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DOI: 10.1016/j.apunts.2017.11.005 Full text access This item has received
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Resumen Load management in tendinopathy:
Palabras clave
Clinical progression for Achilles and
Background
patellar tendinopathy
Gestión de la carga en las tendinopatías: progresión clínica para
tendinopatías de Aquiles y rotuliana

Alfons Mascaróa, , Miquel Àngel Cosb, Antoni Morralc, Andreu Roigb, Craig
d e
Purdam , Jill Cook
a Faculty of Physical Therapy, Lleida University, Lleida, Spain
b High Performance Centre (CAR) Sant Cugat, Barcelona, Spain
c Blanquerna School of Health Science, Ramon Llull University, Barcelona, Spain
d Australian Institute of Sport, Canberra, Australia
e Faculty of Health Sciences, La Trobe University, Victoria, Australia

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ABSTRACT

Achilles and patellar tendons are commonly affected by tendinopathy. Tools

Injury to these tendons can severely impact upon sports, recreational
and everyday activities. Eccentric musculotendinous loading has
become the dominant conservative intervention strategy for Achilles Print
and patellar tendinopathy over the last two decades. Eccentric loading Send to a friend
involves isolated, slow lengthening muscle contractions. Systematic
Export reference
reviews have evaluated the evidence for eccentric muscle loading in
CrossMark
Achilles and patellar tendinopathy, concluding that outcomes are
Mendeley
promising but high-quality evidence is lacking. Eccentric loading may
not be effective for all patients (athletes and non-athletes) affected by Statistics
tendinopathy. It is possible that in athletes, eccentric work is an
inadequate load on the muscle and tendon. A rehabilitation program
aiming to increase tendon load tolerance must obviously include
strength exercises, but should also add speed and energy storage and
release. The aim of this paper is to document a rehabilitation protocol
Supplemental materials
for Achilles and patellar tendinopathy. It consists of simple and
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pragmatic exercises designed to incorporate progressive load to the

PDF 1
tendon: isometric work, strength, functional strength, speed and
jumping exercises to adapt the tendon to the ability to store and release
energy. This article would be the first step for an upcoming multicentre
randomized controlled trial to investigate its efficacy.

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Keywords:
Apunts Sports Medicine
Tendinopathy Achilles Patellar Exercise

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RESUMEN Language Editing services

Las tendinopatías de Aquiles y rotuliana son muy frecuentes. Las

lesiones en estos tendones pueden afectar severamente a las
actividades deportivas, recreativas y cotidianas. En las últimas 2
décadas, los ejercicios excéntricos se han convertido en la principal
intervención conservadora para tratar las tendinopatías de Aquiles y
rotuliana. Los ejercicios excéntricos no son efectivos en todos los
pacientes afectados por tendinopatías (atletas y no atletas). Es posible
que en atletas, la carga que genera el trabajo excéntrico sobre el
músculo y el tendón sea insuficiente. Un programa de rehabilitación
que tenga por objetivo aumentar la tolerancia del tendón a la carga
debe, obviamente, incluir ejercicios de fuerza, pero también debe
agregar ejercicios de velocidad y ejercicios que aumenten la capacidad
para almacenar y liberar energía. Este trabajo muestra un protocolo de
rehabilitación para las tendinopatías de Aquiles y rotuliana. Consiste en
ejercicios simples y pragmáticos diseñados para incorporar carga
progresiva al tendón: mediante trabajo isométrico, fuerza, fuerza
funcional, velocidad y ejercicios pliométricos que aumenten en el
tendón la capacidad de almacenar y liberar energía. Este trabajo es el
primer paso para diseñar un ensayo clínico aleatorizado y multicéntrico
que permita evaluar su eficacia.

Palabras clave:

Tendinopatía Aquiles Rotuliana Ejercicio

Carga Terapia física

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FULL TEXT

Background
Achilles and patellar tendons are commonly affected by tendinopathy,
which are overuse injuries characterized by localized tendon pain with
loading and dysfunction.1–3

I understand tendinopathy as pain and dysfunction not related to the

pathology, and knowing that there isn’t a direct connection between
structure, pain and dysfunction, a classification based on the structure
is called into question. The interaction between structure, pain and
function hasn’t been completely understood. One can find regions in
the tendon which are in different stages at the same time. The clinical
presentation is a hybrid of reactive and degenerative pathologies, where
the structurally “normal” part (in the regular image modalities) has a
reactive response, and there is a silent degenerative part of the tendon,
mechanically and structurally incapable of transmitting tractive load,
and this leads to overloading the normal part of the tendon. The
tendon pain is partially related to the function, to the tendinopathy,
diminishing muscle strength and motor control which, at the same
time, reduces the function. The function in this context refers to the
muscle's ability to produce the appropriate strength so that the tendon
can accumulate and release energy for the sports movements.
However, one can find function changes when there is a structural
pathology, independent from the pain.4

Both are common among athletes and Achilles tendinopathy may also
affect sedentary people. Injury to these tendons can severely impact
upon sports, recreational and everyday activities.1–3 The prevalence of
patellar tendinopathy is high in sports characterized by high demands
on speed and power for the leg extensors (i.e. volleyball and
basketball).5 In the general population, the incidence of Achilles
tendinopathy is 1.85 per 1000. In the adult population (21–60 years),
the incidence is 2.35 per 1000. In 35% of the cases, a relationship with
sports activity was recorded.6

Tendinopathy is commonly associated with tendon pathology.

