Sportverletz Sportschaden 2010; 24(4): 188-189
DOI: 10.1055/s-0029-1245824

© Georg Thieme Verlag KG Stuttgart · New York

Eccentric Calf Muscle Training – The Story

Exzentrisches Muskeltraining – über den AnfangH. Alfredson1
Further Information

Publication History

Publication Date:
14 December 2010 (online)

This started 1995. Myself I was a recreational runner, who gradually started to get midportion Achilles tendon pain. I tried rest and alternative training for 3 – 4 months without effect on the painful condition. My friend the radiologist Dr Lars Öhberg had a look with the ultrasound machine, and this showed a thickened midportion (11 mm) with structural abnormalities located on the ventral side of the tendon. At that time I was responsible for the tendon treatments at our clinic, and we treated patients with this condition with open surgery (central longitudinal tenotomy, excision of macroscopically abnormal tendon tissue), followed by immobilization in a cast for 6 weeks and althogether a 4 – 6 months rehabilitation period. I went to talk to my boss, Professor Ronny Lorentzon, about him operating me in my Achilles. He looked at me like I was telling him a joke and said, forget it, you have yourself in a recent study shown that it takes about 4 – 6 months to recover from surgery, and there will be a period with sick leave. We have many patients on our waiting list and cannot afford to have you on sick leave. I went away, being very disappointed and a little angry.

This started me to study the literature about conservative treatment methods. I found the proposal raised by Curwin and Stanish, saying that eccentric training should be included in the treatment of chronic tendon conditions, and decided to give this method a try. Performing the eccentric calf muscle training over the step was not very pleasant. It was very painful, and the pain got worse than ever after a week of training. I went back to my boss Ronny Lorentzon, now limping badly, and asked again about him operating me. He looked at me shortly and said, maybe you didn’t understand me when we had this discussion previously. This made me angry, and I went back into the gym and continued with my eccentric training, now thinking, well, if I rupture my tendon during this painful training, then Professor Lorentzon needs to operate on my tendon anyway! However, after altogether about 2 – 3 weeks of painful eccentric training strange things started to happen. My Achilles gradually started to get pain-free! The morning stiffness was gone, I could walk without pain, and I could load more during my eccentric training. After about 5 – 6 weeks I was back jogging again, which was fantastic.

This was the start of our research on eccentric training as a treatment model for patients with chronic painful midportion Achilles tendinosis. We should thank Professor Lorentzon, because if he had operated my Achilles, we would never have started this research.

After the successful treatment of my own Achilles, we designed an eccentric training regimen to be tried on our patients at the waiting list for surgical treatment of chronic painful midportion Achilles tendinosis. In the pilot study, all 15 included patients were satisfied with the treatment, and didn’t want to have surgery. After one year, one patient had regained pain symptoms and this patient was surgically treated. All the other 14 are still satisfied and active in Achilles tendon loading activities. After this pilot study we have performed multiple studies on the effects of eccentric training. Overall the results are good in about 80 % of the cases. However, it seems that high level athletes, especially spike shoe runners and jumpers, have less good results with this treatment. Also, it is important that the patients have a correct diagnosis before this treatment is instituted. A partial rupture has to be excluded. Eccentric training on a patient with a partial rupture will lead to a worsening, not seldom a lengthening of the Achilles tendon, a condition that is very difficult to treat. An interesting observation is that in the successfully treated patients the tendon thickness is decreased and the structure is normalized sonographically. Consequently, it seems that eccentric calf muscle training has a potential to remodel, and possible also induce a regeneration, of the previously so-called degenerative tendon.


  • 1 Alfredson H, Pietilä T, Lorentzon R. Chronic Achilles tendinitis and calf-muscle strength.  Am J Sports Med. 1996;  24 829-833
  • 2 Alfredson H, Nordström P, Lorentzon R. Prolonged progressive calcaneal bone-loss despite early weightbearing rehabilitation in patients surgically treated for Achilles tendinosis.  Calcif Tissue Int. 1998;  62 166-171
  • 3 Alfredson H, Pietilä T, Öberg L et al. Achilles tendinosis and calf-muscle strength. The effect of short-term immobilization after surgical treatment.  Am J Sports Med. 1998;  26 166-171
  • 4 Alfredson H, Pietilä T, Jonsson P et al. Heavy-loaded eccentric calf-muscle training for the treatment of chronic Achilles tendinosis.  Am J Sports Med. 1998;  26 360-366
  • 5 Alfredson H, Nordström P, Pietilä T et al. Bone mass in the calcaneus after heavy loaded eccentric calf-muscle training in recreational athletes with chronic Achilles tendinosis.  Calcif Tissue Int. 1999;  64 450-455
  • 6 Mafi N, Lorentzon R, Alfredson H. Superior results with eccentric calf-muscle training compared to concentric training in a randomized prospective multi-center study on patients with chronic Achilles tendinosis.  Knee Surg, Sports Traumatol, Arthrosc. 2001;  9 42-47
  • 7 Öhberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis-normalized tendon structure and decreased thickness at follow-up.  Br J Sports Med. 2004;  38 8-11
  • 8 Fahlström M, Jonsson P, Lorentzon R et al. Chronic Achilles tendon pain treated with eccentric calf-muscle training.  Knee Surg, Sports Traumatol, Arthrosc. 2003;  11 327-333
  • 9 Öhberg L, Alfredson H. Effect on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis?.  Knee Surg, Sports Traumatol, Arthrosc. 2004;  12 465-470

Prof. Dr. Håkan Alfredson

Sportmedizin, Universität Umeå

Gösta Skoglunds väg 3

SE-901 85 Umeå