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Rehabilitation of Achilles and patellar tendinopathies

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Achilles and patellar tendinopathies affect a broad range of the population and are difficult conditions to manage clinically. The pathology is persistent in the chronic tendon and can be considered to be failed healing. The exact cause of tendinopathy pain is unclear but may be related to changes in neurovascular structures.

Rehabilitation for Achilles and patellar tendinopathies is based on an exercise programme that aims to improve muscle–tendon function and normalise the pelvic/lower limb kinetic chain. This incorporates a programme for restoring and improving muscle strength, endurance and power and retraining sport-specific function.

Rehabilitation may take a prolonged period of time, both the athlete and clinician must be patient and persistent to maximise results from an exercise-based treatment.

Introduction

Achilles and patellar tendinopathies occur most commonly in people participating in sporting and physical activity1, 2, 3, 4 but have also been reported in non-athletic populations.5 The exact aetiology of these conditions is unknown but is thought to consist of a combination of impact loading, genetic make-up, inefficient lower limb biomechanics and musculoskeletal function. Rehabilitation of Achilles and patellar tendinopathies can be difficult and prolonged and it requires both careful planning by the clinician and discipline from the patient to adhere to an often long rehabilitation programme.

The pathology of chronic tendinopathy and the source of pain must be considered when planning a rehabilitation programme. The current knowledge of tendon pain, pathology and repair will be presented in this chapter together with an explanation of how this impacts on rehabilitation.

The essential components of the rehabilitation programme required to maximise success in managing these clinically difficult injuries will also be explained. Finally, there will be a discussion of the planning and implementation of a specific rehabilitation programme for Achilles and patellar tendinopathy, with particular emphasis on the indicators for the success or failure of rehabilitation.

Section snippets

Tendon pathology and repair

Despite the anatomical proximity of muscle and tendon, the management of tendon pathology varies considerably from that of muscle injury. The differences in the management of muscle and tendon pathologies are reflected in their reparative responses to injury. Whilst the response to muscle injury follows a logical progression of inflammatory phase, muscle fibre regeneration and repair; tendon injury may not have an inflammatory stage and can result in a permanent state of pathology (failed

Tendon pain

The cause of pain in tendons is not known. The fact that tendon pathology is present in both symptomatic and asymptomatic individuals indicates that there may be specific aspects of histopathology that cause pain19, *20 or that the source of pain is from structures independent of the pathology. Neovascularisation, a core part of tendon pathology, has provided a potential explanation into the pain mechanism associated with tendinopathy.

Blood vessels (imaged using Doppler ultrasound) are present

Aetiology of tendinopathy

The aetiology of Achilles and patellar tendinopathies is multifactorial; therefore it is important to establish if these factors are associated with the patient's tendon pain. Any identified aetiological factors need to be managed as part of a rehabilitation programme.

Assessment of Achilles and patellar tendinopathy

Achilles tendinopathy occurs most commonly at the midportion of the tendon and less frequently at the calcaneal insertion.2, 41 Patellar tendinopathy, however, occurs most commonly as an enthesopathy at the attachment to the inferior pole of the patellar rather than the mid-tendon or distal insertion.42 A detailed assessment of an individual presenting with Achilles or patellar tendinopathy is essential as it dictates the content of the rehabilitation programme. Here, we will briefly explain

Monitoring improvement and evaluating the effectiveness of the rehabilitation programme

The main aim of tendinopathy rehabilitation should be to decrease or abolish pain during tendon loading activities and restore normal function. An important component of any rehabilitation programme is being able to monitor progress and make appropriate adjustments to attain the best possible results. As tendinopathy is a state of failed healing, improvement in tendon morphology on radiological imaging will be slow or may not occur at all.19, *46, *50 Imaging is also not an accurate reflection

The tendinopathy rehabilitation programme

The rehabilitation programme consists of a number of inter-related components, namely:

  • 1.

    Managing tendon pain with the modification of tendon load

  • 2.

    Exercise-based rehabilitation programme and adapting the tendon to increasing load

  • 3.

    Additional treatment options for tendinopathy

Conclusion

We have described the pathophysiology of chronic Achilles and patellar tendinopathy as a state of failed healing. This healing response and the unclear source of tendon pain means that tendinopathy rehabilitation is often difficult and prolonged. The initial part of the rehabilitation process should include a thorough clinical assessment to establish the functional status of the patient's lower limb muscle–tendon function, lumbo–pelvic control, lower limb kinetic chain function and to identify

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