Megathread for tendon loading for 16 y/o XC athlete

[Scott Resetar]

***Subjective Asterisks***
16 year HS XC athlete
• Minimal Running summer
• Begins practice – 20 miles/week with workouts
• Acute local non Insertional Achilles pain
• Constant pain – Increased with walking, Stair
ascending; Unable to run; Sharp pain/stiffness
in AM
• Easing Factors: Rest, ice, NSAIDs
• Denies : Insertional pain, heel pain, NT, Proximal
sxs
• PMHx: MTSS beginning of past 3 seasons

***Objective Asterisks***

Very tender to palpate – Non Insertional aspect of Achilles
• Mobile effusion
• Decreased Ankle DF, Hip EXT, EXT/ROT
• Single leg Stance: Calcaneal EVR, STJ pronation. Poor
balance
• Single leg Squat: Limited TC DF –> STJ EVR, Fem
ADD/IR
• Hop Test: Apprehension/sharp local pain
• Gait: Walking – Excessive STJ pronation mid –> late
stance
• Unable to run – pain

Phase 1 – Pain Reduction
Phase 2 – Improve Biomechanical Efficiency
Phase 3 – Strengthen the Complex
Phase 4 – Progress the Load
Phase 5 – Sport Specific/Functional Training
Phase 6 – Maintenance Loading

Treatment for each phase to follow soon.

[Scott Resetar]

Scott: Phase 1 and 2
Nic: Phase 3 and 4
Katie: Phase 5 and 6

[Scott Resetar]

Phase 1 – Pain Reduction

1.Trial heel lift to see if this decreases her pain with walking
Avoid running at this time, Cross training to tolerance (swim/bike/elliptical) in order to keep cardiovascular endurance up.

2. Perform Mid-ROM isometric holds, 5 reps x 40-60 second holds for pain relief, 2-3x/day. This can be done either using the leg press machine, or in standing with a mod/heavy load.

3. Continue NSAIDs at this time

4. Begin discussion of training errors

5. Modalities or grade I/II talocrural AP glides for pain relief.

Phase 2 – Improve Biomechanical Efficiency / Improve load capacity of entire kinetic chain

1. Address frontal, transverse plane loading – Patient displays excessive STJ pronation in mid/late stance, so education on neutral foot position and practice SLS without falling into pronation, modifying as necessary. (w/ or w/o UE support, w/ or w/o eyes closed)

2. Proximal -–> Distal stability. Patient displays increased hip ADD/IR during SLS, so working on hip strengthening, glute med/max activation, preventing that compensation while still working on neutral foot position.

3. Address Muscle imbalances -Flexibility/Strength. Perform Grade III/IV talocrural AP glides to increase DF ROM, Prone hip PA mobilizations with hip in ER and in neutral to improve hip extension and ER ROM. Follow these up with strengthening and motor control interventions to improve carryover.

4. Orthotic management – consider increased medial support/arch support to decrease falling into dynamic valgus.

5. Continue to progress cross training, continue to work on isometrics and loading in Mid ROM, gradually increasing the ROM as tolerated.

[nhoover17]

Phase 3: Strengthen The Complex

Improve muscle and tendon’s ability to produce force and manage load.

1. Start with bilateral tendon strengthening in mid-range tendon positions (neutral/no DF) with slow, tempo controlled movements.
2. Concentrics first, maintaining slow, tempo control.
3. Progress to unilateral strength, maintain mid-range tendon positions (neutral/no DF)
4. Rest to full recovery between sets for optimal strength and safe loading in pain free positions.
5. Strength training on non-consecutive days for ample rest/recovery time

2-3 sets x 15 reps -> 3-4 sets x 8-12 reps with increasing load based on pt response.

Bilateral Exercises -> progression
Squats on total gym -> leg press -> Squats w/ UE assist via hand rail/TRX straps -> free squats
Heel raise on total gym -> on leg press -> in standing w/ UE assist -> free heel raise
Prone hip ext -> bird dog -> deadlift/good mornings

Unilateral exercises
SL squats on total gym -> SL leg press -> SL stand/DL sit
SL heel raise on total gym -> SL heel raise on leg press -> SL heel raise/DL return
Step up w/ UE assist -> step up -> step up w/ row for post chain activation
4 way steamboats on air -> against resistance
SL cone taps -> SL deadlift w/ KB/DB (Flamingos)
Fwd and bwd stepping lunges -> add resistance w/ KB/DB/barbell

Phase 4 – Progress load

1. Progress from concentric to eccentric loading
2. Progress from mid-range to full range tendon position (past neutral into DF)
3. Start with bilateral and progress to unilateral exercises
4. Rest to full recovery b/n sets for optimal recovery/hypertrophy
5. Continue with strength training on non-consecutive days for ample rest/recovery
6. Heavy, slow resistance with controlled tempo
7. Progress from phase 3 increasing sets and decreasing reps with increased resistance

Exercises from phase 3 can carry over with increasing ROM and focusing on eccentric phase of movements. As strength and tolerance improves, can begin to implement explosive concentric phase with controlled eccentric phase.

Additional exercises to consider:
Baps Board w/ weights for progression of foot/ankle control through stance phase
Lunge with high knee -> progress to include heel raise at end of concentric phase
step up row -> progress to include heel raise
KB swing in bilat stance w/ both UEs -> progress to tandem stance w/ 1 UE

Educate patient on importance of compliance of 3-4x/week for proper rest/recovery to allow tissue healing, strength improvement and increased tolerance to load gradually prior to beginning return to run program through phase 5 and 6. Educate pt on the length of the strengthening phase, taking several weeks to months prior to tolerance to running.

[Michael McMurray]

Phase 5 – Sports Specific/Functional

Increase strength/power: Incorporate double limb and single limb squat progressing with weight and repetition to target strength and endurance. Initiate quarter, half, full lunge. Continue to address dynamic stabilization of the hip.

Increase speed of contraction: Potentially initiate a jump progression program starting with reduced weight at total gym or on leg press, double limb to single limb improving push off and landing mechanics.

Specific demands of sport: To address strength continue with or initiate hip and core strengthening program to improve proximal stability. Progress maintaining neutral foot with single limb stance on firm or complaint surface with contralateral leg swing to address movement pattern. Teach dynamic self posterior hip mobilization in lunge or child pose to address hip extension/rotation deficits. Continue with or provide static/dynamic stretching.

Drills: Start push off and sprint drills, should be performed pain free.

Plyometrics: Potential jumping plyometric exercises to improve push off speed and performance, including resisted jumping, squat jumps, single limb vertical jump.

Graduated/progressive return to sport/running: Perform graded treadmill program increasing incline/decline, speed, duration. Gradual return to sport with running in increments dependent on duration or mileage of pain free running.

Phase 6: Maintenance Loading

Off season training: Educate regarding appropriate off season training schedule including gradual increase in milage. If pain returns/persists, reduce training level.

Adequate loading: Continuation of eccentric exercise.

Gait mechanics and gait retraining: Treadmill training with verbal and/or visual feedback (mirror if available) for self correction of training errors starting with level surface progressing with incline/decline and speed.

[Michael McMurray]

Great job everyone – I hope that was a helpful activity for clinical decision making with tendinopathy.

Cheers

[Author]

Posts