Lower Limb Tendinopathy

I recently attended Sports Medicine Australia's National Conference 2016.  They held a masterclass with some of the most published experts in the area of tendinopathy.  This is an attempt to summarize the issues discussed.

The Continuum Model

(Cook & Purdam., 2009, p. 410)


Those running the workshop, Craig Purdham, Jill Cook, Ebonie Rio and Sean Docking, were very upfront admitting there is a gap in the evidence for their model presented above and from which they currently work (and have been called on to produce evidence for it).  However, it fits well with what we currently see clinically and in is useful to explain the current evidence.

There is a shift away from the word tendonitis.  Tendonitis suggests inflammation in tissues. However, research has demonstrated a remarkable lack of inflammatory markers in the area of pain.  Tendinopathy better describes the changes we see in pathological tissue.  And not all tendinopathy is the same.

Reactive Tendinopathy

Firstly, younger populations (15 to 25) are likely to have reactive tendinopathy.  These patients will present with a sudden onset of pain following a direct trauma to the tendon, or after abuse to the tendon such as a sudden increase in demand in an athlete (ie training camps).  There is fusiform swelling.  There will also be individual traits which may predispose them to flair ups of the tendon.  They are slow to settle and can take up to 4 to 8 weeks for recovery.

Degenerative Tendinopathy

Older populations (30 to 60+) are more likely to have a degenerative tendinopathy.   Here the tendon has lumps and bumps, with a long history of symptoms.  The patient often exhibits unloading strategies and there may be associated atrophy.  Because the patient has learned to cope, or because the symptoms are not very acute and painful, these patients may not present clinically.  Degenerative tendons never completely repair themselves regarding imaging, however, the symptoms can be managed.   It is therefore important to shift the focus away from imaging, and treat the patient rather than the image.

Reactive on Degenerative Tendinopathy

This is the most common clinical presentation.  Here we have a shift towards older patient presentations (20-50).  There may be a "flare up" of the normal part of the tendon due to relative overload, such as a sudden shift in training loads (Ie, suddenly training for a marathon while unconditioned).  Imaging may show signs of degeneration, however, it is important to focus on the intact tissue.  Treat the doughnut, not the hole.  The"hole" or degenerative part is never going to improve, however, it is unlikely that this is the area of concern.  The patient's symptoms may improve by treating the intact tissue and increasing it's ability to cope with load.

What is the Aetiology of Tendinopathy?

  1. A change in load

    1. A single high intensity session or multiple sessions (less recovery between intensive sessions which should be on 2 or 3 day cycles of Langberg and Heinemeier.

    2. Increased frequency of training especially high loads (ie training camps)

    3. Different drills such as jumping or sprints at the end of training

    4. A change in footwear

    5. Training with tight calf/quad muscles

    6. Changes in track surface, such as sand or uneven terrain

  2. Unload-Reload
    1. Most common scenario.  Consider an athlete who is forced to rest through illness, then returns to training suddenly.  A sudden drop and then spike in training loads is a red flag for injury.  Present modelling suggests a change in workload of 107%/week as safe.

How do we rehabilitate a tendon?  Prevention is key!

  1. Establish a moderate, protective training load, consistently, over a long period of time (.3 months to multiple years of consistent loading ) 

  2. Minimize week-to-week changes in load.  Avoid large training spikes or reductions in load.  Red Flag scenarios for injury are training camps, new drills introduced at the end of a session, sprints at the end of a session, a change of coach with a no-pain-no-gain mentality.  Interestingly, this scenario was commonly mentioned throughout SMA's conference with cause and effect examples of injury.

  3. Do not exceed the workload ceiling of safety for the sport.  There are limits to how much the body can withstand.

  4. Ensure a minimum training workload is maintained, particularly in the off season.  Avoid undertraining through selection, reduced workload, taper, travel or holiday, such as the Christmas break. If time is taken away from training for holiday, illness, injury, then reloading must be done gradually and planned accordingly. 

