Managing Tendons
Can we manage them with load?
Introduction
Athletes who run, jump & kick can be affected by tendon issues. Almost any tendon can become painful whether it is the Achilles, Patella, Gluteal, High Hamstring or Adductor in the groin. A common theme that links all tendon pain is ‘load’. The management of of a ‘tendinopathy’ is one of the most challenging characteristics of sports medicine.
What does the Tendon do?
The role of a tendon is to transfer force from muscle to bone, the tendon initially lengthens and force is transferred to the structure it attaches to. The extent it lengthens before transferring force depends on the stiffness of the tendon itself. Tendons are also really good at energy storage and play an essential role in the elastic recoil to return energy during movement. A tendon can recoil at twice the speed of muscle; therefore pre-loading it with stretch allows the muscle-tendon unit to propel a limb at high velocity with great efficiency.
Tendinopathy Continuum
Tendons love homeostasis and any variance from a normal training routine can trigger a reaction. The reaction is suggested to lie within a continuum from normal tendon through to a degenerative tendon and even reactive-on-degenerative tendon.
Some risk factors for this occurring can be an increased training stimulus following a period of rest such as the current 'lockdown' scenario, an off season break, a rapid change in training or game volume, preparing for a race, event or playing extra cup ties, a change in footwear or playing surface such as grass to artificial.
(Cook et al 2016)
How do we manage this continuum of Tendinopathies?
A general overview of how to manage tendon issues using exercise can be seen in the table below which is based research and my own experience of managing tendon issues in athletes. The continuum model proposed by Cook et al (2016) correctly suggests that to optimise an intervention the therapist needs to consider the stage of pathology and the primary driver. Individual rehabilitation plans are essential to create the best outcome so my advice would be to be guided by your own therapist and their clinical decision making processes which may include additional interventions and medications.
Individual Sports
Athletes do not like stopping training at all, its a hard pill to swallow for sure, so I always try my best to be creative in adapting training to allow the athlete to continue in some capacity. A scenario where we want to offload the athlete completely does occur, but there are ways to modify training to ensure we still get physiological loading such as using sessions in water or the ski-ergo. We can complete much of the other strength and conditioning with a few alterations to ensure we are not flaring the tendon.
I always challenge my patients to reflect and use this time wisely, I really do see these 'injured times' as a positive. It allows the athlete and coach to take some time to review training schedules, look hard at why they train in that style and to develop new ideas on how to get the same training effect whilst minimising injury risks. It also gives the athlete a chance to work on all those small training intricacies which they may have been missing previously.
Team Sports
The really difficult scenario is managing the team player in season and keeping them playing. It’s likely they won’t be able to tolerate high tendon load training sessions so training will have to be adapted in a creative way that allows the player to join in. This may be something as simple as using a stationary bike & lunges interspersed with low load skipping rather than competing the full team warm up that includes running & jumping.
Other ways to manage the vulnerable tendon is to utilise a 7-4-2 in-season program which only allows the player to complete 4 loaded on feet sessions including matches and training sessions per week with a maximum of two back to back. Depending on the players tendon issue it may be worth considering a 7-3-1 or 7-2-1 schedule. Inevitably a tendon compromised player is likely to incur a flare, it can be beneficial to completely offload which allows the tendon to settle.
Specific Tendon management - Example Exercise Progressions
Achilles Tendon
Patella Tendon
Gluteal Tendon
Hamstring Tendon
Adductor Tendon
Summary
Tendons are designed to transfer force, they love homeostasis but small changes to training intensity, volume, surfaces or footwear can cause the tendon to react. The tendinopathy continuum covers a variety of issues from early reactive to chronic conditions and management can be difficult especially when players are in-season. Careful load management is the key to maintaining healthy tendons. Final note - be patience tendons take time to adapt and exercise plan progressions are based on at least 12 weeks, once the athlete returns to sport it is likely they will require a suitable maintenance program to keep the tendon quiet.
References
Cook et al (2016). Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?. British Journal of Sports medicine. 50:1187-1191.
Galloway et al (2013). The role of mechanical loading in tendon development, maintenance, injury and repair. Journal of Bone and Joint Surgery. 95(17): 1620-1628.
Grimaldi et al (2015). Gluteal Tendinopathy: A review of mechanisms, assessment and management. Sports Medicine. 45: 1107-1119.
Malliaras et al (2013). Achilles and patellar tendinopathy loading programmes. A systematic review. Sports Medicine. 43: 267-286.
Voigt et al (1995). The influence of tendon youngs modulus, dimensions and instantaneous moment arms on the efficiency of human movement. Journal of Biomechanics. 28(3): 281-291.