In-Season Management of Tendons
Managing lower limb tendinopathies in athletes can be a challenge. Managing an athlete in-season management can be an even more daunting prospect. When managing tendinopathy, provocative loads should be removed, and a progressive loading programme followed. An in-season athlete needs to train at a high level and will be subjecting their tendons to high loads whilst competing.
By following simple principles around load and capacity, it may be possible to keep an athlete playing while still managing their tendinopathy.
In-season management of tendons centres around pain control and this can be best achieved by managing the loads that the tendons are placed under. Complete rest of a tendon is not the prefered management strategy in tendinopathy, and appropriate loading and load modification is the best evidence-based practice. Randomised controlled trials of athletes in season are challenging to perform, and as such, there is limited evidence in this specific field.
To be able to treat tendinopathy effectively, an understanding of tendon load and capacity is required. A tendon's capacity will only ever exceed the load under which it is placed.
Tendons are subjected to 4 different types of loads:
- Tensile loads - where tendons store and release energy like a spring. (eg. jumping for the patellar tendon)
- Compressive loads - where the tendon passes bony protuberances (e.g. sitting for hamstrings where hamstring tendons are compressed on the ischial tuberosities)
- Combination - where tendons are subjected to both compressive and tensile loads (e.g. running in hip flexion for a hamstring tendon)
- Shear or friction loads - such as in repetitive activities (running/ cycling). These loads are more provocative to the peritendon structures such as the sheath.
Recognising High Loads for Tendons
In tendinopathy, determining the type of loads that caused the tendons to become painful is essential. Compressive loads are exceptionally provocative for tendons as well as FAST tensile loads. If you combine compression and fast tensile loading, there is even more chance of aggravating tendinopathy.
Tendons react to Fast, not Heavy Loads.
An important factor to consider especially for an in-season athlete is that it is fast tensile loads that provoke tendons and NOT heavy tensile loads. This can be helpful when considering that you do not want to decrease a tendons capacity by completely unloading it and slow, heavy loads should not be particularly provocative to tendinopathy.
If the patient's symptoms are not characteristic of tendinopathy where they are undergoing repetitive loads rather than fast tensile loads such as cycling. It may be helpful to look outside of the tendon as a source of the symptoms and possible the peritendon. It is important to make sure the diagnosis of tendinopathy in an athlete is correct because the treatment of choice for tendinopathy of heavy, slow, progressive loading will more than likely aggravate a Paratenonitis.
Replacement of Exercises to Avoid Tendon Load
The best evidence available for managing tendinopathy is with an active approach. Rest is not indicated in managing tendons. However, loading a tendon incorrectly with provocative loads can be highly aggravating and result in ongoing problems. An athlete in-season will be subjecting their tendons to fast and compressive loads whilst competing or during matches and removing those provocative loads from their training and rehabilitation programs is key to managing their symptoms.
Managing an athlete who is in-season requires careful scrutiny of their entire programme. This includes warm-up, training sessions and gym work. Each aspect should be screened for any fast or compressive tendon loads and these loads should be removed. Removing provocative loads is important to settle the pain associated with tendinopathy, but it is important to replace those loads with other appropriate strengthening exercises. Removing a load entirely, particularly with an in-season athlete will result in further problems as the tendons and muscles will decrease their capacity and be vulnerable to further injury.
Their entire programme should be examined. You may find that during their normal warm-up routine, they possibly have plyometric exercises that may be provocative to the tendon or compressive loads during their routine stretching. Once all provocative loads, primarily compressive, have been identified, these should be replaced with appropriate loads.
An example of this could be, deadlifts for a sprinter with hamstring tendinopathy provide a compressive load of the hamstrings against the ischial tuberosities when in hip flexion. These could potentially be replaced with prone hamstring curls so the hips are in neutral and the tendon is not compressed.
