- wrong use vs over use - Not every tendon problem is the same; location matters
o Midsubstance- Most common: associated with over/wrong use; treat with load and reload;
-Most common (have ICF guidelines); goal is to stiffen it (so isometrics/eccentrics verse stretches)
-Can use tape, soft tissue, heel lifts, some modalities, all can help with pain (for the itis), but do not reload tendon, needed for Osis treatment
-Treatment: slow and controlled, involving cognition (think about it), need to exceed elongation than during walking (on step); high volume required, and overload it;
- Progression from flat ground to step to adding weight
- Goal with treatment is to make tendon more organized, thinner, faster reaction time;
-Palpation: if very localized, may more degeneration/thickening, verse entire tendon than more related to inflammation;
o Tenosseous junction (insertional)- associated with collagen disease, wide age range- teat surgery, casting, shockwave; Avoid resistive exercises, more to rest and boot/immobilize
-Running technique/skill training (change how they load the foot/calcaneus);
- Look at rear foot and mid foot mechanics.
Muscle Tendinous Junction: associated with immobilization (deprived loading); treat with progressive reloading- more rare, often inflammatory and need rest first
Sports Med. 2012 Nov 1;42(11):941-67. doi: 10.2165/11635410-000000000-00000.
Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning.
MID PORTION ACHILLES
- Evidence was strong for eccentric loading exercises and extracorporeal shockwave therapy; moderate for splinting/bracing, active rest, low-level laser therapy and concentric exercises (i.e. inferior to eccentric exercise). In-shoe foot orthoses and therapeutic ultrasound had limited evidence.
J Orthop Sports Phys Ther. 2015 Nov;45(11):876-86. doi: 10.2519/jospt.2015.5885. Epub 2015 Sep 21.
A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation.
Mid protion; 2-6 cm proximal to insertion (55-65%)
Eccentric protocol: 15x3, knee straight and 15x 3 knee bent; 2x a day, 7 days, no more than 5/10 during and after next day, slowly add load.
Return to sport: 3x15 with weight off step SL heel raises; 3x15 eccentric off step with weight, and 3x20 quick rebounding heel raises - 3 days recovery - need to load heavy, and speed
Clin J Sport Med. 2009 Jan;19(1):54-64. doi: 10.1097/JSM.0b013e31818ef090.
Nonoperative treatment of midportion Achilles tendinopathy: a systematic review.
Eccentric exercises have the most evidence of effectiveness in treatment of midportion Achilles tendinopathy.
Sports Med. 2013 Apr;43(4):267-86. doi: 10.1007/s40279-013-0019-z.
Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness.
- CONCLUSION: There is little clinical or mechanistic evidence for isolating the eccentric component,
- Concentric- eccentric loading better (3 sec up, 3 sec down)- time under tension- 3 sets of 10-20, enough load to be painful in third set
J Orthop Sports Phys Ther. 2016 Aug;46(8):664-72. doi: 10.2519/jospt.2016.6494. Epub 2016 May 12.
Patellofemoral Joint and Achilles Tendon Loads During Overground and Treadmill Running.
- Treadmill running resulted in greater achilles tendon loading compared with overground running ; peak concentric ankle power greater with Treadmill runnning
Am J Sports Med. 2015 Jul;43(7):1704-11. doi: 10.1177/0363546515584760. Epub 2015 May 27.
Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial.
- chronic mid portion achilles tendinopathy;
- eccentric training 3x15 7x week, 12 weeks vs: Heavy slow resitance 3x week, knee flexed seated, and knee extended standing (15 rep max to 6 rep max);
- sports allowed if < 3; 4-5/10 while training if subsides next session
- Both groups: improved pain, and sports assessments, reduction in tendon thickness and neovascularization
- Patient satisfaction > in heavy slow resistnace group (96 vs 76%), with higher compliance (96% vs 76%))