Lower limb tendinopathy is commonly seen in the patella tendon, right under the knee cap, and Achilles tendon. The main cause is usually due to an increase in load on the tendon, exceeding the capacity it can handle. Other risk factors can contribute such as age, gender, etc. (Rudavsky & Cook, 2014).
A model to help understand tendinopathy is presented below. Tendinopathy can progress across this continuum depending on the loading and individual factors. When overloaded, the tendon can progress to a reactive tendinopathy as well as degenerative tendinopathy or a combination of both (Rudavsky & Cook, 2014).
Both reactive and degenerative will be treated similarly across the stages that are mentioned later in this article. Even in the stage of “degenerative,” it doesn’t mean you have a tendon at risk of rupture or you have a “bad” tendon. By properly loading the tendon adaptations can happen to progress it back to a functionally “normal tendon.” Ongoing maintenance will be required and it might take longer than you’d prefer, but it is possible to get back
to doing your sport/activity.
Isometric And/Or Heavy Slow Resistance Training:
As mentioned, tendons need to be loaded to adapt and progress. This means rest is not the
answer. De-loading from sport/activity is recommended initially, but finding what load the tendon can tolerate and starting at there the first step. Feeling discomfort levels of 3-4/10 has been recommend to be ok to work through (Wood, 2020).
This stage places a focus on isometrics and/or heavy slow resistance training depending on the person and response. The main point is going to be getting whatever load is tolerable through the tendon that the person responds best to. An example for the knee for isometric exercises could be a split lunge hold or a Spanish squat and for heavy slow resistance training be a leg extension machine or squats. When unable to participate in sport due to the degree of irritation, off feet conditioning such as ski erg or bike/assault bike can be options to keep conditioning levels up.
Stretch Shortening Cycle/Jump & Plyometric Progressions:
After the tendon has adapted well to the strength based work the next step is progressing jumps and plyometric exercises. These require the tendon to handle and utilise forces our body makes with the jumping action that are more than the weighted exercise place on it.
There are different ways to progress along these exercises as well depending on the tendon and sporting requirements. Early stages might start with something such as a low box jump and late stages continuous single leg hurdle hops.
Progressions through different degrees of difficulty of these exercises will set you up for the final stage below.
Training Integration/Sporting Activities:
Once the jump and plyo exercises have been performed and the tendon responds well both from a pain tolerance and performance standpoint the last stage is to build up the sporting activities. Depending on the sport this should start with controlled return to run program to build up the tendon capacity in a monitored manor and slowly progressed back into training to a more chaotic environment.
Ongoing Work:
After these stages have been progressed through and the return to sport has happened, it is still recommended some ongoing work is done. This doesn’t have to be as intense as the rehab to get here, but some prefer isometric exercises for warm up and making sure to keep some heavier lower body strength exercises targeting the specific tendon is also a good idea.
References:
Rudavsky, A., & Cook, J. (2014). Physiotherapy management of patellar
tendinopathy (jumper's knee). Journal of physiotherapy, 60(3), 122-129.
Wood, P. (Host). (2020, September 22). Tendinopathy (Jill Cook – Researcher & Physiotherapist) (No. 27) [Audio podcast episode]. In No Weak Links. https://open.spotify.com/episode/3DwFdxNb4ZuXmop4m3rDbt? si=f96268ecb60145d7