Tendinopathy Rehabilitation

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Introduction

The development of a rehabilitation plan for an individual presenting with confirmed symptomatic tendinopathy requires complex clinical reasoning, with reference to the pathoanatomical diagnosis. Tendon pathology and subsequent rehabilitation will vary considerably depending on the site of pathology; stage of the tendinopathy; functional assessment; activity status of the person; contributing issues throughout the kinetic chain; comorbidities; and concurrent presentations.  

Our key goal in tendinopathy rehabilitation is improving the capacity of the tendon and muscle to manage load. Each component of the rehabilitation programme, in particular loading, must be manipulated in relation to the nature, speed and magnitude of the forces applied to the muscle/tendon/bone unit in order to achieve the goals of the particular management phase without causing an exacerbation of the pathological state or pain.

Rehabilitation Progression

Goon suggests considering tendinopathy rehabilitation in phases:

Phase 1 - reduce pain

Pain is a key presentation in the reactive phase.  Key to reducing pain is managing the load on the tendon:

1. Avoid activities that place a compressive load on the tendon, usually this is any activity that would involve stretching the effected muscle or direct tendon compression.
2. Cut out activities that involve the Stretch-Shortening-Cycle (SSC) which occurs when the tendon has to behave a like a spring, stretching then shortening to store and then release energy.
3. Isometric exercises can help to reduce pain. These exercises should be done in a position where there is no tendon compression, usually in the mid-range of the muscle.
4. Anti-inflammatory medications, such as ibuprofen can be used to help to reduce the reactive response.

Phase 2 - improve stength

Once pain has settled you can progress to phase 2 and work on strength. Research has focused on tendinopathy loading programmes that generally fit within 3 categories eccentric, combined or heavy slow resistance training.  Goon summarises the evidence for lower limb strength programmes:

For this phase of rehab you are aiming to achieve strength changes by exercising with sufficient load in a a muscle’s mid-range position. Avoid exercising with heavy loads in positions where there is likely to be tendon compression.  Following research by Alfredson et al. eccentric exercises have been considered the gold standard for many years. More recently research has demonstrated the importance of also including the concentric phase of exercises with heavy slow resistance training.

References

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