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Insertional Achilles tendinopathy is a troublesome condition, most often seen among middle-aged to older individuals who are not physically active and are overweight. 1 The suggested aetiology is degenerative lesions at the enthesis due to either excessive tensile loading 2 3 or, more recently, to stress-shielding. 4 There is often a combination of pathologies, including superficial and retrocalcaneal bursitis, Haglund deformity of the upper calcaneus and tendinopathy. 5 6
The mechanisms behind this painful condition are unknown 7 8 and treatment is often ineffective. 7 9 Consequently, many different conservative treatments have been proposed, including rest, nonsteroidal anti-inflammatory drugs (NSAIDs), ice, strength training and high-energy extracorporeal shock-wave therapy. 1 10 11
Eccentric training is a frequently-used treatment model. 12 - 15 The eccentric exercise programme that has been shown to be successful for patients with mid-portion Achilles tendinosis was less successful for patients with insertional Achilles tendinopathy. 12 It was thought that this was because of differences in pathology; however, the pathology appears similar in both mid-tendon and insertional tendinopathy. 16 The concept of an "enthesis organ", 17 where the insertion is subject to compressive forces in dorsiflexion because of impingement between tendon, bursa and bone suggests that the Achilles tendon insertion may respond to eccentric load without dorsiflexion.
This pilot study aimed to evaluate eccentric calf-muscle training without dorsiflexion in patients with chronic painful insertional Achilles tendinopathy.
MATERIAL AND METHODS
Participants
Participants with pain in the Achilles tendon insertion for more than 3 months were recruited from the Sports Medicine Unit in Umeå and the Capio Artro Clinic in Stockholm, Sweden. Participants were included if they had insertional pain and pathology based on a clinical examination (HA) and abnormality on ultrasonography. A high-resolution grey-scale ultrasound with the aid of colour Doppler (Siemens Acuson Segoia) and a linear multifrequency (8-13 MHz) probe was used. Abnormalities included Achilles tendon and bursal thickening, bone pathology (calcification, spur, fragment), and neovascularisation. The contralateral tendon was also examined. Participants with chronic inflammatory disease were excluded. All patients gave written consent to participate in the study. The study was approved by the ethics committee of the Medical Faculty at the University of Umeå.
Eccentric training regimen
All patients were given a practical demonstration and hand-written instructions of the exercises by...