Top Tips for Eccentric Training & Tendinopathy

Eccentric Training for Tendinopathy Injuries:

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Eccentric training is a form of training in which the muscle is worked as it lengthens. In contrast, concentric training involves a muscle working as it shortens. A good example of these can be observed within a bicep curl – as the elbow bends the biceps work concentrically and the muscles shorten as they work. However, as the elbow then straightens the bicep muscles are lengthening, but they continue to contract and work as they control the movement.


It has been found that the faster a muscle contracts concentrically (shortening), the lower the tension it is able to generate (1). Tension in muscle fibres when lengthening (eccentric) is considerably greater than when muscle fibres are shortening (2).

Previous studies have shown that when a muscle is eccentrically lengthened, the energy requirement falls substantially in comparison to concentric contractions because ATP breakdown and heat production are both slowed (2). Furthermore, with increased heat generation during concentric work, there is a concurrent increase in cellular metabolism. Thus, more waste products will be generated with concentric work, potentially leading to chemical irritation of nerves and eventually pain (6).


Tendons are the extremities of a muscle that attaches to bone and injury to tendons can occur from sudden trauma, overuse or repetitive strain. Tendon injuries account for 30-50% of injuries in sports (4). Specifically, chronic problems caused by overuse of tendons result in 30% of all running-related injuries, and elbow tendon injuries can be as high as 40% in tennis players (8). Incidence of patellar tendonopathy is reported to be as high as 32% and 45% in basketball and volleyball players, respectively (5). It is therefore important to quickly diagnose and treat such injuries with physiotherapy.

Eccentric training for tendinopathies

The Alfredson et al (1) protocol has frequently been used since its production in 1998 and appears to be a safe, effective method of implementing the eccentric training program for tendinopathies. However, this protocol was produced for and used in the treatment of achilles tendinopathies and their exact recommendations may not be appropriate for all tendons or regions.

The Alfredson protocol used three sets of 15 repetitions of bent knee and straight knee calf raises, twice a day, seven days per week over 12 weeks. Athletes were told to work through pain, only ceasing exercise if pain became disabling. Training load was increased in 5 kg increments with use of a backpack that allowed for the addition of the weight once training with bodyweight was pain free. The eccentric phase of the exercise should be performed relatively slowly, counting to 3-4 seconds as you complete the movement. The concentric phase should be avoided and the other limb can return you to the starting position of the exercise.

All of the subjects within the initial study (1) who used this protocol, returned to pre-injury activity levels and found a significant decrease in pain with a significant increase in strength.

According to Lorenz & Reiman (6), the physiotherapist may use the Alfredson protocol for an example of volume and frequency of training, but addition of weights and resistance should be dictated by the amount of pain experienced by the individual, and the exercises should be dictated by a physiotherapist to ensure correct technique and suitability of exercises.

Curwin (3) has also proposed a method to determine training load in eccentric training for tendon injuries. One significant difference between Curwin’s and Alfredson’s programs is that the athlete performs both the concentric and eccentric portion of the exercise in Curwin’s program, with the eccentric portion being performed faster. In Curwin’s protocol, they suggest that the athlete should experience pain and fatigue between 20 and 30 repetitions at a given load, when performing three sets of 10 repetitions.

Their rationale for experiencing pain is based on the premise that exercise load should be determined by the tendon tolerance, which is indicated by pain experienced during the exercise. If there is no pain after 30 repetitions, the stimulus is inadequate. Either load or the speed of exercise performance should be increased, but not both simultaneously.

Based on the clinical experience of the authors and others (7), it is recommended that 6-12 repetitions over four sets be completed to emphasize strength in the muscle-tendon complex. The athletes use the load from the six repetition resistance and build up to twelve repetitions prior to increasing load again. This process helps to maintain safe and progressive eccentric training. Additionally, the authors advocate three to four sessions per week instead of every day.

Lorenz & Reiman (6) suggest that the physiotherapist or athlete do not perform the concentric portion of the exercise or perform it with the assistance of the uninvolved limb, followed by having the athlete perform the eccentric portion of the exercise independently. Based on clinical experience, the concentric portion of the exercise can be attempted without assistance once non-sport/day-to-day activities, like walking, stair climbing and washing, are pain free.

