Tips for Treating Lower Extremity Tendinopathies: Part 3: INDIVIDUALIZING TREATMENT (CASE EXAMPLES)

Welcome to Part 3 of my blog series on lower extremity tendinopathies.

If you missed Parts 1 and 2 on assessment and treatment principles that set the foundation for these cases, check those out:

Part 1: ASSESSMENT

Part 2: EXERCISE PRESCRIPTION

In this post, I want to discuss treatment progressions for two hypothetical patient cases with lower extremity tendinopathies. I truly believe that the key to treating lower extremity tendinopathy is OPTIMIZING TENDON LOAD

On to the cases…

Patient #1: Achilles’ Tendinopathy (28 year old, male trail runner)

Patient #2: Gluteal Tendinopathy (55 year old, female architect)

**PLEASE NOTE: CASES HAVE BEEN ADAPTED AND USE COMBINATIONS OF PATIENT PRESENTATIONS AS WELL AS FICTIONAL ADDITIONS TO MAINTAIN ANONYMITY. THESE DESCRIPTIONS DO NOT REPRESENT A SINGLE PATIENT!!!**

Patient #1: Achilles’ Tendinopathy (28 year old, male trail runner)

This patient was a 28 year-old male computer programmer who did recreational trail running (had run cross country in college) and presented to physical therapy with typical subjective complaints consistent with Achilles’ tendinopathy:

  • Pain at Achilles’ tendon
  • Worse pain with longer runs and speed work
  • Decreased pain 10-15 minutes into running: tendon “warms up”

(see figure below from Part 1: ASSESSMENT):

Evaluation for this patient included load testing and staging based on irritability, which guided initial exercise prescription and treatment recommendations including:

  • Stage 1: Activity Restriction: reduced running volume to 3-4 days/week of 3 mile runs (patient could tolerate 3 miles with < 3/10 pain)

  • Stage 2: Therapeutic Loading: beginning with isometric single leg calf raises: 5x 30 second holds, every day, and progressing to eccentric/concentric exercises with heavier weights 3-4 days/ week

Over the course of his 6 weeks of physical therapy (he had an additional follow up visit at 8 weeks to advise on progression of volume/intensity of running workouts and strength maintenance program) we added concentric and eccentric exercises including the calf raise exercises as outlined below:

Check out this patient’s evaluation and treatment progression below:

If we try to apply these treatment principles to other forms of tendinopathy, here are some example exercises that may be appropriate as you move into Stage 2: Therapeutic Loading:

Lower Extremity Tendinopathy:

Exercise Prescription by Body Area

Achilles’ tendon/

Plantar fascia1,2,3,4,5

·      Standing Calf Raises- straight knee

·      Standing Calf Raises- bent knee

·      Seated Calf Raise- weighted

·      Stretches for plantar fascia and gastrocnemius/soleus muscles6

Posterior tibialis tendon ·      Calf Raises (all variations)

·      Combined Plantarflexion/Inversion with resistance

·      Short foot drills- with and without body weight

Patellar tendon ·      Knee extensions- weighted (if tolerated)

·      Single or double-leg squat variations (e.g., single leg decline squat)

·      Single or double-leg leg press

High hamstring tendon(s)

 

·      Supine bridge variations- double/single leg, bridge walkouts

·      Hamstring curls with machine or cable weight

·      Single leg deadlifts

·      Nordic hamstring curls (or adapted versions)

·      Hamstring “Divers” “Gliders” and “Extenders”: nice “Lengthening” exercise program for hamstring rehab from this paper (Askling et al., 2013)7

Gluteal tendon8,9 ·      Single leg stance holds (level pelvis)

·      “Steamboats”, lateral band walks/monster walks

·      Step-ups: forward and side

·      Hip hikes on a box or step

·      Standing hip abduction with band or cable weight

ALL TENDONS3 Later stages: add speed by introducing

·      Hopping/jumping

o   Jump rope- double or single leg

o   Double or single leg hops in place

o   Box jumps

o   Multiplanar jumps (forward/back, side to side, diagonals)

·      Running: start slow > then increase speed!

