I attended my first lecture held by Jill Cook in September , when Jill presented to our masters class on about current trends in tendon management. To say that Jill Cook is at the forefront of the best tendon research in the world would be an understatement. What an incredible impact Jill has already made and such a contribution to Physiotherapy internationally. There are many great ideas that I learnt from this master class, one of which is the continuum of tendon pathology.
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Apunts is focused, on the one hand, on the impact of high sports performance on men and women and, especially, in the study of team sports and muscle and tendon injuries. On the other hand, on the behaviour to follow while practicing sport or physical activity during illnesses or in certain situations.
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Achilles and patellar tendons are commonly affected by tendinopathy. Injury to these tendons can severely impact upon sports, recreational and everyday activities. Eccentric musculotendinous loading has become the dominant conservative intervention strategy for Achilles and patellar tendinopathy over the last two decades. Eccentric loading involves isolated, slow lengthening muscle contractions. Systematic reviews have evaluated the evidence for eccentric muscle loading in Achilles and patellar tendinopathy, concluding that outcomes are promising but high-quality evidence is lacking.
Eccentric loading may not be effective for all patients athletes and non-athletes affected by tendinopathy. It is possible that in athletes, eccentric work is an inadequate load on the muscle and tendon. A rehabilitation program aiming to increase tendon load tolerance must obviously include strength exercises, but should also add speed and energy storage and release.
The aim of this paper is to document a rehabilitation protocol for Achilles and patellar tendinopathy. It consists of simple and pragmatic exercises designed to incorporate progressive load to the tendon: isometric work, strength, functional strength, speed and jumping exercises to adapt the tendon to the ability to store and release energy. This article would be the first step for an upcoming multicentre randomized controlled trial to investigate its efficacy..
Las lesiones en estos tendones pueden afectar severamente a las actividades deportivas, recreativas y cotidianas. Achilles and patellar tendons are commonly affected by tendinopathy, which are overuse injuries characterized by localized tendon pain with loading and dysfunction.
One can find regions in the tendon which are in different stages at the same time. The tendon pain is partially related to the function, to the tendinopathy, diminishing muscle strength and motor control which, at the same time, reduces the function.
The function in this context refers to the muscle's ability to produce the appropriate strength so that the tendon can accumulate and release energy for the sports movements. However, one can find function changes when there is a structural pathology, independent from the pain. Both are common among athletes and Achilles tendinopathy may also affect sedentary people.
In the adult population 21—60 years , the incidence is 2. Tendinopathy is commonly associated with tendon pathology. Pathological features of tendon pathology include altered cellularity increased or decreased , break down in the extracellular matrix ground substance accumulation, disorganized collagen, neurovascular ingrowth. Systematic reviews have evaluated the evidence for eccentric muscle loading in Achilles 9—13 and patellar 14,15 tendinopathy, concluding that outcomes are promising but high-quality evidence is lacking.
It consists of simple and pragmatic exercises designed to incorporate progressive load to the tendon: isometric work, strength, functional strength, speed and jumping exercises to adapt the tendon to the ability to store and release energy Fig. This article would be the first step for an upcoming multicenter randomized controlled trial to investigate its efficacy.
Programme to incorporate progressive load to the tendon. The development of a rehabilitation plan for any individual with tendinopathy requires complex clinical reasoning, with reference to the pathoanatomical diagnosis and the functional requirements of the person.
Tendinopathy and subsequent rehabilitation will vary considerably depending on the site of the pathology i. Scientific literature suggests that the pathogenesis of Achilles tendinopathy is heterogenic. Several risk factors and interactions between them have been identified.
Both extrinsic e. The literature on the rehabilitation of tendinopathy suggests that the most important treatment is appropriate loading. Exercise prescription can target matrix reorganization and collagen syntheses, 28 reduce tenocyte activity, affect tendon compliance 29,30 or have an analgesic effect. An accurate diagnosis is essential, imaging tests are helpful, but what really is important is a good clinical assessment.
Based on the continuum model, we need to stage where the tendon pathology is: reactive tendinopathy, tendon dysrepair, degenerative or reactive on degenerative tendinopathy. The management of the load is the gold standard treatment at all stages.
Early load management in a reactive tendon may keep them in the early stages of tendon pathology and limit the progression of their pathology. Pain inhibits the athlete using the elastic energy storage and release capacity of the tendon, thereby compromising function and performance. Excessive training volume or too intense training involving the elastic function of tendons may induce tendon overload and are important factors in the onset of athletic tendinopathy.
Repeated training combined with too short resting periods can result in a net degradation of the matrix and lead to overuse injury. Managing tendinopathy in season centers around load management, these include strategies that control pain, both reducing aggravating loads and introducing pain-relieving loads.
No medication or injectable treatment to date has been shown to alter tissue properties; only tendon load can stimulate remodeling. The only option for repeated failures to accommodate athletic load is a comprehensive rehabilitation program that can increase the load absorption ability of the tendon.
Loads that reduce pain should be introduced as early as possible. Loading to decrease pain will maintain a load stimulus on the tendon that is critical to maintain cell function and matrix integrity. In painful reactive, reactive on degenerative tendons, isometric contraction with some load decreases pain for several hours.