As with eccentric exercise, progression of the concentric portion of exercise should involve a gradual increase. Once the concentric portion of exercise is pain free, the athletes can begin jogging or more sport specific activities.


1. Alfredson H, Pietila T, Jonsson P, & Lorentzon R. (1998) Heavy-load eccentric calf muscle training for treatment of chronic Achilles tendinosis. Am J Sports Med. 26: 360-366.

2. Curtin N A & Davies R E. (1970) Chemical and mechanical changes during stretching of activated frog muscle. Cold Spring Harb Symp Quant Biol. 37: 619-626.

3. Curwin S L. (1996) Tendon injuries: Pathophysiology and treatment. In: Athletic Injuries and Rehabilitation. J Zachazewski, DJ Magee, WS Quillen, ed. Philadelphia, PA: WB Saunders Co. 27-54.

4. Khan K M & Scott A. (2009) Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med. 43: 247-251.

5. Lian O B, Engebretsen L & Bahr R. (2005) Prevalence of jumper’s knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med. 33: 561-567.

6.Lorenz D & Reiman M. (2011) The role and implementation of eccentric training in athletic rehabilitation: Tendinopathy, hamstring strains, and acl reconstruction. International Journal of Sports Physical Therapy 6(1): 27-44.

7. Ratamess N A, Alvar B A, Evetoch T K, et al. (2009) Progression models in resistance training for healthy adults: ACSM Position Stand. Med Sci Sports Exerc.  41(3): 687-708.

8 Sharma P & Maffulli N. (2006) Biology of tendon injury: healing, modeling, and remodeling. J Musculoskelet Neuronal Interact. 6: 181-190.

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Road Testing BOXJOX

Road Testing BOXJOX

As all sports men know, securing your crown jewels whilst partaking in your sport of choice is important. I’ve come across a novel way of doing this and thought I’d share it with you. Have you heard of BOXJOX? If not, don’t be ashamed.20120811-190940.jpg

BoxJox is a compression base layer and a state of the art update on the athletic support. It wraps around the waist and through the legs creating a unified 3D structure providing both support and stability for the genitals. Engineered to use the stretch base material that flexes and moves with you in contrast to the support bands which remain controlled.

I trialled mine for the past two weeks whilst cycling to work and attending the gymnasiums, and to my surprise, they are noticeably more comfortable than ordinary sports pants or cycling shorts.

Having contacted the team at BOXJOX, I’m reliably informed that the future holds a nice variety of sports under garments for differing sports.

They’ve got an interesting blog:

And if you’re interested in joining the revolution, click here


No more need for those awkward ‘magic sponge’ moments thanks to BOXJOX.

TA Physio

Football Injury Prevention

As discussed in the previous posts, some the commonest footballing injuries involve the knee and ankles. Football being a demanding and physical sport results in injuries. In this post we are going to discuss injury prevention for football injuries.

No athlete wants to get injured and sometimes it’s not possible to avoid it but here are some exercises that will prehab the muscles to reduce injuries. The four key components to preventing injuries are

-Challenge balance & neuromuscular control systems

-Core strength is essential

-Strengthen large muscles groups

-Functionally train the body

A) Strength:

– Squats – Stand with your feet about hip width apart. – Sit back. – Bend from your hips and knees. Stick your buttocks out with your chest high. – Keep your knees behind your toes. – Remember, keep your knees and feet facing straight ahead as you squat.

– Try squatting on just on leg. Careful! Don’t let your knee turn inward.

– Lunges Walking Lunges Perform walking lunges halfway across the field and then back. As you step, keep your front knee over your ankle in line with your toes.

B) Core Strength:

Plank – its best getting advice about posture for this exercise as wrong positioning can defeat the object. Hold the position for 30 seconds and repeat 5 times.

Side Plank – Hold the position for 30 seconds and repeat 5 times.

Bridging – Hold the position for 30 seconds and repeat 5 times. The use of a gymball under the feet in this exercise challenge the neuromuscular control and balance.

C) Balance

Balance is important as many injuries are caused when athletes are off-balance. All strengthening exercises can be completed with a balance element, just add a wobble board or wobble cushion when completing.

D) Plyometrics and external cueing

– Jump side-to-side with both feet over the line.

– Jump from your left to right foot over the line.

– Jump forward-and-back with both feet over the line.

– Jump forward-and-back over a line leading with your right foot. Keep feet hip width apart. Now lead with your left.