As we transitioned into Stage 3 of Rehabilitation for this patient (at about 5-6 weeks into treatment), we added load (weighted calf raises) and running volume (increased running to 5 days/week and up to 5-7 miles).

Here are some general tips on exercise progressions in this final stage of rehabilitation…

Stage 3: Adding Load & Speed: General Tips:

  • Progress to HEAVY LOADS!
    • Example strength goal (Achilles’ Tendinopathy): 25-30 reps of pain-free single leg calf raise
    • Example strength goal (Gluteus Medius Tendinopathy): 15kg resisted single leg cable hip abduction 3×6-8
  • Increase volume and weight BEFORE you increase speed
    • Once strength is there > add speed, meaning introduce plyometrics such as single and double leg hopping, multidirectional hops, and/or box jumps if appropriate. Also, this may be the time to start a return to run program or run/walk program

  • Continue to USE THE PAIN MONITORING MODEL10, 11, 12: This is pretty self explanatory. You should always be re-evaluating the patient’s load tolerance and adjusting exercise and load recommendations accordingly. The goal is to keep pain < 3/10 during and after activity.
  • Remember Rehabilitation is NOT always linear: It is not uncommon to have some hiccups as you reintroduce higher-level activity. Just back off to a tolerable symptom level, stay consistent with your loading progression for strength, and don’t be stingy with recovery days following high efforts (e.g., long run, sprinting efforts, high volume strength training day).
  • Do NOT STOP STRENGTH TRAINING TOO EARLY!
    • Continue heavy loading long enough to see lasting tendon adaptations (and prevent recurrence of symptoms)- tendons may take 12 weeks to adapt to loading and remodel! (One systematic review looking at prognosis for Achilles’ Tendinopathy concluded that there could be tangible improvements in symptoms and function by 4 weeks, but IMPROVEMENTS PEAKED AROUND 9-12 WEEKS after starting rehabilitation)13 .
  • Having strength goals specific to the body region of interest can help guide you in this area (achieve these BEFORE adding speed to loading):

Strength Goals for Lower Extremity Tendinopathy Rehabilitation:

Achilles’ tendon/

Plantar fascia

·      Minimum: 25-30 repetitions of unbroken single leg calf raises (my standard for most patients)

OR

·      Higher level: single leg calf raise bent and straight leg 3×10 and seated single-leg calf raises with up to 1-1.5x body weight3

Posterior tibialis tendon ·      Calf raise strength standards from above

AND

·      Combined Plantarflexion/Inversion for:

6x 30 second holds or 3×10 with heavy resistance (e.g., black theraband)

Patellar tendon ·      Single leg knee extension (if tolerated): up to 40-60kg3

OR

·      Single-leg ¼ squats to bench (single leg sit to stands): 25 repetitions OR 3×10-15, with #5-10kgs

OR

·      Single-leg leg press with 1x body weight for 3×10

High hamstring tendon(s)

 

·      Single leg supine bridges (25 repetitions)

OR

·      Nordic hamstring curl variation or bridge walkouts 3×10-15 repetitions

OR

·      Higher level: Heavy single-leg hamstring curls up to 15-30kgs for sets of 6-8 repetitions3

Gluteal tendon

 

·      Sidelying hip abduction: 3x 25 or 3×10 with heavy theraband

OR

·      Standing hip abduction with cable weight: up to 15-30kgs for sets of 6-8 repetitions3

The “Hundreds Test” can be a decent general test for minimal lower extremity strength goals. As discussed by Physical Therapist Tom Goom, this test does not have an incredible amount of research support, but still could be clinically useful as a gross baseline strength assessment; Discussion of the “Hundreds Test” is at time point 38:45 of this Podcast episode: Physio Edge podcast episode 083: Running gait retraining, strengthening, glutes & ITB syndrome. Q&A with Tom Goom14

The “Hundreds Test” suggests that as a strength minimum an individual should be able to perform 25 consecutive repetitions each of 4 single-leg exercises

(Totaling 100 repetitions on each leg):

