Notes & References

-       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.

Rowe V1, Hemmings S, Barton C, Malliaras P, Maffulli N, Morrissey D.

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.

Silbernagel KG, Crossley KM.

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.

Magnussen RA1, Dunn WR, Thomson AB.

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.

Malliaras P1, Barton CJ, Reeves ND, Langberg H.

• 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.

Willy RW, Halsey L, Hayek A, Johnson H, Willson JD.

• 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.

Beyer R1, Kongsgaard M2, Hougs Kjær B3, Øhlenschlæger T2, Kjær M2, Magnusson SP4.

• 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%))