Pathological features of tendon pathology include altered cellularity
(increased or decreased), break down in the extracellular matrix (ground
substance accumulation, disorganized collagen, neurovascular
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ingrowth).7 Endocrine tenocytes and nerve endings release biochemical

substances that are thought to have a role in tendon pain (e.g.
substance P).8

Eccentric musculotendinous loading has become the dominant

conservative intervention strategy for Achilles and patellar tendinopathy
over the last two decades. Eccentric loading involves isolated, slow
lengthening muscle contractions. Systematic reviews have evaluated
the evidence for eccentric muscle loading in Achilles9–13 and patellar14,15
tendinopathy, concluding that outcomes are promising but high-
quality evidence is lacking.16 Eccentric loading may not be effective for
all patients (athletes and non-athletes) affected by tendinopathy.17 It is
possible that in athletes, eccentric work is an inadequate load on the
muscle and tendon. A rehabilitation program aiming to increase
tendon load tolerance must obviously include strength exercises, but
should also add speed and energy storage and release.18 The aim of this
paper is to document a rehabilitation protocol for Achilles and patellar
tendinopathy. It consists of simple and pragmatic exercises designed to
incorporate progressive load to the tendon: isometric work, strength,
functional strength, speed and jumping exercises to adapt the tendon
to the ability to store and release energy (Fig. 1). This article would be
the first step for an upcoming multicenter randomized controlled trial
to investigate its efficacy.

Programme to incorporate progressive load to the tendon.

Fig. 1.

Programme to incorporate progressive load to the tendon.

(0.12MB).

The development of a rehabilitation plan for any individual with

tendinopathy requires complex clinical reasoning, with reference to the
pathoanatomical diagnosis and the functional requirements of the
person. Tendinopathy and subsequent rehabilitation will vary
considerably depending on the site of the pathology (i.e. insertional or
mid-substance), the stage of the tendinopathy, functional assessment,
fitness level of the person, contributing issues throughout the kinetic
chain, comorbidities and concurrent presentations.19

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Scientific literature suggests that the pathogenesis of Achilles

tendinopathy is heterogenic. Several risk factors and interactions
between them have been identified. Both extrinsic (e.g. overuse) and
intrinsic factors may predispose to injury.20–22 These include lipid levels,
genes, metabolic disorders, age, circulating and local cytokine
production, genre, biomechanics and body composition.23 It is crucial
to have a holistic view of the patient and assess the risk factors.21,24 It is
also important to take into account the total amount of load in the
tendon, both at work and in sport.25 Understanding and addressing
these factors may improve the outcomes.

The literature on the rehabilitation of tendinopathy suggests that the

most important treatment is appropriate loading.26 The continuum
model of tendinopathy27 provides a reasoned basis for considering
targeted rehabilitation dependent on current clinical presentation.

Each component of the rehabilitation program, in particular loading,

must be handled in relation to the nature, speed and magnitude of the
forces applied to the muscle/tendon/bone unit in order to achieve the
goals of the particular management phase, without causing
exacerbation of the pathological state or pain. Exercise prescription can
target matrix reorganization and collagen syntheses,28 reduce tenocyte
activity, affect tendon compliance29,30 or have an analgesic effect.31 While
matrix reorganization and improved collagen integrity are sometimes
considered to be goals of the rehabilitation process, measurable
structural change does not necessarily correlate with therapeutic
outcome.32 There is reasonable evidence to refute observable structural
change as an explanation of the benefits of eccentric work in
tendinopathy.33 Exercise prescription may exert positive therapeutic
effects through other mechanisms, such as change in mechanical
properties of the tendon, functional strength, innervation, vascularity or
perception of pain.

An accurate diagnosis is essential, imaging tests are helpful, but what

really is important is a good clinical assessment. Based on the
continuum model, we need to stage where the tendon pathology is:
reactive tendinopathy, tendon dysrepair, degenerative or reactive on
degenerative tendinopathy. The management of the load is the gold
standard treatment at all stages. Early load management in a reactive

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tendon may keep them in the early stages of tendon pathology and
limit the progression of their pathology.

Key points to design and manage tendon load

progression

Pain relief and balanced training

1. Pain inhibits the athlete using the elastic (energy storage and release)
capacity of the tendon, thereby compromising function and
performance.18

2. Excessive training volume or too intense training involving the elastic

function of tendons may induce tendon overload and are important
factors in the onset of athletic tendinopathy.

3. Repeated training combined with too short resting periods can result
in a net degradation of the matrix and lead to overuse injury.26

4. Managing tendinopathy in season centers around load management,

these include strategies that control pain, both reducing aggravating
loads and introducing pain-relieving loads.18

5. No medication or injectable treatment to date has been shown to

alter tissue properties; only tendon load can stimulate remodeling.18

6. The only option for repeated failures to accommodate athletic load is

a comprehensive rehabilitation program that can increase the load
absorption ability of the tendon.18

7. Loads that reduce pain should be introduced as early as possible.

Loading to decrease pain will maintain a load stimulus on the tendon
that is critical to maintain cell function and matrix integrity.18

8. In painful (reactive, reactive on degenerative) tendons, isometric

contraction with some load decreases pain for several hours.18 These
loads can be repeated several times a day, using 40–60″ holds, 4–5
times, to reduce pain and maintain some muscle capacity and tendon
load.18 In highly reactive and painful tendons, bilateral exercises, shorter
holding time and fewer repetitions per day may be indicated.18
Literature supports the use of isometric work in painful conditions;

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sustained isometric fatiguing muscle contraction recruits segmental

and/or extrasegmental descending inhibition mechanisms. The
recruitment of descending inhibition results in mechanical hypoalgesia
and increased pressure pain threshold in healthy individuals.18 Although
there isn’t a golden standard for tendinopathy rehab,34 the guidelines
(progression protocols) described in this article match the standards
that other authors had previously presented and discussed.18,34,35 During
the strength training sessions, the patients can use metronomes or
phone apps, which provide a better control of the number of
repetitions of each exercise. Adding these external stimuli has proven to
maximize the effects of the workout and to prevent relapses34–36 and it
must be taken into account.

