP, Maffulli N (2007) Eccentric Loading, Shock- Wave Treatment, or a Wait-and-See Policy for Tendinopathy of the Main Body of Tendo Achillis. Am J Sports Med 35: 374-383.
  16. Knobloch K (2007) Eccentric training in Achilles tendinopathy: is it harmful to tendon microcirculation? Br J Sports Med 41: e2-e7.
  17. Mayer F, Hirschmüller A, Müller S, Schuberth M, Baur H (2007) Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy. Br J Sports Med 41: e1-e5.
  18. Rompe JD, Furia JP, Maffulli N (2008) Eccentric Loading Compared with Shock Wave Treatment for Chronic Insertional Achilles Tendinopathy: A Randomized, Controlled Trial. J Bone Joint Surg 90: 52-61.
  19. Henriksen M, Aabo J, Bliddal H, Langberg H (2009) Biomechanical characteristics of the eccentric Achilles tendon exercise. J Biomech 42: 2702-2707.

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