External cueing is important as in competitive sport your decisions and therefore movements are based upon the external influences of the game. External cueing should be introduced with plyometrics and is simply done by a coach or trainer clapping to signify changing direction or drill.

Common football Injuries and Treatments

As non-contact sports go, football involves a lot of contact. The result of this or the fact that footballers go over easily, are injuries.

Three of the commonest ones are torn cartilage, ankle sprains and anterior cruiciate ligament tears. Below are the in’s and oput of these injuries and how to treat them:

Torn Cartilage

The menisci are the shock absorber cartilage of the knee consisting of two crescent shaped pads of cartilage. The inner knee menisci (medial menisci) is larger than the outer menisci (lateral menisci). The important role the menisci play for optimum knee function includes: – spreading the load across the joint, up to 50% of supporting loads in standing and 90% in flexing (knee bending). – improve joint congruency – increase the surface area of the knee joint allowing body weight to be spread across a greater area – they assist in synovial fluid circulation.

The meniscus get injured commonly, with medial menisci more likely than the lateral. The limited healing potential of the menisci , due to their blood supply only reaching the outermost 10% to 30% means they often require professional intervention. The mechanism of injury is usually a twisting injury to the knee with the foot planted.

Typical signs of a meniscal tear include:

– swelling of the knee

– increasing pain when attempting to fully squat to floor

– difficulty moving through range of motion

– or unable to fully extend

Painful knees require full assessment by a physiotherapist or orthopaedic surgeon. Symptomatic tears can result in further damage to articulate surfaces of the knee. Surgery is not always necessary and this can be discussed with a professional.

Operative Approach:

In the case of ‘bucket Handle’ tears, where a meniscal flap or loose cartilage causes frequent locking in the knee, surgical intervention may be indicated. Both types of tears in the knee include ‘degenerative’ tears which are part of the normal wear and tear process, but has been known to occur in athletes in their twenties.

Non-Operative Management:

To help your self during the initial stages of any injury, follow the PRICE guidelines:

– protect

– rest

– ice

– compression

– elevation.

The application of ice should be for 10 minutes and can be repeated every two hours. Make sure the ice pack is NOT put directly on the skin as it can cause ice burns. Compression can come in the form of ‘tubing-grip’ and elevation is making sure your knee is above your hip.

Kinesiology taping is affective at relieving and reducing swelling when PRICE advice is not practical.

Physiotherapy can help to gain further ranges of motion in the knee, and strengthen the surrounding muscles of the knee with a specific treatment programme personalised to your requirements. Soft tissue massage or sports massage can help to reduce the initial muscular bracing response secondary to pain. Sports taping and specifically kinesiology taping can help not only with the initial swelling but also to assist with muscular rehabilitation.

Returning to sport may take time and surgery will lead to a long rehabilitation process but again this can be assisted with physiotherapy. Athletes with meniscus tears can use ‘pool running’ to functionally simulate running and assist in returning to running sports. The buoyancy of the water will reduce the loads acting on the meniscus and the resistance offered when moving through the water will functionally strengthen the muscles.

The Ankle Sprain

The lateral ankle sprain is one of the commonest sporting injuries in the world. As a therapist, we see these types of sprains in patients that play weight-bearing sports. Most athletes can walk them off with the self-management of PRICE in the initial stages. However, there is a difference between mild ankle sprain and severe ankle sprains. Incorrect management can easily turn a recovery time from 3-4 months into 12-18 months.

Severe ankle sprains, once cleared of any fractures on x-ray, typically present as:

– a history of heavy weight bearing and rotary force type injury

– significant swelling

– pain

– lack of normal movement

– and inability to walk or run without pain

The first week of rehabilitation is crucial and a clear diagnosis needs to be achieved. If weight bearing can be tolerated, then rehabilitation and inflammation management can begin. If weight bearing can not be tolerated, then significant damage to the ankle may of occurred. In this case weight bearing needs to be re-introduced steadily from partial weight bearing to full weight bearing, then walking. Each step should be delayed and introduced at the right time, this will be increasing frustrating for the athletes as they want to return to sport sooner ratherthan later.

Rehabilitation from ankle sprains firstly begins with swelling management and isolated range of motion in the pain free range. Getting the ankle moving is also key to manage the swelling. Swelling can be managed with PRICE advice as well as kinesiology taping to increasing swelling dissipation.