9. Moderate to heavy loads with slow machine-based weights rarely

cause pain.18 These exercises should be completed in the mid to inner
range of the muscle-tendon unit to reduce compression at the tendon
insertion.18

Measuring tendon response to load

10. Provocative tests and objective scoring methods should be used to

monitor tendon pain. As the VISA scales give substantial scores on pain
during high-level activity, they are not responsive to short-term change
and are best used on a month-to-month basis. Pain behavior the day
after loading is the critical load response test. The athlete can monitor
tendon response to training loads by completing a simple loading test
every day at a similar time (avoid early morning except in the Achilles
where morning pain and stiffness can be a good guide to
progression).18

11. Perhaps it is the magnitude of the structural tendon response to a

load what matters, as this appears to occur before pain arises or
changes. An instrument that could quantify the response of a tendon to
load would mean a huge advance in the management of
tendinopathy.18

Prevention of tendon rupture. Evidence for changing tendon

structure: aerobic training, synthesis of collagen and rest time

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12. Kannus and Józsa examined 891 spontaneously ruptured tendons

histologically and found that 864 (97%) of them had degenerative
changes.37 If there's degeneration and tendon overload for a prolonged
period, the whole tendon can become degenerative and may fail
completely.38,39 Avoiding these pathological changes is the main
prevention to prevent rupture of the Achilles tendon.40,41 So, in addition
to improving the pain and the functional-capacity load tolerance, we
must maintain or improve tendon structure to prevent tendon
rupture.27

13. Mechanical loading seems to induce changes in gross morphology,

mechanical properties as well as biochemical parameters of tendon
tissue.42 It appears that both intense and regular exercise raise human
collagen synthesis (Langberg et al., 1999,43 2000,44 200145; Miller et al.,
200546), which suggests that human tendon tissue is more metabolically
active in response to activity than what was previously believed.47
Intense exercise increased the formation of type I collagen during the
recovery process, which suggests that intense physical loading leads to
some kind of adaptation.48 Intense exercise in humans is followed by an
increase of collagen synthesis and degradation. Over the first 24–36 h,
this response results in a net loss of collagen, but this is followed by a
net synthesis 36–72 h after exercise.26 An increased collagen synthesis is
consistently observed as a part of the tendon adaptation response to
mechanical loading,42 however the integration of new collagen into the
matrix has not been shown. The COOH-terminal propeptide of type I
collagen (PICP) is an indicator for collagen type I synthesis. PICP
initially decreased after exercise and an increase in this marker of
collagen synthesis was detected 72 h after exercise.48 In healthy
humans, both synthesis and degradation increased after 4 week of
physical training, whereas after 11 weeks only the collagen synthesis,
and not the collagen degradation, was chronically raised.48

The idea that the tendon can hypertrophy in response to mechanical

loading suggests that there is a net formation of connective tissue.47
Both long-term (years) and relatively short-term (months) loading
induce tendon hypertrophy. The degree of hypertrophy is rather small
and seems to occur only in certain tendon regions.42 However, this

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appears to be true only in young people as collagen turnover after the

age of 17 years is limited (Heinemeier et al., 2011).42

14. Persons who undergo regular training have a greater Achilles

tendon cross-sectional area than other age-matched persons
(Magnusson and Kjaer, 200349; Kongsgaard et al., 200550), which
indirectly reflects a region-specific hypertrophy in response to long
term loading,47 possibly during adolescent loading when the tendon is
able to adapt structurally to load.

15. The potential region-specific adaptation to running appears to be

far greater in men than in women. The ability of the tendon to adapt to
regular loading is attenuated in women.47

16. A similar increase in collagen synthesis is seen that is independent

of exercise volume (repetitions), which suggests that there is a ceiling
effect in collagen synthesis.26

17. The fact that pro collagen expression is regulated the same way in
the tendon regardless of the type of muscle contraction (eccentric,
isometric or concentric) supports the belief that the collagen protein
synthesis response is regulated by fibroblast strain.26

18. With regard to tendon mechanical properties, increased tendon

stiffness is generally observed in response to large volumes of loading.42

Integrating structural effects of exercise into rehabilitation

19. Studies suggest that appropriate loading during rehabilitation of

tendinopathy is the most important treatment method.19 Exercise
prescription can target matrix reorganization and collagen synthesis,
reduce tenocyte activity, affect tendon compliance or have an analgesic
effect.19 The way the absorption of energy is distributed across the
kinetic chain is important and each tendinopathy requires a holistic
approach in terms of rehabilitation.15 Each component of the
rehabilitation program, in particular loading, must be handled in
relation to the nature, speed and magnitude of the forces applied to the
muscle/tendon/bone unit in order to achieve the goals of the particular
management stage (Table 1), without causing an exacerbation of the
pathological state or pain. When planning a rehabilitation strategy, it is

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crucial to find an approach that addresses the re-education of muscle

function instead as considering the tendon as an isolated unit. While
early stimulus of the muscle tendon unit is typically focused on
isometric muscle activation, which may include muscle stimulation,
most programs advocate the progression to higher loads as guided by
symptom presentation.19 Progression beyond the early isolated strength
and hypertrophy loading requires functional conditioning of the
muscle-tendon unit, adjusting tendon load through faster eccentric
work prior to starting skill specific re-education such as landings,
before introducing sports specific challenges such as sprinting and
cutting.19 Consideration of the cortical effects of exercise on the motor
cortex are critical.

Table 1.

