Common subjective findings of tendinopathy
- recent change in activity/load
- localized pain (point)
- pain may initially decrease (warm up phenomenon)
- load related to pain (faster they run=more pain)
- increased pain the morning after activity
Objective: Functional loading test for achilles
- heel raise/hopping
- pain localized to mid portion of achilles/insertion at calcaneus
Objective: Functional loading test for patellar tendon
- single leg squat/jumping
- pain localized to mid portion patellar tendon/inferior pole of patella
Objective: Functional loading test for gluteal tendon
- single leg stance
- pain localized to mid portion gluteal tendon
Principles of tendon rehabilitation
*same as muscle rehab
1. Relative rest
2. Early mobilization
3. Early strengthening
Tendon loading program - eccentrics (FITVP)
F: 2 x day, 7 days per week x 12 weeks
I: non disabling pain
T: eccentrics
V: 3 sets x 15 reps, 3sec/rep, 3 min rest
P: once no pain, add load until non-disabling pain
Do structural changes (collagen/matrix) explain the response to therapeutic exercises (eccentrics) in tendinopathy?
- NO
- they do work, but not in the way we thought
How long does structural change take in tendons with rehab?
- at least 12 weeks due to slow metabolic activity
Pain monitoring model
No pain –> acceptable zone –> high risk zone
1. Pain is allowed to reach 5 on the NPRS during the activity
2. The pain after completion of the activity is allowed to reach 5 on NPRS
3. The pain the morning after the activity should not exceed a 5 on the NPRS
4. Pain and stiffness is not allowed to increase week to week
Are isotonics useful for tendon rehab?
- yes
Achilles tendinopathy rehab protocol: Phases
- Symptom management (weeks 1-2)
- Recovery (weeks 2-5)
- Rebuilding (weeks 3-12)
- Return to sport (month 3-6)
Achilles tendinopathy rehab protocol: Status
- Pain with all activities, pain when performing 10 one legged heel rises
- Pain with exercise, morning stiffness, pain when performing heel rises
- Tolerates program with no pain
- Minimal symptoms
Achilles tendinopathy rehab protocol: treatment program
- Progress loading up to 100% body weight w slow motion - 3x10 once a day (inner range)
- Increased speed and external resistance- 3x15 once a day (outer range)
- Progress external resistance and initiate plyometrics- 3x15 2-3x/week (add load)
- Sport-specific loading speed and movement patterns - 3x15 2-3x/week (add speed)
Energy storage and release exercises
- plyometrics
- initial rapid eccentric contraction followed immediately by rapid concentric contraction
How does speed of loading a tendon impact energy storage?
- the faster a tendon is loaded, the stiffer is becomes and the more elastic energy it stores
Why are energy storage and release exercises a good option for tendon loading programs?
- good for safely resuming activities that require power bc it generates high tensile forces without much external load
Tendon loading programs - Heavy slow resistance (FITVP)
F: 3x/week, 12 weeks
I: 15-6 RM
T: isotonics
V: 3-4 sets, 15-6RM, 6sec/rep, 3 min rest/set
P: increase volume, increase intensity
Was there a structural change in tendon with heavy slow resistance?
- yes in one study
Did the eccentric tendon loading program or heavy slow resistance have more participation satisfaction?
- HSR bc eccentric exercises can be time consuming and high volume
Was there better outcome in patients who performed eccentric vs HSR training?
- no SD in pain or function
What does tendon structural adaptation depend on?
- loading intensity (must be >70%) NOT contraction type
- needs to be longer durations (>12 weeks)
How are isometrics important in tendon rehab?
- induces analgesia (reduces pain for short period of time)
- reduces inhibition for short time
What are the different tendon loading programs we can use in rehab?
- isometric
- strength (isotonics)
- functional strength
- speed
- plyometrics
- return to play
When is it a good idea to prescribe isometric over isotonic loading for tendons?
- if there is pain with isotonic exercise
