In-Season Management of Tendons

Introduction[edit | edit source]

Managing lower limb tendinopathies in athletes can be a challenge. Managing an athlete in-season can be even more daunting. When managing tendinopathy, provocative loads should be removed, and a progressive loading programme should be followed.[1] However, an in-season athlete needs to train at a high level, and they subject their tendons to high loads when 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.[1] Strategies to achieve these goals include:[1][2]

  • 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.[1]

Features of Tendon Pain and Aspects to Consider in the Differential Diagnosis[edit | edit source]

  • Tendon pain is well localised - it does not refer much beyond the tendon (unless associated bursa / fat pad are affected)[1]
  • Loading provokes tendon pain - as load increases, pain increases[1]
  • 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[1]
  • Tendon pain will not usually cause night pain or pain at rest (unless it is a reactive tendinopathy or "associated with a metabolic or seronegative condition"[1]

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

Tendon Load and Capacity[edit | edit source]

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

"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."[3] -- Ebonie Rio

Compared to muscles, tendons have a lower rate of tissue turnover, and they adapt more slowly to increased loading.[4] Any load that is excessive and not well managed is considered overload.[5] Overload can "result in anatomical, physiological and/or psychosocial conditions that will manifest as altered performance and injury and illness."[5]

"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."[6]

Tendons are subjected to four different types of loads:

  • Tensile loads[7][3]
    • 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[8]
    • 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[8]
    • one of the most provocative loads for a tendon
    • occur when tendons are subjected to both compressive and tensile loads (e.g. running in a position of hip flexion, such as when playing 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[3][8]
    • 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 tendon loads:
      • cause 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[edit | edit source]

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.[9] 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."[8] -- 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 (i.e. paratenonitis), heavy, slow, progressive loading will most likely be aggravating.[10]

Replacement of Exercises to Avoid Tendon Load[edit | edit source]

The current evidence-base supports an active / exercise-based approach to manage tendinopathy.[11] 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.[8]

When managing athletes, we must carefully scrutinise their entire programme, including their warm-up, training sessions and gym work:[8]

  • 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. As Cook and Purdum note: "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."[1]

Maintaining a Strengthening Programme In-Season[edit | edit source]

Key points from the research:

  • Both isotonic and isometric exercises have been found to reduce pain for athletes in-season with patellar tendinopathy.[2][12]
    • Van Ark et al.[2] compared isometric and isotonic exercises for jumping athletes with patellar tendinopathies. Participants played their sport at least three times per week. They found that both isometric and isotonic exercises had a positive impact on pain levels and function.
    • While both isometric and isotonic exercise protocols appear to be effective for athletes to reduce pain in-season, Rio et al. note that isometric exercises had a "significantly greater immediate analgesia throughout the 4-week trial."[12] This is significant as an enhanced analgesic effect may positively impact an athlete's ability to load or perform.[12]
    • A 2019 case series study by Rio et al.[13] found that an isometric quadriceps squat exercise using a rigid belt can be effective at reducing patellar tendinopathy pain in-season.
  • Eccentric loads may NOT be appropriate for athletes in-season as they are generally highly provocative, and athletes are already loading their tendons from their sports schedule.[2] Moreover, it has been suggested that eccentric exercises may actually place an inadequate load on the muscle or tendon of athletes.[14]
  • Heavy, slow resistance training is another exercise option to manage tendinopathy (high loads are approximately 70-85% of one repetition maximum (1RM)).[15]

With other training commitments, it can be challenging to include a comprehensive strength training programme in-season, but this sort of programme is vital to manage a tendinopathy. While the optimum exercise prescription for tendinopathy has not yet been determined,[2] it is important to remember the following points when planning a programme:

  • Tendons do not like change. Progressive training loads are best, and sudden spikes or prolonged periods of rest should be avoided:[9]
    • Slow progressive exercises allow the tendon to increase its capacity
    • Sudden spikes in load often lead to tendinopathy
    • Excessive rest will decrease the tendon's capacity, which will make it vulnerable to injury
  • Assess the entire kinetic chain for any compensatory strategies or deficits that may be contributing to the tendon problems:[9]
    • Example: patellar tendinopathy:[1]
      • reduced ankle dorsiflexion in landing can increase the load on the patellar tendon
      • important to consider gluteal strength and recruitment, calf strength, and re-educate on landing
  • Single-sided loading is important when rehabilitating tendons:
    • If there are differences in strength between sides, the strong side may carry the weaker side during double-leg exercises
  • Perform strength training on both the affected and unaffected:
    • By strengthening the unaffected side, cross-education occurs - this promotes strength in the affected side[9]
    • The loads applied on each side must be appropriate to the capacity of that side[9]
  • Fitting strength training into a busy athlete's schedule may be difficult. The timing of strength training sessions must be carefully considered in terms of the athlete's overall training schedule:
    • Cook et al.[9] propose that athletes with tendinopathy in-season should participate in a minimum of two strength training sessions per week, but that three times per week is optimal