Treatments and considerations for different tendinopathy stages.27

Pathology Treatment Considerations

Reactive Load management (reduction). 1. The tendon shows no
tendinopathy Assessment and modification of adaptation to load → back
intensity, duration, frequency and to the load used before the
type of load is the key clinical symptoms
intervention. 2. Isometrics
Tendon Process of adaptation to load → load Progression of strength
dysrepair management and exercise. work:
Isometrics
2. Slow dynamic functional
work (first progressing the
strength, then the speed)
3. Add endurance as
required
4. Progressing the
compression
5. Energy storage and
release loads
Degenerative Process of adaptation to load → load Progression of strength
tendinopathy management and exercise. work:
Isometrics
Slow dynamic functional
work (first progressing the
strength, then the speed)
Progressing the
compression

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Pathology Treatment Considerations

High load elastic
(plyometric work)
Reactive on Settle the reactive tendon first and The reactive tendinopathy
degenerative then address the degenerative settles relatively quickly
component

Effect of loading on tendon. Goals according to key points

1. Removing the cause of reactive or reactive on degenerative

tendinopathy (usually unaccustomed load)

2. Reduce the pain through reduction of high loads

3. Introducing isometric loads that reduce pain at early stages

4. Adapt the training volume and resting periods to the amount that
the tendon can safely handle at that moment

5. Increasing load capacity of the tendon up to that required by the

person by improving the structural and/or mechanical properties of the
tendon

6. At the end of the progression the athlete should be able to use the
elastic capacity of tendon and have regained function of the kinetic
chain suitable for performance

Methods that lead to goal achievement according to key point

1. Load management (reductions) removes the cause of reactive or

reactive on degenerative tendinopathy.23 Assessment and modification
of the intensity, duration, frequency and type of load is the key clinical
intervention.23 Intensity seems to be the most important feature;
therefore this is the first factor we should modify by removing intensity
peaks (i.e. sprinting, sets, Fartlek, fast changes of direction, explosive
jumping). Frequency is a very flexible value that we can use to adapt the
load (more or less resting hours between workouts depending on the
pain level of the next day). Volume seems to be the less aggressive
feature, if there is enough time of rest among workouts, therefore at
early stages we can keep the volume of training and change intensity
and frequency. If pain increases the day after the workout we need to
assess if the person should maintain regular training or adapt their

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training. Sometimes the athlete may need a different approach than the
rest of the group (alternate days, half track, specific work,...). The
change on the Numeric Pain Scale (NPS) value the day after the
workout tells us if the load is tolerated. Daily NPS: NPS should not
raise on the loading test the day after training.

2. Isometric exercises reduce the pain in the early phase of

rehabilitation or while managing an athlete in season. Isometrics must
be heavy (up to 70% maximal voluntary isometric contraction) for the
musculotendinous unit and be held for a long time (up to 45 s).51,52

3. How the tendon responds to the training volume and rest periods
indicates if the amount of load is within the load that the tendon can
safely handle. During early stages of rehabilitation high energy storage
loads should not be repeated in less than 48 h. Adapting the training
according to the NPS observed the next day: If NPS increases keep 72 h
rest between workouts, if NPS does not increase, keep 48 h rest
between workouts, if NPS decreases it is possible to increase the
frequency or intensity of high load training.

4. To Increase load capacity of the tendon up to that required by the

person by improving either structural or mechanical properties of the
tendon, we must increase load absorption ability of the
musculotendinous unit and the kinetic chain, through progressive
loading. Mechanical properties of tendon, including tendon
compliance, are improved later in rehabilitation by retraining landings,
running, changing pace or direction, jumps (energy storage loads).
Eccentric exercises incorporated in all the loads proposed in this paper
seems to be the best way to stimulate remodeling of tissue.

5. The ultimate goal is that the athlete should be able to use the elastic
capacity of tendon and have regained function of the kinetic chain
suitable for performance. Functional exercises and individual technical
exercises that involve high loads at maximum speed, to apply high force
and achieve high velocity, maximum expression of force in sports where
tendon have to show their ability to store and release energy in
functional and asymptomatic form.

Monitoring effect: load dosage and pain management

according to pain level the day after the training Numeric
Pain Scale (NPS)

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Numbered scale from 0 to 10, where 0 means lack of pain and 10 the
highest imaginable level of pain. The patient chooses the level that
better suits his symptoms, knowing that 7 means an exaggerated pain
resulting in modified function. It is essential to correlate pain during
training with change on the loading test the next day (Table 2).

Table 2.

Numeric pain scale and its correlation with training intensity.

0 1 2 3 4 5 6 7 8 9 10
No Light Moderate Intense pain, resulting in modified Highest
pain pain pain function pain
Safe training Excessive training intensity
intensity

Exercises progression
This is an example of progression, which would vary depending of the
goals of each patient. Goals are different for an elite volleyball player
and a weekend warrior. The program must be unique to each
individual, since the needs of each person are also unique. The highest
demanding parts of this program only apply to high performance level
of competitive sports (Table 3).

1. On early stages, we keep a daily isometric work: 4–5 isometrics,

holding 40″ (from 30 to 60″) and resting at least 1 min and up to 2 min
between each, 3 times a day. High loads provide best results. The load
needs to be high but avoid muscle fatigue. Muscle vibration during the
execution of the exercise means that we are approaching fatigue and
that the load is excessive. The exercise needs to be stopped at that
moment and we will take that time (being 20″, 30″, 40″ or any other
amount) as a reference for progression.

Table 3.

Example daily monitoring and evolution of pain.

Do I feel pain for the next few hours? No = maintain and gradually
increase the time you hold the isometric contraction or the load if I stay

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below or equal to pain level 4 for 2 or 3 days. Yes = reduce the time you
hold the isometric contraction

2. Progression: start slow isotonic exercises on alternate days. 4 sets of

slow concentric–eccentric, 6–8 repetitions of 4“concentric + 4”
eccentric. Increase the load (2 kg, 4 kg, 6 kg–12 kg). Rest 30″ between
sets. Once a day, on alternate days. We keep the isometric work,
alternating slow dynamic exercises (one-day isometric work, next day
slow dynamic work, next one isometric,...)