    1. In the off season, it is important that demands of the sport be considered.  For example, an Australian Rules Football player may choose to keep fit by running.  However, the greatest demand for their sport will be jumping, as the load on the patella tendons increases most rapidly with this activety.  Furthermore, running does not load the patella tendon whatsoever!  Therefore, running alone is not a sufficient training to in this population.  Skipping rope, jumping, weight training and sport specific drills will be more preventative. 

  5. Avoid inconsistent 'boom-bust' workload patterns.  Don't rest injuries unnecessarily or play catch-up for missed sessions.  

  6. Ensure training loads are proportionate to the workload demands of the individual/sport.  If training camps are to be held, then prepare athletes weeks before with a 'load to withstand load'.  

  7. Monitor the athlete throughout the latent period. Risk continues 3-4 weeks after the spike is seen in the individual's training load.

How do we implement changes in a tendon to create an optimized load and positive tendon adaptation?

tendon loading.jpg

(My apologies for the poor quality of the above image, but I like the continuum.  It's a photograph from one of the slides of the presenters' workshop). 

Adaptation occurs slowly and in small, incremental steps!

Current capacity--->small steps--->Resistance training/strength--->Energy Storage--->Energy storage and release--->Required capacity

A Program of Tendon Rehabilitation

Four stages of a progressive rehabilitation program are listed below.  It obviously must be tailored to the individual.

  1. Isometrics

    • Goal: to reduce pain and introduce safe load

    • Static.  Should be performed without tendon moving, fluctuating

    • No Compression: situate the tendon so that there are no compression forces.  Particularly true for the calcaneus and other "round" insertional tendonopathies.

    • Heavy: Should be performed very heavy weights for 30-45 seconds

    • Regularly: These have an analgesic affect.   Perform several times a day. 5 sets of 45 sec

    • Short Lived.  This is a brief period of rehabilitation.  It does not sufficiently load the tendon.  It should be progressed as soon as tolerable.

  2. Strength:

    • Goal: Get Strong!

    • Concentric/Eccentric: (The need to emphasize eccentric only is not supported by evidence!)

    • 4 sets of 6-8 repetitions performed slowly

    • 3 Times/week

    • This is not high tendon load

  3. Energy Storage:

    • Goal: Teach tendon to be springy again.  These are high tendon loads.

    • Skipping rope 2-3 times/week

    • Must be concomitant with strength phase.  Always continue strength work.

  1. Energy Storage and Release:

    • Goal: To meet the demands of sport or daily loads.  These are VERY high tendon loads.

    • Sport Specific exercises, jumping drills, dropping off a box and jumping back onto a box.

In conclusion, the management of lower limb tendon pain is largely an issue of load management.  Working with coaching staff and/or individual athletes to educate them about appropriate training load management and progression is key to preventing tendon injuries.  However, when tendon injuries occur there is no need to rest these patients.   Isometric loading can begin at once.  Isometric exercises performed with enough weight and for long intervals (45 second holds) can have an analgesic effect.  Progression to concentric/eccentric strength work can commence soon after the pain is manageable.  There is no need to focus on the eccentric only portion of strength training.  Instead, perform the exercise slowly and under control.  Following strength training, there should be a period of adaptation to tendon demands.  Skipping rope is a good example of a high tendon load, and is often sufficient for achilles tendon pain in your average patient.  Sport specific progressions may be required to meet the tendon demands required by certain sports, athletes or individuals that place very high load onto tendons, ie, jumping sports.   Lastly, the role of pain science can not be ignored.  Educating your patients away from catastrophizing their ultrasound report, which may use words like "tear" or "degeneration" is an important clinical tool.   Focus more on the doughnut rather than the hole, the patient rather than the image.  A good clinical outcome can occur despite the presence of disorganized tissue and tears, and structural repair is not the focus of treatment.  The human machine is clever enough to adapt the remaining tissue to make it strong enough to cope with many activities of daily living such as sport.