I wonder if anyone else does this, subscribe to podcast channels and store them on your phone in an attempt to convince yourself that you’re doing CPD, but never get round to listening to them? I’ve also been known to do this with articles, printing them out then cluttering mine & my colleagues desks but never reading them.
Well I decided to catch up on a few podcasts and start listening to them in the car on the way to work. Flicking through the different channels I subscribe to, I saw 2 separate discussions about tendons. So I thought I would listen to both in succession and see what similarities or differences the experts had. These aren’t necessarily the only podcasts to talk about tendons, just 2 I had on my phone:
1) Physioedge #23: Lower Limb Tendinopathies with Dr Peter Malliaris (here)
2) The PhysioMatters Podcast session 6: Achilles Tendons with Seth O’Neil (here)
Before we start, a quick opportunity to revise some key topics discussed below. Figure 1 demonstrates Cook & Purdhams continuum of tendinopathies.
Difference between Achilles and Patella Tendon:
A particularly interesting theme throughout the podcasts was the difference between Achilles and Patella tendon pathologies. None of the podcasts openly said “lets start addressing different tendons with different management” but they pretty much edged that way.
Malliaris was careful not to align himself with any particular “recipe” for tendon treatment, but did say that if he were to prescribe a protocol, he would use a different one for Achilles than he would Patella tendons. Later in the podcast, he explains his theory on not loading the patella tendon beyond 70 – 80 degrees knee flexion, explaining that there is no benefit to heavy loading into the end range for tendons… except the achilles tendon. This makes sense, if we understand that tendinopathies are a reaction to a combination of tensile and compressive loads. For the patella tendon to be lengthened, with the knee in full flexion, the patella will be acting as a fulcrum on the tendon tissues. However, when loading the achilles in a lengthened position the calcaneous doesn’t cause as much compression on the tendon (excluding Haglund’s deformity).
A quick cameo from a third podcast (BJSM Apophyseal injuries in children and adolescents with Dr Mattheiu Sailly, here) but interestingly discusses different processes between Osgood-Schlatters and Severs disease, with less tendon involvement seen in Severs. Could this paediatric presentation be similar in adult tendinopathies?
While on the topic of lengthening tendons and putting them under load, it seems apt to discuss the one exercise method that goes hand in hand with tendons, Eccentrics.
“Eccentrics are not essential – Dr Peter Malliaris”
Malliaris comes across as a big fan of eccentrics. They are a useful method of increasing time under tension (TUT) and applying a heavy load, however they do not have to be a part of every program!
If a patient is unable to perform an isometric exercise, don’t even bother attempting an eccentric exercise as they will lack the quality throughout the movement. Another example would be a program designed for a player in mid-season. In these circumstances, it could be better to provide high load isometric exercises. O’Neill supports this theory for mid-season. While we accept that eccentric exercises will help the tendon, remember that they will also fatigue the muscle and therefor could impact on performance.
It is also important to recognise the stage of tendinopathy (see Figure 1). While a degenerative tendon can be treated quite aggressively in order to increase stiffness, however most athletes are likely to present with a reactive tendinopathy. In these cases, the cellular matrix is generally intact so the management can afford to be less aggressive. In these cases, activity modification to acutely lower the load would be beneficial and combined with isometrics, which Malliaris believes have an analgesic effect.
With any program for tendons, it is important to continuously monitor pain responses. A short duration of pain following activity suggests a stable tendon, however pain for a couple days suggests a very reactive and unstable presentation. O’Neill quotes a theory based on Delayed Onset Muscle Soreness (DOMS) as the characteristics of tendon pain and DOMS are strikingly similar. He explains that fascia seems to be a source of pain as opposed to the contractile tissues. The paratenum contains most of the nerves and the structures here will suffer from the delayed onset soreness. Much like actual DOMS, the tendons respond well to loading. O’Neill uses the analogy of going for a gentle jog when you have DOMS in your legs, and feeling a bit better afterwards.Over time, changes in both central and peripheral sensititsation may cause the heightened peripheral sensitisation we see with chronic loading – hence part of our management is activity modification.
Moving on from mid-season management, Malliaris discusses the off-season and the tendency of athletes to put their feet up for a few weeks after a gruelling season. This would be detrimental to a problematic tendon and as soon as they resume intense pre-season training you will spend the whole pre-season fighting fires with a reactive tendon. Therefore prescribe off-season tendon programs that include jumping, hopping, running drills to maintain control of the tendon.
“True tendon problems tend to be aggravated by a Stretch Shortening Cycle – Seth O’Neill”
In his exercise programs, Malliaris ensures that the Stretch Shortening Cycle (SSC) is as long as the “slower exercise” phases. However, these do not have to be done in simaltenous blocks. The SSC exercises should be incorporated as early as possible, providing the movement patterns are fluid and symptoms are under control (again, its important to understand and recognise a reactive or degenerative phase tendinopathy).
“Patella tendinopathies love intensity and loves load”
Tendon management remains a complex and daunting task for physiotherapists, yet in an age where we promote individualised management of injuries we still seem keen to follow a “recipe” for tendon management. Both podcasts discuss the importance of treating the individual, with reference given to their demands and tailoring programs to suit them. However, we seem happy to discuss “tendons” as a whole. Hamstring management has its own niche, at the same time we don’t treat all ligament injuries like an ACL. Should we start discussing individual tendons separately? As mentioned at the top, Malliaris changes his stance on loading through range when managing Patella tendons and Achilles tendons. We have only discussed these two tendons, without any reference to the rotator cuff, the hamstring tendons, flexor and extensor complexes in the forearm – all of which have different roles and demands.
What is exciting is the amount of research going into tendons and our understanding is evolving very quickly. Since my short time of being a physio, we have dropped “itis” and introduced “opathy”; eccentrics fell out of favour recently and Alfredssons protocol has been dissected and critiqued to death, yet now, with the support of Malliaris and O’Neill (amongst others) we feel comfortable using eccentrics again, but as part of a bigger program.
I highly recommend listening to the above podcasts and subscribing to their channels, they are a hugely resourceful… resource!
Yours in sport
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