Do I feel more pain the next day? No = increase the load in slow
dynamic exercises every 2 or 3 days when I stay below or equal to pain
level 4 for 2 or 3 days. Yes = reduce the load in slow dynamic exercises

3. Then increase the speed with functional exercises when base

strength is adequate

Do I feel more pain the next day? No = increase the speed in functional
exercises every 2 or 3 days when I stay below or equal to pain level 4.
Yes = reduce the speed in functional exercises.

Maintain the strength exercises

4. Progression: add fast dynamic exercises every three days. 3 sets of

fast concentric-eccentric contraction (explosive), 6–8 repetitions. Rest 2
min among sets. Once a day, every three days. Alternating fast dynamic
work with slow dynamic and isometric work. (One day fast dynamic, the
next day slow dynamic, the other day isometric, then again fast
dynamic,....)

Do I feel more pain the next day? Yes = reduce the number of energy
storage exercises. No = increase the number of energy storage exercises
every 5–6 days

Maintain the strength exercises

Discussion
Achilles and patellar tendinopathy are the most common
tendinopathies of the lower limbs. The ideal treatment to manage these
tendinopathies doesn’t exist. There is a need for further research to
resolve which is the best therapeutic strategy to help those patients who
suffer from tendinopathies.

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On the other hand, there is a number of effective exercise programs for

Achilles and patellar tendinopathies. Eccentric training is the most
commonly used. It was first posed by Alfredson et al.53 Systematic
reviews have evaluated the results of eccentric loading of the injured
tendon in tendinopathy, concluding that outcomes are promising, but
high-quality evidence is lacking.54,55

In our experience, the results obtained by athletic patients

(professionals and nonprofessionals) in an isolated eccentric exercise
program are poor.

Malliaras et al.16 performed a systematic review of studies comparing

two or more loading programs for Achilles and patellar tendinopathy.
His conclusions recommend bearing in mind the eccentric and
concentric exercises.

There are studies that recommend a Heavy Slow Resistance (HSR)

program to treat lower limb tendinopathy.56,57 Keep in mind that the
eccentric-exercise training is slow lengthening of a muscle-tendon unit
while it is under load and Heavy-slow resistance training is a series of
exercises in which each repetition is performed slowly (>6 s) for both
the eccentric and concentric phase. In these studies, the HSR program
achieved the same pain and function improvement (VISA score) than
the Alfredson eccentric program, but with a significantly higher patient
satisfaction at the six months follow-up. This clinical improvement
came with a collagen rise in the HSR group. This data allows us to
recommend the HSR program as an alternative to the eccentric
workout for Achilles and patellar tendinopathy rehab.

Isometric exercises have been recommended to reduce and treat

patellar tendon pain35 and to initiate muscle-tendon unit loading when
the pain limits the ability to perform isotonic exercises.18 Five
repetitions of 45-s isometric mid-range quadriceps exercise at 70% of
maximal voluntary contraction have been shown to reduce patellar
tendon pain for 45 min after the exercise and this was also associated
with a reduction in the motor cortex inhibition of the quadriceps that
was associated with patellar tendinopathy.36

Some authors recommend including functional activities (like speed

and leap exercises) in the tendinopathy rehab protocols for athlete

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patients. But they haven’t been implemented in the scientific literature

yet.58,59

In this sense, the progressive exercises protocol presented in this article

takes into account the isometric and strength exercises (concentric and
eccentric). The innovation resides in the incorporation of functional
strength exercises, speed and leaps to adapt the tendon to the ability to
store and release energy. In our clinic experience, incorporating these
exercises is very important for the patellar and Achilles tendinopathy
rehab for athletic patients.

Conclusion
This protocol can be useful to improve symptoms and function in
Achilles and patellar tendinopathies. We have shown the exercises and
their progression, we have been using this protocol in our clinical
practice for the past 7 years. Our patients get positive results. But this is
just a protocol. Randomized clinical trials are needed to demonstrate its
efficacy, to devise an adequate dose-response model and to determine
its long-term effects.

Conflict of interests
Authors declare that they don’t have any conflict of interests.

Appendix A

Supplementary data

The following are the supplementary data to this article:

REFERENCES

[1] A.D. Lopes, L.C. Hespanhol Júnior, S.S. Yeung, L.O. Costa.
What are the main running-related musculoskeletal injuries? A systematic review.
Sports Med, 42 (2012), pp. 891-905
http://dx.doi.org/10.2165/11631170-000000000-00000 | Medline

https://www.apunts.org/en-load-management-in-tendinopathy-clinical-articulo-S1886658117300580 16/23
2/11/24, 7:54 PM Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy | Apunts Sports Medicine

[2] J. Zwerver, S.W. Bredeweg, I. Van den Akker-Scheek.

Prevalence of Jumper's knee among nonelite athletes from different sports: a cross-sectional
survey.
Am J Sports Med, 39 (2011), pp. 1984-1988
http://dx.doi.org/10.1177/0363546511413370 | Medline

[3] S. De Jonge, C. Van den Berg, R.J. De Vos, et al.

Incidence of midportion Achilles tendinopathy in the general population.
Br J Sports Med, 45 (2011), pp. 1026-1028
http://dx.doi.org/10.1136/bjsports-2011-090342 | Medline

[4] J.L. Cook, E. Rio, C.R. Purdam, S.I. Docking.

Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and
research?.
Br J Sports Med, 50 (2016), pp. 1187-1191
http://dx.doi.org/10.1136/bjsports-2015-095422 | Medline

[5] O.B. Lian, L. Engebretsen, R. Bahr.

