Tendinopathy + patellofemoral pain + bone stress injury

Tendinopathy Mx 1

First line treatment for Achilles/ patellar/ gluteal tendinopathy : exercise monotherapy 

Initial load management: 

1. Reduction of load to level where patient symptoms settle 

2. Build back up to regular loading 

3. Compressive loading avoided → 

Positions avoided: 

Achilles: Ankle DF → avoid walking uphills + provide heel lift 

Gluteal: hip adduction → sleeping on back/ on side w/ pillow bwt legs; X cross legs when sitting 

Hamstrings( upper): hip flexion → avoid lunges  

Adductor: hip abduction 

Quadriceps: deep knee flexion → less deep squats 

Tendinopathy Mx 2

Activity management ( deloading): 

Pain monitoring scale: 

Inc pain in: 

1. Activity 

2. After activity 

3. Morning after activity 

4. Weekly basis 

→ should be 5/10 or <

→ shared decision making abt what pain level is acceptable → too high: regress 

Higher required capacity of tendon loading to lower: energy storage + release → energy storage → strength 

Exercise programs from isometric —> isotonic —> energy storage —> functional

Early exercises for gluteal tendinopathy

Stage 1:

1) Static abduction

2) Bridging + double leg squat

3) Side stepping for abductors

Stage 2:

—> same as stage one but optimise movement quality + introduce load

Stage 3:

—> same as stage 2 but increase loading ( band slides )

Stage 4: high level of loading —> bilateral abduction in minisquat + pelvic control in functional loading

Achilles tendinopathy ex

Stage 1;

1. Circulation: moving foot up + down ) 

2. 2 legged heel standing raising 

3. 1 legged heel standing raising 

4. Sitting heel rises 

5. Eccentric heel rises standing on floor

Stage 2:

—> same as stage 1 but w/ quick rebounding heel rises

Stage 3:

1. heel standing raising w/ added weight 

1. Sitting heel rises 

2. Eccentric heel rises standing on edge of a step w/ added weight 

3. Quick rebounding heel rises 

4. Plyometrics training 

→ reps decrease slightly

Stage 4:

1. 1 legged heel standing raising w/ added weight

2. Eccentric heel rises standing on edge of a step w/ added weight 

1. Quick rebounding heel rises

Patellar tendinopathy

Isometric: single leg press/ extension: 60’ knee F 5× 45s

Wall sits

Isotonic: single leg press in 10-60’ knee F —> 4 × 15 RM —> 90’ knee F—> 6 RM

Energy storage: plyometric 3×10 reps —> 6 × 10 reps

Sports specific:

Proximal hamstring

Isometric: hip bridge

Isotonic: nordic hamsstring exercise + single leg hip bridges 15 to 8 RM x 3 sets every 2nd day

Graduated loading: romanian dead lifts + single leg hip thrust + walking lungs + single leg dead lifts

Sports sepcific: A skip + sprinter leg curls, bounding —> 15-20 × 3 sets

Patellofemoral pain patterns + prognosis

1. Anchor: pain in infrapatellar + superior regions → most common

2. Hook: under + around inferior edges of patella 

3. Ovate: over patella

Symptoms worsen —> AKPS score worse

Patellofemoral pain Mx

Combined hip + knee exercises

Short term pain relief: foot orthoses

???: patellar taping + gait retraining

Low risk + high risk stress fractures

Low risk: lateral malleolus + posteromedial tibia + femoral shaft + pelvis + calcaneus + diaphysis of second to fourth metatarsals

—> low risk of complications + less conservative intervention

High risk: femoral neck + anterior tibia + medial malleoli + talus + navicular + proximal diaphysis 5th MT + 2nd MT base

—> prone to non-union + more conservative intervention

Ways to reduce load

Adjusting load volume, progression, type , frequency

Alter equipment/ environment

Biomechanics

—> optimal load: X sympatoms during, after, day after oading

High arch Mx for bone stress injury

Cushioned foot wear

Disipate force

—> prone to leg stress injury

Pronated foot Mx

Rigid foot wear —> reduce bending in foot

—> mid-forefoot injuries

Heel stroke initial contact Mx

Increase cadence

Alter foot wear pitch

Low stride rate Mx

Metronome

Greater hip abduction + knee IR

Kinematic correction of movement

Increase stride rate

Decreased endurance / strength

Exercise program

Low energy availability questionnaires

Ensure eating for training needs

—> 5 days suboptimal —> -ve affects bone metabolism

—> LEAF/ LEAM-Q

Return to sport/ exercise when + schedule

When: 5 consecutive days with no pain doing ADL

Schedule: at least one day of rest in bwt