A PRACTICAL APPROACH
TO MANAGE PATELLAR TENDINOPATHY
Due to the high demand in competing
athletes, quantifying the type and amount of
tendon load of different exercises could help
to optimize exercise prescription and load
management.
Jill Cook & Daniel Martinez-Silvan
Aspetar Sport Medecine 2024
@LucasDubois
THE VICIOUS CIRCLE OF PATELLAR
TENDINOPATHY
Muscle
Pain
Inhibition
Motor Muscle
Compensation Weakness
Mr Physio, how can we stop
this vicious circle ? How can I
@LucasDubois proceed ?...
WHAT ABOUT LOAD QUANTIFICATION
IN REHABILITATION ?
Isometric, Isotonic & Energy storage exercises induce
changes in tendon mechanical properties, which increase
it’s capacity to tolerate higher load exercises.
Load magnitude will be more relevant for tendon
mechanical adaptation than the muscle contraction
type.
How can we quantify the load intensity from our
rehabilitation exercise in clinical practice ?
@LucasDubois
THE SILVAN EXERCISE SCORE FOR
PATELLAR TENDINOPATHY (SES-PT)
This scale measures tendon load by analyzing various aspects
of an exercise. Each exercise was classified based on its tensile
load and plyometric load rate, which are key elements for
rehabilitation and preparing the tendon for sports demand.
TENSILE LOAD DOMAIN PLYOMETRIC LOAD DOMAIN
Dominant muscle contraction Kinetic chain application
Time under tension (/rep) Ground contact
Estimated Quad MVIC % Breaking forces
(Max vulontary isometric contraction)
Lengthening of MTU Knee flexion at landing
(Muscle tendon unit)
Specificity to the tendon Sports specificity
SCORE : .../10.0 SCORE : .../10.0
Each exercise was analysed based on the importance of each
item placed above for these two categories, allowing the
development of 18 exercises presented below.
TENSILE LOAD EXERCISES CONTINUUM FOR
PATELLAR TENDINOPATHY
DL : Double leg
SL : Single leg
TENSILE LOAD
Standing knee extension SL 4.7
Wall Squat Isometric DL 5.3
Wall Squat Isometric SL 6.0
Knee Extension 30° Isometric SL 6.0
Knee Extension 70-0° SL 6.0
Press 30° Isometric SL 6.0
Spanish Squat Conc-Ecc dynamic 6.7
Spanish Squat Isometric 6.7
Press Eccentric SL 7.3
Decline Squat Eccentric SL 7.3
Spanish Squat Eccentric slow 8.7
Spanish Squat Eccentric SL 9.3
0.0 2.0 4.0 6.0 8.0 10.0
@LucasDubois
PLYOMETRIC & TENSILE LOAD EXERCISES
CONTINUUM FOR PATELLAR TENDINOPATHY
DL : Double leg
SL : Single leg
TENSILE LOAD PLYOMETRIC LOAD
3.3
Step Up dynamic
4.0
3.3
Step up Jump
5.3
4.0
Box jumps 80 cm
6.0
4.0
Plyo hops over 50cm hurdles DL
8.0
5.3
Plyo Squat Jump DL
8.0
5.3
Plyo Hop for distance SL
9.3
0.0 2.0 4.0 6.0 8.0 10.0
@LucasDubois
HOW ABOUT SOMETHING MORE SPORT-
SPECIFIC ?
A more pragmatic approach could involve grouping
training activities based on their estimated load on the
patellar tendon, tailored to each sport, context, and
training framework.
SPORTS Nil Demand Low Demand Medium Demand High Demand
Reduce space
Passing drills Positional game
Football Pool session with full
w/o opposittion attacking task
opposition
Quarter court
Basketball Free Shots Full court drills Defensive drills
training
Penalty Positional 5:1 defense Defensive drills
Handball
shooting defensive drills game (top def) 6v6 (full back)
Forearm passing Serve receive Blocking
Voleyball Spiking drills
drills drills technique drills
@LucasDubois
WHICH MANAGEMENT WITH ATHLETES
IN-SEASON ?
(Van Ark et al., 2016)
1. Isometric or isotonic for pain relief ? (Vang & Niznik, 2020)
Isotonic exercise could reduce pain immediately and
after 4-weeks intervention as well as isometric
protocol.
Select the program that suited your athlete's needs, ensuring
good adherence from them.
2. Keep exercising after PT !
Try to introduce HSR exercises 2-3x/week
4x8 reps with load progression (include the healthy
side)
Don’t forget the role of the kinetic chain with the
calf muscle complex !
@LucasDubois
WHAT ABOUT LOAD MODIFICATION WITH
ATHLETES IN-SEASON ?
OPTION 1 : Decreasing training load
Good option for short-term pain relief but can cause
de-training & decrease tendon capacity in long term.
OPTION 2 : Monitoring load
You can use the acute:chronic workload ratio (ACWR) to
monitor spike load which is associated with a greater injury risk.
BUT
Even if the load plays a crucial role in tendinopathy, it is
not the only injury risk in competitive sports !
Like training surface modification, potential site of
compression (shoes, equipment), new exercise program etc.
@LucasDubois
WHAT’S MY OPINION ?
The Silvan Scale is an interesting tool, particularly due to the
various items it uses to quantify tensile and plyometric load.
Following this article, we provide a list of 18 progressive
exercises classified according to their tensile and plyometric
load, which is particularly relevant for athletes.
BUT
We need certain materials to evaluate specific aspects of an
exercise, some of which are not accessible to individuals at
their rehab center.
FOR THE CURIOUS...
Have you heard about the Scattone Silva & al study for patellar
tendon ? Jump on the QR code just below !
@LucasDubois
THANKS FOR THE READING !
Don’t hesitate to read the full article !
2024 2019
@LucasDubois