The progression with rehabilitation then focuses on introducing instability, such as wobble boards in order to stimulate the neuromuscular control systems. All therapy should be functional and sports specific once full weight bearing can be achieved. Once returning to running, strapping and taping can assist in stabilising and supporting joints and muscles. However, a word of warning, don’t be reliant on these strapping once the pain dissipates, it can become habitual and superstition to use them.

The Anterior Cruciate Ligament Tear

The Anterior Cruciate Ligament (ACL) is the most commonly injured of the four major knee ligaments and is commonest amongst footballs. It often comes injured in combination with the meniscus tear. It has an important role in stabilising the knee and providing the body with proprioceptive feedback. Specifically, the ACL is responsible for maintaining the correct relationship between the femur and tibia throughout movement of the knee, stopping excessive tibial translation forwards.

The ACL can be ruptured typically with sudden twisting motions such a changing direction with the lower leg planted to the ground and turning inwards. Instant signs of an ACL rupture are pain, swelling, and potentially ‘popping’ noise. Later signs can be giving way in the knee or feeling of instability.

The management of ACL ruptures can be operative or non-operative. Returning to sport may take time and surgery will lead to a long rehabilitation process but again this can be assisted with physiotherapy. Typically, the athletes wanting to return to sports requires surgical intervention and a 9-12 month rehabilitation programme. Footballers have a whole medical team dedicated to their return to math fitness and typically return to playing within about 6 months. The more complex injuries require more intervention.

The ACL requires full assessment but rehabilitation, guided by a physiotherapist, need to be thorough and starting from basics. All rehab should have instability in the programme as this challenges the body’s neuromuscular control and proprioceptive feedback.

If you want to prevent furhter injuries and last longer through the season, then check out the next post on injury prevention exercises.

Euro 2012 Injury Patterns

So the European Championships 2012 coming to a close- the showcase of europe’s elite footballers. Despite the theatrics of some footballers, injuries do commonly occur within the sport. Technically, football is a non-contact sport but rarely is this seen even at the highest levels. The contact within the sport and the pace at which it is played these days results in injuries.

Professional footballers train daily to condition their bodies and prevention injury as a result of playing regular matches. Despite everyone’s best efforts, players still get seriously injured. We all remember David Beckham rupturing his achilles tendon in preparation for World Cup 2010, and Wayne Rooney fracturing his 4th metatarsal back in 2006.

Following the completion of European Championships 2008 in Austria and Switzerland, UEFA compiled a dossier on the injuries sustained within the tournament. The EURO’s provided thrilling competitive football from 16 countries consisting of 368 players. Forty-nine players (13%) suffered 56 injuries during the tournament. A total of 46 of the injuries occurred during matches (82%) and 10 during training (18%). The incidence of injury was approximately 16 times higher during match play (41.8 injuries/1,000 match hours) than during training (2.6 injuries/1,000 training hours). It has previously been shown that the risk of injury during match play increases with the level of play (about 10-15 injuries/1,000 hours at amateur level, about 20 injuries/1,000 hours at low professional level and signifi- cantly above 25 injuries/1,000 hours at top professional level). The injury risk during EURO tournaments, where the competitive nature of almost all matches is especially intense, is higher than the risk during longer- term competitions where especially high levels of intensity are not usually sustained.

Injury patterns

The majority of injuries (86%) were to the lower extremities, the most frequent locations being the ankle (n=11, 20%), lower leg (n=10, 18%), thigh (n=8, 14%), knee (n=8, 14%), hip/groin (n=8, 14%) and head/face (n=5, 9%). Sprains (ligament injury) were the most dominant injury type at EURO 2008 (n=16, 29%) and nine of these injuries were to the ankle and seven to the knee. The 15 muscle strain injuries mainly occurred in the thigh (n=6), calf (n=4) and groin (n=2). The physical demands of football do lead to injuries, and some are more serious than others. Cartilage tears are ten to a penny amongst footballers, from the premiership to Sunday league. Despite this, some sports people continue regardless whilst others seek intervention.