  • 25 single leg calf raises
  • 25 sidelying hip abduction raises
  • 25 single leg hip bridges
  • 25 single leg sit to stands (rise from chair)

With these principles in mind, here is a discussion of another lower extremity tendinopathy case example…

Patient #2: Gluteal Tendinopathy (55 year old, female Architect)

Check out this patient’s evaluation and treatment progression below:

Stage 1: Activity Restriction: for this patient included recommendations for offloading the tendon:

  • Avoid provocative positions such as crossing legs, sleeping on her side (not on the same side to avoid compression and not on the opposite side to avoid stretch as the leg fell over her body)
  • Use of a walking stick or hiking pole to reduce the load on the hip abductors in single leg stance

Stage 2: Therapeutic Loading: included the following:

It is important to eventually include some CLOSED CHAIN loading (as pictured above in the Hip Hike exercise). This is because:

  • Our functional use of the gluteus medius is mostly in closed chain activities: walking, running, stepping, any single leg activity…
  • Glute medius activation, as measured by EMG is higher in weight-bearing exercises vs. non-weight bearing exercises.8

Stage 3 Progressions for this patient included adding volume to her walking and reducing use of the walking stick as pain allowed (keeping pain < 3/10) over the course of weeks 10-12.

Closing Thoughts on Lower Extremity Tendinopathy Management:

Remember, that the key to treating lower extremity tendinopathy is

OPTIMIZING TENDON LOAD

We do this by:

  • First: ASSESS LOAD TOLERANCE: (Evaluation and Stage Based on Irritability)
  • Second: MANAGE LOAD: (Stages 1 and 2: Activity Restrict, Therapeutic Loading, *Adjunct Treatments)
  • Third: PROGRESS LOAD: (Stage 3: Add Load and Speed)

I hope this series has been useful for you in your understanding and treatment of lower extremity tendinopathies.

Good luck and happy tendon loading!

Part 1: ASSESSMENT

Part 2: EXERCISE PRESCRIPTION

Part 3: INDIVIDUALIZING TREATMENT (CASE EXAMPLES)

References:

  1. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. The American Journal of Sports Medicine. 1998; 26(3):360-366.
  2. Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: A randomized controlled trial. The American Journal of Sports Medicine. 2015; 43(7):1704-1711.
  3. Malliaras P. Mastering Lower Limb Tendinopathy 2nd https://www.tendinopathyrehab.com/ Accessed: December 18th, 2018.
  4. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes: A systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Medicine. 2013; 43(4):267-286.
  5. Stevens M, Tan C-W. Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: A randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(2):59-67.
  6. Martin RL, Davenport TE, Reischl SF, et al. Heel Pain—Plantar Fasciitis: Revision 2014. Journal of Orthopaedic & Sports Physical Therapy. 2014;44(11):A1-A33.
  7. Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. British Journal of Sports Medicine. 2013;47(15):953-959.
  8. Bolgla LA, Uhl TL. Electromyographic analysis of hip rehabilitation exercises in a group of healthy subjects. J Orthop Sports Phys Ther. 2005;35:487-494.
  9. Grimaldi A, Fearon A. Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management. J Orthop Sports Phys Ther. 2015;45(11):910-922.
  10. Silbernagel K, Crossley KM. A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation. J Orthop Sports Phys Ther. 2015;45(11):876-886.
  11. Silbernagel KG, Thomeé R, Thomeé P, Karlsson J. Eccentric overload training for patients with chronic Achilles tendon pain—a randomized controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports. 2001; 11:197-206.
  12. Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: A randomized controlled study. The American Journal of Sports Medicine. 2007; 35(6):897-906.
  13. Murphy M, Travers M, Gibson W, et al. The prognosis for mid-portion Achilles tendinopathy with rehabilitation: A systematic review and longitudinal meta-analysis. Journal of Science and Medicine in Sport. 2018;21:S83.
  14. Physio Edge podcast episode 083: Running gait retraining, strengthening, glutes & ITB syndrome. Q&A with Tom Goom: https://www.clinicaledge.co/podcast/physio-edge-podcast/083

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