Managing Expectations[edit | edit source]

Tendons are notoriously slow to recover, especially in-season, as they are subjected to high loads while competing. Everyone involved in the athlete’s recovery, including the coach, manager, doctor, physiotherapist etc., should be in agreement with the treatment plan. Appropriate expectations of recovery time and pain levels should be communicated to everyone.[9] Sports physiotherapists should ensure that coaches understand both the pathophysiology of tendinopathy and the importance of adapting a training programme. They should also work collaboratively with coaches to develop appropriate training programmes.

"It's critical then that when we're talking with athletes or strength and conditioning or coaching staff, that we're all on the same page about what we mean by different loads." -- Ebonie Rio

Adjuncts[edit | edit source]

Specific adjuncts might help reduce pain and improve function in athletes with tendinopathy in-season.[1]

  • Extracorporeal shock wave therapy reduces C fibre activity and can provide some pain relief for several weeks. However, it can disrupt the tendon tissue structure[1]
  • Might consider supportive strapping, bracing, orthoses, footwear and other equipment "as small gains made in this realm may provide enough to allow satisfactory athlete function."[1]

Preventing Tendinopathy In-Season[edit | edit source]

  • Early intervention, modifying training and setting realistic timelines are important strategies to help prevent tendinopathy in-season[1]
  • We must be able to identify at-risk athletes, create individualised training programmes, monitor for changes in pain and adjust loads in response to any changes / pain[1]
  • Maintaining appropriate loading in the off-season is an important consideration, as is managing any return to loading for athletes after injury or surgery[1]

Summary[edit | edit source]

As with any tendinopathy, appropriate loading is key to the management of in-season tendinopathies, but there are specific considerations:

  • athletes will be exposed to high loads during competition
  • we must carefully assess and structure training programmes to eliminate provocative loads, but continue with safe loading
  • exercises can be adapted to reduce compressive and fast tensile loads
  • isotonic and isometric exercises have been found to reduce pain and improve function for athletes with tendinopathy in-season

References[edit | edit source]

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. Br J Sports Med. 2014 Apr 1;48(7):506-9.
  2. 2.0 2.1 2.2 2.3 2.4 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.
  3. 3.0 3.1 3.2 Rio E. Clinical Reasoning in Tendons Course. Plus, 2019.
  4. Mersmann F, Laube G, Marzilger R, Bohm S, Schroll A, Arampatzis A. A functional high-load exercise intervention for the patellar tendon reduces tendon pain prevalence during a competitive season in adolescent handball players. Frontiers in physiology. 2021 Mar 10;12:626225.
  5. 5.0 5.1 Herring SA, Ben Kibler W, Putukian M, Berkoff DJ, Bytomski J, Carson E, Chang CJ, Coppel D. Load, overload, and recovery in the athlete: Select issues for the team physician-A consensus statement. Current Sports Medicine Reports. 2019 Apr 1;18(4):141-8.
  6. Steinmann S, Pfeifer CG, Brochhausen C, Docheva D. Spectrum of tendon pathologies: Triggers, trails and end-state. International journal of molecular sciences. 2020 Jan 28;21(3):844.
  7. 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):1620-1628.
  8. 8.0 8.1 8.2 8.3 8.4 8.5 Rio E. In-Season Management of Tendons Course. Plus, 2023.
  9. 9.0 9.1 9.2 9.3 9.4 9.5 9.6 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.
  10. Wongsithichai P, Chang KV. Paratenonitis. Journal of Medical Ultrasound (2014) 22, 55e56
  11. Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Practice & Research Clinical Rheumatology. 2019 Mar 8.
  12. 12.0 12.1 12.2 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.
  13. 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.
  14. 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.
  15. Physiopedia. Tendinopathy Rehabilitation.