The recruitment of descending inhibition results in mechanical hypoalgesia and increased pressure pain threshold in healthy individuals. Adding these external stimuli has proven to maximize the effects of the workout and to prevent relapses 34—36 and it must be taken into account. Moderate to heavy loads with slow machine-based weights rarely cause pain. Provocative tests and objective scoring methods should be used to monitor tendon pain.
As the VISA scales give substantial scores on pain during high-level activity, they are not responsive to short-term change and are best used on a month-to-month basis. Pain behavior the day after loading is the critical load response test. The athlete can monitor tendon response to training loads by completing a simple loading test every day at a similar time avoid early morning except in the Achilles where morning pain and stiffness can be a good guide to progression.
Perhaps it is the magnitude of the structural tendon response to a load what matters, as this appears to occur before pain arises or changes. An instrument that could quantify the response of a tendon to load would mean a huge advance in the management of tendinopathy. Mechanical loading seems to induce changes in gross morphology, mechanical properties as well as biochemical parameters of tendon tissue. Over the first 24—36 h, this response results in a net loss of collagen, but this is followed by a net synthesis 36—72 h after exercise.
PICP initially decreased after exercise and an increase in this marker of collagen synthesis was detected 72 h after exercise. The idea that the tendon can hypertrophy in response to mechanical loading suggests that there is a net formation of connective tissue. The degree of hypertrophy is rather small and seems to occur only in certain tendon regions. Persons who undergo regular training have a greater Achilles tendon cross-sectional area than other age-matched persons Magnusson and Kjaer, 49 ; Kongsgaard et al.
The potential region-specific adaptation to running appears to be far greater in men than in women. The ability of the tendon to adapt to regular loading is attenuated in women. A similar increase in collagen synthesis is seen that is independent of exercise volume repetitions , which suggests that there is a ceiling effect in collagen synthesis.
The fact that pro collagen expression is regulated the same way in the tendon regardless of the type of muscle contraction eccentric, isometric or concentric supports the belief that the collagen protein synthesis response is regulated by fibroblast strain. With regard to tendon mechanical properties, increased tendon stiffness is generally observed in response to large volumes of loading.
Studies suggest that appropriate loading during rehabilitation of tendinopathy is the most important treatment method. When planning a rehabilitation strategy, it is crucial to find an approach that addresses the re-education of muscle function instead as considering the tendon as an isolated unit. While early stimulus of the muscle tendon unit is typically focused on isometric muscle activation, which may include muscle stimulation, most programs advocate the progression to higher loads as guided by symptom presentation.
Treatments and considerations for different tendinopathy stages. Removing the cause of reactive or reactive on degenerative tendinopathy usually unaccustomed load. Reduce the pain through reduction of high loads.
Introducing isometric loads that reduce pain at early stages. Adapt the training volume and resting periods to the amount that the tendon can safely handle at that moment. At the end of the progression the athlete should be able to use the elastic capacity of tendon and have regained function of the kinetic chain suitable for performance. Load management reductions removes the cause of reactive or reactive on degenerative tendinopathy. Frequency is a very flexible value that we can use to adapt the load more or less resting hours between workouts depending on the pain level of the next day.
Volume seems to be the less aggressive feature, if there is enough time of rest among workouts, therefore at early stages we can keep the volume of training and change intensity and frequency. If pain increases the day after the workout we need to assess if the person should maintain regular training or adapt their training.
Sometimes the athlete may need a different approach than the rest of the group alternate days, half track, specific work, Isometric exercises reduce the pain in the early phase of rehabilitation or while managing an athlete in season.
How the tendon responds to the training volume and rest periods indicates if the amount of load is within the load that the tendon can safely handle. During early stages of rehabilitation high energy storage loads should not be repeated in less than 48 h. Adapting the training according to the NPS observed the next day: If NPS increases keep 72 h rest between workouts, if NPS does not increase, keep 48 h rest between workouts, if NPS decreases it is possible to increase the frequency or intensity of high load training.
To Increase load capacity of the tendon up to that required by the person by improving either structural or mechanical properties of the tendon, we must increase load absorption ability of the musculotendinous unit and the kinetic chain, through progressive loading.
Mechanical properties of tendon, including tendon compliance, are improved later in rehabilitation by retraining landings, running, changing pace or direction, jumps energy storage loads.
Eccentric exercises incorporated in all the loads proposed in this paper seems to be the best way to stimulate remodeling of tissue. The ultimate goal is that the athlete should be able to use the elastic capacity of tendon and have regained function of the kinetic chain suitable for performance.
Functional exercises and individual technical exercises that involve high loads at maximum speed, to apply high force and achieve high velocity, maximum expression of force in sports where tendon have to show their ability to store and release energy in functional and asymptomatic form.
Numbered scale from 0 to 10, where 0 means lack of pain and 10 the highest imaginable level of pain. The patient chooses the level that better suits his symptoms, knowing that 7 means an exaggerated pain resulting in modified function.
It is essential to correlate pain during training with change on the loading test the next day Table 2.
PE #005: Tendons and tendinopathy with Jill Cook
Apunts is focused, on the one hand, on the impact of high sports performance on men and women and, especially, in the study of team sports and muscle and tendon injuries. On the other hand, on the behaviour to follow while practicing sport or physical activity during illnesses or in certain situations. All of which undergo an anonymous external peer review process. CiteScore measures average citations received per document published. Read more. SRJ is a prestige metric based on the idea that not all citations are the same.
An Interview With Professor Jill Cook on Tendinopathy
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