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Am Fam Physician. 2003;67(5):939-940

to the editor: The most important message from the article, “Common Conditions of the Achilles Tendon,”1 was conservative therapy with nonsteroidal anti-inflammatory drugs, ice, rest, stretching, increased warm-up, and heel lifts. Based on the current literature, heavy eccentric calf muscle training should be given greater consideration as the preferred therapy.

The authors1 mention that “one study2 showed that calf muscle training is associated with a faster recovery time.” The referenced study2 of treatment of chronic Achilles tendinosis compared heavy-load eccentric calf muscle training with standard conservative therapy. Eccentric muscle training applies resistance only during the lengthening of a muscle. In the study,2 15 recreational athletes were treated with conservative therapy and another 15 recreational athletes were treated with heavy eccentric calf muscle training. The mean age was 44 years in the treatment group and 40 years in the control group. All patients had degenerative changes in the tendon 2 to 6 cm above the Achilles tendon insertion on the calcaneus seen on ultrasonographs, and had pain in this area for at least three months. The result of the study2 was that all members of the treatment group were running pain-free in three months, and none of the patients in the “conservative therapy” group had regained full function. Although the treatment group was small (15 patients), the results were compelling. These results are supported by similar studies3,4 of eccentric calf training. Heavy-load eccentric calf muscle training appears to be an effective, safe, and reasonable treatment of a difficult chronic condition.2

The patient population I serve here at the Womack Army Medical Center at Fort Bragg, N.C., is an active one, and Achilles tendinosis is a common complaint. My experience with using this technique of calf muscle training in the treatment of chronic Achilles tendinosis has been that it is effective and superior to conservative measures. One of the greatest values of this treatment is that people can continue to run during therapy. Patients who are prone to recurrent bouts of this condition continue the therapy at a reduced intensity (three times per week) as effective prophylaxis. Active patients do not respond well to clinical recommendations that require (1) prolonged decrease in activity or (2) surgery with a prolonged recovery period.

in reply: I want to thank Dr. Mulvaney for his input and clinical insight into Achilles tendinosis. I agree that calf-strengthening exercises should be considered in the treatment of patients with Achilles tendinosis because it may lead to fast recovery time, as we mentioned in our article.1 The studies24 do show promising results; however, using these exercises as the only therapy may be premature because (1) the studies were small and included patients who were followed very closely, and (2) the studies are not strong enough to show that no harm would come to some patients using this method. One risk of this condition is a full Achilles rupture, which is caused by the microtears of tendinosis, and could be enhanced by the exercises. Therefore, though eccentric calf-strengthening exercises should be used, this method of management should be used cautiously and the methods of ice, stretching, the decrease (not elimination) of activity, and heel lifts should still be used.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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