Management of Lower

Extremity Tendinopathy
Samuel Spinelli
February 28th, 2018
Objectives
AKA Game Plan
❏ Tendinopathy Terminology
❏ Tendinopathy Continuum
❏ Treatment Relevant Physiology
❏ Mechanisms
❏ Tendinopathy Prevalence
❏ Treatment paradigm
❏ Treatment Structure
❏ Phases
❏ Regional examples
Tendinopathy
Pathology (science of cause/effects of disease) related to
tendons
Tendinopathy Tendon
Terminology
Stiffness

Tendon Thickness

Enthesis

Normal Vs Abnormal
Tendinopathy Musculotendinous
unit
Terminology
Load

Collagen

Inflammation*

Crimp
Tendon Structure Tendon Function
Pathology
Causes? Mechanism?

Collagen Disruption Understimulation Cyclical Loading Compression

Tendinopathy Continuum
Tendinopathy Continuum

Old Terminology Current Terminology

- Tendinitis - Reactive Tendinopathy

- Tendinosis - Dysrepair Tendinopathy
- Tenosynovitis - Degenerative Tendinopathy
- Reactive on Degernative
Tendinopathy
Tendinopathy Continuum
Goldiload and Tendinopathy
Just right
Prevalence
Knee conditions - Asymptomatic
Pain
Tendinopathy
Management
Treat the donut
Not the Hole
Treatment Methodology
Evidence based interventions

Load Tolerance Pain Management Function Structure

Is increased load appropriate?
Overload Examples
Treatment Paradigm

Phase 4
Phase 3
Phase 1 Phase 2 Return to
Energy
Isometric Isotonic Sport/
Storage
Elastic
Phase 1:
Isometrics
Pain management

5x45s @ 70% (initially)

Phase 1:
Isometrics
Pain management

5x45s @ 70% (initially)

Phase 2:
Isotonics
Tendon Hypertrophy/Load
Tolerance

2-12 sets of 4-15 reps with

~3:0:3:0 tempo at RPE 8 or
more
Phase 2:
Isotonics
Tendon Hypertrophy/Load
Tolerance

2-12 sets of 4-15 reps with

~3:0:3:0 tempo at RPE 8 or
more
Phase 2:
Isotonics
Tendon Hypertrophy/Load
Tolerance

2-12 sets of 4-15 reps with

~3:0:3:0 tempo at RPE 8 or
more
Phase 3:
Energy
Storage
Progress slowly
Phase 3:
Energy
Storage
Progress slowly
Phase 4:
Return to
sport/Elasticity
Phase 4:
Return to
sport/Elasticity
 Putting It Together
Clinical Reasoning
Start to
“Injury” - progress
pain 6/10 Pain ~3/10 speed on Pain ~3/10 Discharge
SOME
~1 day - sets
1 week ~1-10 weeks ~3-14 weeks

Phase 1 Phase 1 + 2 Phase 2+3 Phase 2,3,4

Progress (~1) (~1)
Isometrics Continue Isometrics HSR sets Isometric as needed
3-5 x 30-45sec Add HSR Keep Isometrics as needed
Continue HSR
@~70% as 2-6 sets initially and effort, for managing pain.
Reduce Energy storage an
tolerated ~15 reps at 8 RPE lower reps Begin adding in energy add in more elasticity/spor
Storage activities
as toleratedContinue HSR progression
In season management
Just maintenance? Or Improvement?

Isometrics
Isometrics
vs Isotonics
vs Isotonics

Week 1
Week 4

NRS - 6.3 vs 5.5 NRS - 4.0 vs 2.0

Visa P - 66.5 vs 69.5 Visa P - 75.0 vs 79.0
Tendon Pain (not Tendon pain
stated) decrease 2.5 vs 2.0
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