Prevalence of jumper's knee among elite athletes from different sports: a cross-sectional study.
Am J Sports Med, 33 (2005), pp. 561-567
http://dx.doi.org/10.1177/0363546504270454 | Medline

[6] S. de Jonge, C. van den Berg, R.J. de Vos, H.J. van der Heide, A. Weir, J.A. Verhaar, et al.
Incidence of midportion Achilles tendinopathy in the general population.
Br J Sports Med, 45 (2011), pp. 1026-1028
http://dx.doi.org/10.1136/bjsports-2011-090342 | Medline

[7] K.M. Khan, F. Bonar, P.M. Desmond, J.L. Cook, D.A. Young, P.J. Visentini, et al.
Patellar tendinosis (jumper's knee): findings at histopathologic examination. US and MR
imaging.
Radiology, 200 (1996), pp. 821-827
http://dx.doi.org/10.1148/radiology.200.3.8756939 | Medline

[8] P. Danielson.
Reviving the “biochemical” hypothesis for tendinopathy: new findings suggest the involvement
of locally produced signal substances.
Br J Sports Med, 43 (2009), pp. 265-268
http://dx.doi.org/10.1136/bjsm.2008.054593 | Medline

[9] J.J. Kingma, R. de Knikker, H.M. Wittink, et al.

Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review.
Br J Sports Med, 41 (2007), pp. e3-e5
http://dx.doi.org/10.1136/bjsm.2006.030916 | Medline

[10] V. Rowe, S. Hemmings, C. Barton, P. Malliaras, N. Maffulli, D. Morrissey.

Conservative management of midportion Achilles tendinopathy: a mixed methods study,
integrating systematic review and clinical reasoning.
Sports Med, 42 (2012), pp. 941-967
http://dx.doi.org/10.2165/11635410-000000000-00000 | Medline

[11] B.L. Woodley, R.J. Newsham-West, G.D. Baxter.

Chronic tendinopathy: effectiveness of eccentric exercise.

https://www.apunts.org/en-load-management-in-tendinopathy-clinical-articulo-S1886658117300580 17/23
2/11/24, 7:54 PM Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy | Apunts Sports Medicine
Br J Sports Med, 41 (2007), pp. 188-198
http://dx.doi.org/10.1136/bjsm.2006.029769 | Medline

[12] A. Meyer, S. Tumilty, G.D. Baxter.

Eccentric exercise protocols for chronic non-insertional Achilles tendinopathy: how much is
enough?.
Scand J Med Sci Sports, 19 (2009), pp. 609-615
http://dx.doi.org/10.1111/j.1600-0838.2009.00981.x | Medline

[13] L. Satyendra, N. Byl.

Effectiveness of physical therapy for Achilles tendinopathy: an evidence based review of
eccentric exercises.
Isokinet Exerc Sci, 14 (2006), pp. 71-80

[14] H. Visnes, A. Hoksrud, J. Cook, R. Bahr.

No effect of eccentric training on jumper's knee in volleyball players during the competitive
season: a randomised controlled trial.
Clin J Sport Med, 15 (2005), pp. 225-234

[15] J.E. Gaida, J. Cook.

Treatment options for patellar tendinopathy: critical review.
Curr Sports Med Rep, 10 (2011), pp. 255-270
http://dx.doi.org/10.1249/JSR.0b013e31822d4016 | Medline

[16] P. Malliaras, C.J. Barton, N.D. Reeves, H. Langberg.

Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical
outcomes and identifying potential mechanisms for effectiveness.
Sports Med, 43 (2013), pp. 267-286
http://dx.doi.org/10.1007/s40279-013-0019-z | Medline

[17] M.K. Sayana, N. Maffulli.

Eccentric calf muscle training in nonathletic patients with Achilles tendinopathy.
J Sci Med Sports, 10 (2007), pp. 52-58

[18] J.L. Cook, C.R. Purdam.

The challenge of managing tendinopathy in competing athletes.
Br J Sports Med, 48 (2014), pp. 506-509
http://dx.doi.org/10.1136/bjsports-2012-092078 | Medline

[19] A. Scott, S. Docking, B. Vicenzino, H. Alfredson, R.J. Murphy, A.J. Carr, et al.
Sports and exercise-related tendinopathies: a review of selected topical issues by participants of
the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012.
Br J Sports Med, 47 (2013), pp. 536-544
http://dx.doi.org/10.1136/bjsports-2013-092329 | Medline

[20] H. van der Worp, J. Zwerver, P.P. Kuijer, M.H. Frings-Dresen, I. van den Akker-Scheek.
The impact of physically demanding work of basketball and volleyball players on the risk for
patellar tendinopathy and on work limitations.
J Back Musculoskelet Rehabil, 24 (2011), pp. 49-55
http://dx.doi.org/10.3233/BMR-2011-0274 | Medline

[21] F. Franceschi, R. Papalia, M. Paciotti, E. Franceschetti, A. Di Martino, N. Maffulli, et al.

Obesity as a risk factor for tendinopathy: a systematic review.

https://www.apunts.org/en-load-management-in-tendinopathy-clinical-articulo-S1886658117300580 18/23
2/11/24, 7:54 PM Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy | Apunts Sports Medicine
Int J Endocrinol, 2014 (2014), pp. 670262
http://dx.doi.org/10.1155/2014/670262 | Medline

[22] F. Oliva, A.C. Berardi, S. Misiti, N. Maffulli.

Thyroid hormones and tendon: current views and future perspectives, concise review.
Muscles Ligaments Tendons J, 3 (2013), pp. 201-203
Medline
[review]

[23] B. Magnan, M. Bondi, S. Pierantoni, E. Samaila.