Monitoring a tendons response to activity and how it responds to different types of loading is useful in determining which exercises to back off on and which exercises to progress. An in-season athlete may, however, have a certain degree of pain and if it is maintained at a low stable level then this is acceptable.
Maintaining a Strengthening Programme In-Season
Isotonic and isometric exercises have been shown to reduce pain for in-season athletes with patellar tendinopathy. A case series study from 2019 also found that an isometric quadriceps squat exercise using a rigid belt can be effective at reducing patella tendinopathy pain in-season. Eccentric loads may not be the most appropriate loads for athletes in-season as they are generally quite highly provocative, and athletes are already loading their tendons from their sports schedule. It has also been suggested that eccentric exercises may actually place inadequate load on the muscle or tendon of athletes. Heavy, slow resistance training is best for managing tendinopathy and should be performed on a single leg basis. The optimum exercise prescription for tendinopathy has yet to be discovered. 4 sets of 8 repetitions where the load applies fatigues the muscle at the end of a set have been proposed. It can be challenging to include a comprehensive strength training programme in-season but it is important in maintaining and managing the athlete.
Tendons do not like change. Progressive training loads are best and sudden spikes or prolonged periods of rest should be avoided. Slow progressive exercises allow the tendon to increase its capacity, whereas sudden spikes in load are often the mechanism of tendinopathy. Excessive rest will result in a decrease in the tendons capacity, which will result in it being more vulnerable to injury.
It is important to assess the entire kinetic chain for any compensatory strategies or deficits that may be contributing to the tendon problems.
Single-sided loading is significant when rehabilitating tendons. Performing double leg exercises when there are inequalities in strength between sides often lets the stronger side carry the weaker side. Strength training should, however, be performed on both the affected and unaffected. The loads applied on each side should be appropriate to the capacity of that particular side. When strengthening the unaffected side cross-education occurs, which promotes strength in the affected side.
Fitting strength training into a busy athletes schedule may be difficult. Timing of strength training sessions should be carefully thought out in terms of the athletes overall training schedule. Doing strength training exercises after their regular training sessions may allow for adequate recovery time until the next training session. Cook et al propose that twice a week strength training is the minimum and three times a week optimal.
Tendons are notoriously slow to recover, especially in-season as they are subjected to high loads while competing. Everyone involved in the athlete’s life, the coach, manager, doctor, physio etc. should be in agreement with the treatment plan. Appropriate expectations of recovery time and pain levels should be communicated to everyone.
- Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. Br J Sports Med. 2014 Apr 1;48(7):506-9.
- Van Ark M, Cook JL, Docking SI, Zwerver J, Gaida JE, Van Den Akker-Scheek I, Rio E. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. Journal of science and medicine in sport. 2016 Sep 1;19(9):702-6.
- Galloway MT, Lalley AL, Shearn JT. The role of mechanical loading in tendon development, maintenance, injury, and repair. The Journal of bone and joint surgery. American volume. 2013 Sep 4;95(17):1620.
- Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy?. Br J Sports Med. 2012 Mar 1;46(3):163-8.
- Wongsithichai P, Chang KV. Paratenonitis. Journal of Medical Ultrasound (2014) 22, 55e56
- Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Practice & Research Clinical Rheumatology. 2019 Mar 8.
- Rio E, van Ark M, Docking S, Moseley GL, Kidgell D, Gaida JE et al. Isometric Contractions Are More Analgesic Than Isotonic Contractions for Patellar Tendon Pain: An In-Season Randomized Clinical Trial. Clin J Sport Med. 2017;27(3):253-9.
- Rio E, Purdam C, Girdwood M, Cook J. Isometric Exercise to Reduce Pain in Patellar Tendinopathy In-Season: Is It Effective "on the Road"? Clin J Sport Med. 2019;29(3):188-92.
- Mascaró A, Cos M, Antoni M, Roig A, Purdam C, Cook J. Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy. Apunts. Medicina de l'Esport. 2018; 53:19-27.