Despite all this, the Euro 2012 Finals have almost passed without serious injury. The most significant mising players were noted before the tournament began, with David Villa, Frank lampard and Carlos Puyol all missing out. During the past 3 weeks, injuries have largely been a thigh strain for Portugal striker Helder Postiga  sustained in the quarter-final win over the Czech Republic and Germany ‘s Bastian Schweinsteiger battling a chronic ankle ligament problem but has now been passed fit.

See the table below for the list of injuries before and during the Euro 2012 Finals:

England   Total Injuries 8
Player Injury Return Nxt Match
G Cahill Fractured Jaw — Ruled out of Euro 2012 —
F Lampard Hip/Thigh Injury — Ruled out of Euro 2012 —
G Barry Abdominal Strain — Ruled out of Euro 2012 —
J Ruddy Broken Finger — Ruled out of Euro 2012 —
C Smalling Groin Strain — Ruled out of Euro 2012 —
M Dawson Ankle/Foot Injury — Ruled out of Euro 2012 —
D Bent Ankle/Foot Injury — Ruled out of Euro 2012 —
T Huddlestone Ankle/Foot Injury — Ruled out of Euro 2012 —
France   Total Injuries 6
Player Injury Return Nxt Match
E Abidal Liver Transplant — Ruled out of Euro 2012 —
Y Gourcuff Ankle/Foot Injury — Ruled out of Euro 2012 —
L Rémy Hip/Thigh Injury — Ruled out of Euro 2012 —
Y Kaboul Knee Injury — Ruled out of Euro 2012 —
B Sagna Broken Leg — Ruled out of Euro 2012 —
V Diaby Calf Muscle Strain — Ruled out of Euro 2012 —
Croatia   Total Injuries 3
Player Injury Return Nxt Match
I Iličević Calf Muscle Strain — Ruled out of Euro 2012 —
I Olic Hamstring Injury — Ruled out of Euro 2012 —
D Lovren Ankle/Foot Injury — Ruled out of Euro 2012 —
Russia   Total Injuries 3
Player Injury Return Nxt Match
A Kokorin Hamstring Injury — Ruled out of Euro 2012 —
V Berezutski Hip/Thigh Injury — Ruled out of Euro 2012 —
R Shishkin Stomach Problem — Ruled out of Euro 2012 —
Spain   Total Injuries 3
Player Injury Return Nxt Match
A Iraola Ankle/Foot Injury — Ruled out of Euro 2012 —
C Puyol Knee Injury — Ruled out of Euro 2012 —
D Villa Broken Leg — Ruled out of Euro 2012 —
 Denmark   Total Injuries 2
Player Injury Return Nxt Match
D Rommedahl Ankle/Foot Injury — Ruled out of Euro 2012 —
T Sorensen Back Injury — Ruled out of Euro 2012 —
 Greece   Total Injuries 2
Player Injury Return Nxt Match
K Chalkias Hamstring Injury — Ruled out of Euro 2012 —
A Papadopoulos ACL Knee Injury — Ruled out of Euro 2012 —
 Portugal   Total Injuries 2
Player Injury Return Nxt Match
H Postiga Hip/Thigh Injury — Ruled out of Euro 2012 —
C Martins Muscle Injury — Ruled out of Euro 2012 —
 Sweden   Total Injuries 2
Player Injury Return Nxt Match
R Elm Illness — Ruled out of Euro 2012 —
J Elmander Metatarsal Fracture — Ruled out of Euro 2012 —
 Ukraine   Total Injuries 2
Player Injury Return Nxt Match
A Dykan Facial Injury — Ruled out of Euro 2012 —
O Shovkovskiy Shoulder Injury — Ruled out of Euro 2012 —
 Czech Republic   Total Injuries 1
Player Injury Return Nxt Match
T Rosicky Achilles Injury — Ruled out of Euro 2012 —
 Italy   Total Injuries 1
Player Injury Return Nxt Match
I Abate Muscle Injury 1st Jul 12 TBA
 Netherlands   Total Injuries 1
Player Injury Return Nxt Match
E Pieters Metatarsal Fracture — Ruled out of Euro 2012 —
 Poland   Total Injuries 1
Player Injury Return Nxt Match
L Fabianski Shoulder Injury — Ruled out of Euro 2012 —
 Republic of Ireland   Total Injuries 1
Player Injury Return Nxt Match
K Fahey Groin/Pelvis Injury — Ruled out of Euro 2012 —
 Germany     No Injuries

See the next post for common football injuries and treatments