The pathogenesis of Achilles tendinopathy: a systematic review.
Foot Ankle Surg, 20 (2014), pp. 154-159
http://dx.doi.org/10.1016/j.fas.2014.02.010 | Medline

[24] A. Rabin, Z. Kozol, A.S. Finestone.

Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry
recruits: a prospective cohort study.
J Foot Ankle Res, 7 (2014), pp. 48
http://dx.doi.org/10.1186/s13047-014-0048-3 | Medline

[25] A.J. de Vries, H. van der Worp, R.L. Diercks, I. van den Akker-Scheek, J. Zwerver.
Risk factors for patellar tendinopathy in volleyball and basketball players: a survey-based
prospective cohort study.
Scand J Med Sci Sports, (2014),

[26] S.P. Magnusson, H. Langberg, M. Kjaer.

The pathogenesis of tendinopathy: balancing the response to loading.
Nat Rev Rheumatol, 6 (2010), pp. 262-268
http://dx.doi.org/10.1038/nrrheum.2010.43 | Medline

[27] J.L. Cook, C.R. Purdam.

Is tendon pathology a continuum?. A pathology model to explain the clinical presentation of
load-induced tendinopathy.
Br J Sports Med, 43 (2009), pp. 409-416
http://dx.doi.org/10.1136/bjsm.2008.051193 | Medline

[28] K. Khan, A. Scott, Mechanotherapy:.

how physical therapists’ prescription of exercise influences tissue repair.
Br J Sports Med, 43 (2009), pp. 247-252
http://dx.doi.org/10.1136/bjsm.2008.054239 | Medline

[29] N.N. Mahieu, P. McNair, A. Cools, C. D’Haen, K. Vandermeulen, E. Witvrouw.

Effect of eccentric training on the plantar flexor muscle-tendon tissue properties.
Med Sci Sports Exerc, 40 (2008), pp. 117-123
http://dx.doi.org/10.1249/mss.0b013e3181599254 | Medline

[30] E. Witvrouw, N. Mahieu, P. Roosen, P. McNair.

The role of stretching in tendon injuries.
Br J Sports Med, 41 (2007), pp. 224-226
http://dx.doi.org/10.1136/bjsm.2006.034165 | Medline

[31] K.M. Naugle, R.B. Fillingim, J.L. Riley 3rd.

A meta-analytic review of the hypoalgesic effects of exercise.

https://www.apunts.org/en-load-management-in-tendinopathy-clinical-articulo-S1886658117300580 19/23
2/11/24, 7:54 PM Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy | Apunts Sports Medicine
J Pain, 13 (2012), pp. 1139-1150
http://dx.doi.org/10.1016/j.jpain.2012.09.006 | Medline

[32] R.J. De Vos, A. Weir, J.L. Tol, J.A. Verhaar, H. Weinans, H.T. van Schie.
No effects of PRP on ultrasonographic tendon structure and neovascularisation in chronic
midportion Achilles tendinopathy.
Br J Sports Med, 45 (2011), pp. 387-392
http://dx.doi.org/10.1136/bjsm.2010.076398 | Medline

[33] A. Van der Plas, S. De Jonge, R.J. De Vos, H.J. van der Heide, J.A. Verhaar, A. Weir, et al.
A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion
Achilles tendinopathy.
Br J Sports Med, 46 (2012), pp. 214-218
http://dx.doi.org/10.1136/bjsports-2011-090035 | Medline

[34] E. Rio, D. Kidgell, G.L. Moseley, J. Gaida, S. Docking, C. Purdam, et al.

Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a
narrative review.
Br J Sports Med, 50 (2016), pp. 209-215
http://dx.doi.org/10.1136/bjsports-2015-095215 | Medline

[35] M. van Ark, J.L. Cook, S.I. Docking, J. Zwerver, J.E. Gaida, I. van den Akker-Scheek, et al.
Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy
in-season?. A randomised clinical trial.
J Sci Med Sport, 19 (2016), pp. 702-706
http://dx.doi.org/10.1016/j.jsams.2015.11.006 | Medline

[36] E. Rio, D. Kidgell, G.L. Moseley, J. Cook.

Elevated corticospinal excitability in patellar tendinopathy compared with other anterior knee
pain or no pain.
Scand J Med Sci Sports, 26 (2016), pp. 1072-1079
http://dx.doi.org/10.1111/sms.12538 | Medline

[37] P. Kannus, L. Józsa.

Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of
891 patients.
J Bone Joint Surg Am, 73 (1991), pp. 1507-1525
Medline

[38] C. Tallon, N. Maffulli, S.W. Ewen.

Ruptured Achilles tendons are significantly more degenerated than tendinopathic tendons.
Med Sci Sports Exerc, 33 (2001), pp. 1983-1990
Medline

[39] M. Kongsgaard, P. Aagaard, M. Kjaer, S.P. Magnusson.

Structural Achilles tendon properties in athletes subjected to different exercise modes and in
Achilles tendon rupture patients.
J Appl Physiol, 99 (2005), pp. 1965-1971
http://dx.doi.org/10.1152/japplphysiol.00384.2005 | Medline

[40] N. Maffulli, A. Ajis.

Management of chronic ruptures of the Achilles tendon.

https://www.apunts.org/en-load-management-in-tendinopathy-clinical-articulo-S1886658117300580 20/23
2/11/24, 7:54 PM Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy | Apunts Sports Medicine
J Bone Joint Surg Am, 90 (2008), pp. 1348-1360
http://dx.doi.org/10.2106/JBJS.G.01241 | Medline

[41] G.W. Hess.

Achilles tendon rupture: a review of etiology, population, anatomy, risk factors, and injury
prevention.
Foot Ankle Spec, 3 (2010), pp. 29-32
http://dx.doi.org/10.1177/1938640009355191 | Medline

[42] K.M. Heinemeier, M. Kjaer.

