Tendon pain – High and Fast Loads…and our favourite exercises!

Part 5 – High and Fast Loads…and our favourite exercises!

The final part of our five part series was supposed to be an outline of our favourite tendon rehabilitation exercises, however following a valuable discussion with a long suffering tendon pain sufferer this week, I decided to add a bit more and talk about high and fast loads as a component of tendinopathy rehabilitation!

Here’s how this topic came up: when discussing a chronic achilles tendon problem with Kim (her real name!) and how to approach an upcoming marathon in 5 months, we reviewed her tendon rehabilitation regime, which was actually progressing very well. Kim’s achilles problem had returned to about 90% normality, but she was struggling to get that final 10% back, and was easily flaring as soon as she tipped over a specific pace of running. On review, Kim’s running program was excellent, combined well with some cross training activities, and quite a thorough strength program, apart from one aspect… the main exercise for her Achilles strength was a single leg calf raise (which she had progressed over time up to a 45 second hold) with 4 repetitions. This is great, but with tendons, load needs to be progressed and the progression isn’t always just in hold times. When discussing appropriate progressions for Kim, we looked at:

Isometric (or static) holds are very effective in very early stage rehab when the tendon is quite painful and cannot tolerate movement based exercise, but these exercises must be progressed into movement based exercises as soon as the tendon can tolerate it.
Body weight load is good, but when you are running, there can be 4-5 times body weight load impacting through the lower limbs, so we need to find additional loads to these exercises.
Despite the fact that Kim was aiming at running a slow, steady pace over the marathon (and therefore thinking that these static exercise loads were appropriate), even at a slow pace, there are still extremely high impact forces and very quick dynamic load changes within the Achilles tendon – remember the stretch/shorten cycle (SSC) explanation in the last article – the tendon will still change from a loaded/stretched position to a power producing shortened position at a fairly quick rate of recoil. This alone probably explains the high irritability (easily flared) tendon that Kim has when trying to push past a certain running rate – the tendon has not been conditioned to tolerate the higher and faster loads during the SSC phase of running. For runners (of any pace) it is possibly this aspect of exercising and loading the tendon through a SSC with some speed that is key to reducing the risk of recurrence.
And finally (which will be mentioned more with our favourite exercises later on), one of the most critical calf/Achilles strength exercises is completed on a bent knee, as well as a straight knee.
So…back to the SSC – Think of the Achilles as a spring: when the spring is stretched, it develops an internal energy and this energy is released as the spring recoils! This spring like action of the Achilles occurs during walking, running, jumping, and hopping type activities and the key element of stretch shorten cycle is speed. It is this speed of loading that is often a key factor in the development of tendon injuries, so it is a factor that must be carefully structured into the rehabilitation program following injury.

So when considering rehabilitation from tendon injuries, one of early goals is restore “load capacity” or the ability of the tendon to tolerate high levels of force. For many sports though (like Kim’s example above) the rehab shouldn’t finish with high level strength exercises – there should be progression to involve some speed of movement in combination with the higher loads to ensure the lowest risk of re-injury possible!

Now across to a few of our favourite exercises for tendinopathy, but please keep in mind that “one exercise does not fit all”! If you’ve read the whole series of 5 articles, you will release that tendon injures and rehabilitation is a complex topic and the only thing we can say for sure is that you need a program developed that is specific to your body, your injury, your stage of recovery, and your sport! The examples below are just some of the common exercises we include in an achilles/patella/hamstring tendon program to ensure we get adequate loading, SSC involvement, and potential to alter speed.

SEATED CALF RAISE:

A great way to isolate the deeper soleus component of the calf and

load the achilles tendon through full range (if possible) to mimic the SSC.

LEG PRESS:

A good way to get load and strength into the patella tendon. Technique is very important when doing this exercise and range may need to be modified if soreness occurs in the tendon.

HAMSTRING CURL :

Many years ago this was the exercise to avoid, now has returned as a great method of loading the hamstring muscle/tendon unit . Be wary of too much knee bend (or your hamstring may cramp) and this is more a loading exercise than a speed exercise.

Please keep in mind that these are just a few of our favourite exercises to help address some tendon injuries – check with your physio if they are appropriate for you before starting!

Anthony Lance

SSPC Physiotherapist