Managing Tendinopathy Inseason

While abstaining from playing sport during rehabilitation prior to return to play has been recommended in the literature (Paavola et al. 2000), this may not be the most practical or even most beneficial approach to dealing with tendinopathy. Unfortunately, there is a scarcity of evidence recommending a system of modified rest in which the pain-provoking activity should be limited or avoided (Paavola et al. 2002) with the current literature in this area focusing mainly on AT.

Cook and Purdam (2013) discussed the challenge of managing tendinopathy in competing athletes. Tendinopathy begins with a mismatch between the tendon’s load capacity and load placed on the tendon. This occurs most commonly through a sudden or substantial change in the load it is subjected to. This can include a return to sport from an injury or after the off season, where the load capacity of the tendon is reduced due to a loss of a regular loading stimulus. As tendons respond very slowly to load, a tendinopathic response is triggered if the magnitude or temporal distribution exceeds the tendon’s threshold. Examples of overloads that can cause tendinopathic responses in the TA are demonstrated in Table 4.6.

Table 4.6: Table demonstrating overloads that can cause tendinopathic responses in the TA as outlined by Cook and Purdam (2013).

Fig 4.5: Continuum model of tendinopathy as outlined by Cook and Purdam (2009)

The continuum model of tendinopathy outlined by Cook and Purdam (2009) is demonstrated in Figure 4.5. This model provides an overview of the background for the mechanisms by which load management can prevent worsening of symptoms of tendinopathy while continuing with sports participation.

If a tendon is overloaded in an athlete with underlying degenerative tendinopathy participating in sports, they will present with a reactive on degenerative tendinopathy. In addition to the high loads, changes in mechanical properties such as stiffness and elasticity at the interface between areas of differing tendon pathology may predispose degenerative tendons to become reactive in previously unaffected portions of the tendon. By managing the load that the tendon is exposed to the reactive tendinopathy should return the degenerative tendon to its functional low pain status (Cook and Purdam 2013).

Load Management In-Season (Cook and Purdam 2013)

Consideration of total load on the tendon is an important concept, as a combination of small overloads may induce a reactive response. Care with rapid increase or an excessive tensile load is a major consideration.
Reduction of compressive loads and particularly the combination of compression and tensile loads is especially important while the athlete continues with sport participation (Cook and Purdam 2012).
Loads that reduce pain should be introduced reasonably early. Loading to decrease pain will maintain tendon stimulus. There is literature to support the use of isometric exercise in pain conditions for this purpose (Kosek and Ekholm 1995). In reactive tendons, isometric contraction with some load appears to be beneficial in decreasing pain for several hours. These exercises should be completed in the mid to inner range of the muscle-tendon unit to reduce compression. In highly irritable tendons, a bilateral exercise, shorter holding time and fewer repetitions per day may be indicated.
Provocative tests and objective scoring methods should be used to monitor tendon pain. As the VISA scale scores substantially higher on pain during higher level activity, therefore it is only responsive on a month-to-month basis. The athlete can monitor tendon response to training loads by completing a simple loading test daily at a similar time. Table 4.7 demonstrates some suggested provocative tests that can be used to score tendon pain.

Table 4.7: Some suggested provocative tests that can be used to score tendon pain

Silbernagel et al. (2007) evaluated the effect of continued sport and the associated loading on the TA while completing an eccentric exercise regime. The participants were followed over 1 year, with one group continuing to load their tendons and participate in sport while the other group limited this type of activity. There were no significant differences between groups at 6, 12 and 26 weeks or 1 year.

Continued sport, as long as symptoms allow, appears to have a specific positive effect on calf-power and jump performance which is not gained with the Silbernagel loading programme alone even though it includes faster calf loading and stretch-shorten cycle rehabilitation (Malliaras et al. 2013).

Key Points

Tendinopathy is a prevalent injury in athletes and is very common in the competition season when loads are high (Cook and Purdam 2013).

(Silbernagel et al. 2007) found that no negative effects could be demonstrated from continuing TA-loading activity, such as running and jumping, with the use of a pain-monitoring model, during treatment.

By managing the load that the tendon is exposed the reactive tendinopathy should return the degenerative tendon to its functional low pain status (Cook and Purdam 2013). This involves:

Considering total load on tendon
Reduction of compressive loads
Isometric exercises - beneficial in decreasing pain
Using provocative tests and objective scoring methods to monitor tendon pain

Key References

Cook, J. L. and Purdam, C. R. (2013) 'The challenge of managing tendinopathy in competing athletes', British journal of sports medicine, bjsports-2012.

Silbernagel, K. G., Thomeé, R., Eriksson, B. I. and Karlsson, J. (2007) 'Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With AT A Randomized Controlled Study', The American journal of sports medicine, 35(6), 897-906.