In vivo investigation of tendon responses to mechanical loading.
J Musculoskelet Neuronal Interact, 11 (2011), pp. 115-123
Medline

[43] H. Langberg, D. Skovgaard, L.J. Petersen, J. Bulow, M. Kjaer.

Type I collagen synthesis and degradation in peritendinous tissue after exercise determined by
microdialysis in humans.
J Physiol, 521 (1999), pp. 299-306
Medline

[44] H. Langberg, D. Skovgaard, S. Asp, M. Kjaer.

Time pattern of exercise-induced changes in type I collagen turnover after prolonged
endurance exercise in humans.
Calcif Tissue Int, 67 (2000), pp. 41-44
Medline

[45] H. Langberg, L. Rosendal, M. Kjaer.

Training-induced changes in peritendinous type I collagen turnover determined by
microdialysis in humans.
J Physiol, 534 (2001), pp. 297-302
Medline

[46] B.F. Miller, J.L. Olesen, M. Hansen, S. Døssing, R.M. Crameri, R.J. Welling, et al.
Coordinated collagen and muscle protein synthesis in human patella tendon and quadriceps
muscle after exercise.
J Physiol, 567 (2005), pp. 1021-1033
http://dx.doi.org/10.1113/jphysiol.2005.093690 | Medline

[47] E. Westh, M. Kongsgaard, J. Bojsen-Moller, P. Aagaard, M. Hansen, M. Kjaer, et al.

Effect of habitual exercise on the structural and mechanical properties of human tendon, in
vivo, in men and women.
Scand J Med Sci Sports, 18 (2008), pp. 23-30
http://dx.doi.org/10.1111/j.1600-0838.2007.00638.x | Medline

[48] M. Kjaer.
Role of extracellular matrix in adaptation of tendon and skeletal muscle to mechanical loading.
Physiol Rev, 84 (2004), pp. 649-698
http://dx.doi.org/10.1152/physrev.00031.2003 | Medline

[49] S.P. Magnusson, M. Kjaer.

Region-specific differences in Achilles tendon cross-sectional area in runners and non-runners.
Eur J Appl Physiol, 90 (2003), pp. 549-553

https://www.apunts.org/en-load-management-in-tendinopathy-clinical-articulo-S1886658117300580 21/23
2/11/24, 7:54 PM Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy | Apunts Sports Medicine
http://dx.doi.org/10.1007/s00421-003-0865-8 | Medline

[50] M. Kongsgaard, P. Aagaard, M. Kjaer, S.P. Magnusson.

Structural Achilles tendon properties in athletes subjected to different exercise modes and in
Achilles tendon rupture patients.
J Appl Physiol (1985), 99 (2005), pp. 1965-1971

[51] E. Rio, D. Kidgell, C. Purdam, J. Gaida, G.L. Moseley, A.J. Pearce, et al.
Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.
Br J Sports Med, 49 (2015), pp. 1277-1283
http://dx.doi.org/10.1136/bjsports-2014-094386 | Medline

[52] E. Rio, M. van Ark, S. Docking, G.L. Moseley, D. Kidgell, J.E. Gaida, et al.
Isometric contractions are more analgesic than isotonic contractions for patellar tendon pain:
an in-season randomized clinical trial.
Clin J Sport Med, 27 (2017), pp. 253-259
http://dx.doi.org/10.1097/JSM.0000000000000364 | Medline

[53] H. Alfredson, T. Pietilä, P. Jonsson, R. Lorentzon.

Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis.
Am J Sports Med, 26 (1998), pp. 360-366
http://dx.doi.org/10.1177/03635465980260030301 | Medline

[54] B. Habets, R.E. van Cingel.

Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on
different protocols.
Scand J Med Sci Sports, 25 (2015), pp. 3-15
http://dx.doi.org/10.1111/sms.12459 | Medline

[55] A. Saithna, R. Gogna, N. Baraza, C. Modi, S. Spencer.

Eccentric exercise protocols for patella tendinopathy: should we really be withdrawing athletes
from sport?. A systematic review.
Open Orthop J, 6 (2012), pp. 553-557
http://dx.doi.org/10.2174/1874325001206010553 | Medline

[56] R. Beyer, M. Kongsgaard, B. Hougs Kjær, T. Øhlenschlæger, M. Kjær, S.P. Magnusson.

Heavy slow resistance versus eccentric training as treatment for achilles tendinopathy: a
randomized controlled trial.
Am J Sports Med, 43 (2015), pp. 1704-1711
http://dx.doi.org/10.1177/0363546515584760 | Medline

[57] M. Kongsgaard, V. Kovanen, P. Aagaard, S. Doessing, P. Hansen, A.H. Laursen, et al.

Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in
patellar tendinopathy.
Scand J Med Sci Sports, 19 (2009), pp. 790-802
http://dx.doi.org/10.1111/j.1600-0838.2009.00949.x | Medline

[58] P. Malliaras, J. Cook, C. Purdam, E. Rio.

Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case
presentations.
J Orthop Sports Phys Ther, 45 (2015), pp. 887-898
http://dx.doi.org/10.2519/jospt.2015.5987 | Medline

https://www.apunts.org/en-load-management-in-tendinopathy-clinical-articulo-S1886658117300580 22/23
2/11/24, 7:54 PM Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy | Apunts Sports Medicine

[59] R. Scattone Silva, A.L. Ferreira, T.H. Nakagawa, J.E. Santos, F.V. Serrão.
Rehabilitation of patellar tendinopathy using hip extensor strengthening and landing-strategy
modification: case report with 6-month follow-up.
J Orthop Sports Phys Ther, 45 (2015), pp. 899-909
http://dx.doi.org/10.2519/jospt.2015.6242 | Medline

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