5Rehabilitation of Achilles and patellar tendinopathies
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
References (67)
Epidemiology of tendon injuries in sports
Clinics in Sports Medicine
(1992)- et al.
Achilles tendinopathy
Manual Therapy
(2002) - et al.
cDNA-arrays and real-time quantitative PCR techniques in the investigation of chronic Achilles tendinosis
Journal of Orthopaedic Research
(2003) - et al.
Vascular NK-1R receptor occurrence in normal and chronic painful Achilles and patellar tendons. Studies on chemically unfixed as well as fixed specimens
Regulatory Peptides
(2005) - et al.
Reduced ankle dorsiflexion range may increase the risk of patellar tendon injury among volleyball players
Journal of Science and Medicine in Sport
(2006 Aug) - et al.
The VISA score: an index of the severity of jumper's knee (patellar tendinosis)
Journal of Science and Medicine in Sport
(1998) - et al.
Decline eccentric squats increases patella tendon loading compared to standard eccentric squats
Clinical Biomechanics
(2006) - et al.
Effects of different levels of torso coactivation on trunk muscular and kinematic responses to posteriorly applied sudden loads
Clinical Biomechanics
(2006) - et al.
Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial.[see comment]
Lancet
(1999) - et al.
Jumpers knee: an epidemiological study of volleyball players
Physician and Sports Medicine
(1984)