In-Season Management of Tendons

Original Editor - Mandy Roscher Top Contributors - Jess Bell, Mandy Roscher, Kim Jackson, Tarina van der Stockt and Robin Tacchetti

Introduction

Managing lower limb tendinopathies in athletes can be a challenge. Managing an athlete in-season management can be even more daunting. When managing tendinopathy, provocative loads should be removed, and a progressive loading programme should be followed. However, an in-season athlete needs to train at a high level, and they subject their tendons to high loads while competing. But 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 aims to control pain and maintain performance. Strategies to achieve these goals include:

• load management (reducing aggravating loads and adding in loads that relieve pain)
• medication
• monitoring
• complete rest is NOT advised

It is important to note that it is challenging to complete randomised controlled trials of athletes in-season, so there is limited evidence in this specific field.

Features of Tendon Pain and Aspects to Consider in the Differential Diagnosis

• Tendon pain is well localised - it does not refer much beyond the tendon (unless an associated bursa or fat pad is affected)
• Loading provokes tendon pain - as load increases, pain increases
• Tendon pain has a short latency - this means that pain occurs when the load is applied, but it stops quickly after the load is removed
• Tendon pain will not usually cause night pain or pain at rest (unless it is reactive or "associated with a metabolic or seronegative condition"

For more information on diagnosing tendinopathy, please see: Differential Diagnosis of Tendinopathy.

Tendon Load and Capacity

To treat tendinopathies effectively, an understanding of tendon load and capacity is required.

It is important to understand that "the capacity of your tendon or muscle or bone or any tissue in our body, only ever just exceeds the loads that we put on it. So it's truly use it or lose it." -- Ebonie Rio

Compared to muscles, tendons have a lower rate of tissue turnover, and they adapt more slowly to increased loading. Any load that is excessive and not well managed is considered overload. Overload can "result in anatomical, physiological and/or psychosocial conditions that will manifest as altered performance and injury and illness."

"In general, tendon disorders may be attributed to abnormal tendon loading, abnormal [extracellular matrix] composition and malfunction alongside altered biological and genetic variations that may consequently lead to exceedance of tendon’s capacity followed by ruptures."

Tendons are subjected to four different types of loads:

• Tensile loads
  • tensile stress is applied when two forces pull in opposite directions
  • tendons are designed to withstand high tensile loads - they store and release energy like a spring (e.g. jumping for the patellar tendon)
• Compressive loads
  • occur in tendons where the tendons pass bony protuberances
  • the tendon can become compressed against these bony protuberances during certain movements (e.g. the hamstring tendon is compressed at the ischial tuberosity in sitting)
• Combination loads
  • occurs when tendons are subjected to both compressive and tensile loads
  • examples include running in a position of hip flexion (e.g. hockey)
  • please note that there is no source of compression for the patella tendon, so there are not many combined loads in the patella tendon
• Shear or friction loads
  • a load of differential diagnosis
  • occur when a tendon is subjected to repetitive activities (e.g. swimming / cycling) that do not require the tendon to act like a spring - instead, the sheath is repeatedly moving over the tendon
  • these loads are more provocative to the peritenon
  • present differently to other loads:
    • diffuse pain
    • aggravated by low tendon load activities (e.g. calf raises, isometrics, cycling)

For more information, please see: Tendon Load and Capacity.

Recognising High Loads for Tendons

To effectively manage tendinopathy, we must determine the type of loads that cause a tendon to become painful. Compressive loads are exceptionally provocative for tendons, as are FAST tensile loads. In situations where there are both compressive forces and fast tensile loading, the likelihood of an aggravating tendinopathy is increased.

Tendons react to fast, not heavy loads - "we know for tendons, if it's heavy, if it's static or slow it doesn't provoke them because they are all about rate of loading." -- Ebonie Rio

This is significant when planning in-season management. We don't want to decrease a tendon's capacity by completely unloading it, but slow, heavy loads should not be particularly provocative. If, however, the peritenon is affected, heavy, slow, progressive loading will most likely be aggravating.

Replacement of Exercises to Avoid Tendon Load

The current evidence-base supports an active / exercise approach to manage tendinopathy. Rest is not indicated when managing tendinopathy. However, loading a tendon incorrectly with provocative loads can be highly aggravating and result in ongoing problems. An athlete in-season will place fast and compressive loads on their tendons during games or competitions. Thus, the key to managing symptoms, is to focus on removing these provocative loads from training and rehabilitation programmes. We can continue to apply safe loads and loads that will have a positive impact on the tendon.

When managing athletes, we must carefully scrutinise their entire programme, including their warm-up, training sessions and gym work:

• We need to check for and remove any fast or compressive tendon loads - this will help to reduce / settle the pain associated with a tendinopathy
• These loads should be replaced with other appropriate strengthening exercises
• Removing a load entirely can lead to further problems as the tendons and muscles will decrease their capacity and be vulnerable to further injury (remember the use it or lose it principle mentioned above)
• Examples:
  • An athlete has a hamstring tendinopathy. While screening their programme, the therapist identifies that compressive loads are being applied during exercises with the hips in flexion. These exercises are removed. Potential replacement exercises include prone hamstring curls with the hips in neutral. The therapist also encourages them to reduce compression during sitting in general (e.g. by using a wedge or chair to reduce the amount of hip flexion)
  • An athlete has an Achilles tendinopathy. During training sessions, they are jumping on a mini-trampoline. The therapist identifies this increased load on the tendon and removes it from their programme.

Monitoring a tendon's response to activity and how it responds to different types of loading is useful in determining which exercises to back off and which exercises to progress. An in-season athlete may, however, have a certain degree of pain - "Managing pain to acceptable levels, guided by some appreciation of the underlying pathology and tissue properties, underpins the best option for treating tendon pain in season."

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.

Managing Expectations

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.