*Continued from part three:

Achilles Tendon Programming

You should approach Achilles tendon programming in one to four weeks per stage, depending on the severity of the tendinopathy and the patient’s goals: 

 

Stage One

Stay away from dorsiflexed (DF)positions. Always check your 24-hour response! 

  • Two-leg (2L) calf raise – start with body weight (BW), then progress to adding load.  
  • Five reps isometric hold for 45 seconds – Smith machine is a great tool. 
  • Start just above the neutral ankle and progress to full plantar flexion (PF). 
  • Progress to single-leg (SL) and repeat the process.  

 

Stage Two

Start to enter DF positions, adding compression load. Check 24-hour response! 

  • 2L calf raise using a step to add DF angle.  
  • Five reps – 10 seconds concentric starting in full DF, five-second hold isometric in full PF, followed by 10 seconds eccentric back to full DF. Again, Smith machine is a great tool. 
  • Progress by reducing the tempo in order to make the movement faster over time.
  • Start with low weight and progressively add weight.  
  • Progress to single-leg and repeat the process. 

 

Stage Three

Start to add speed = Plyometrics = Increase Tendon Load – Check 24-hour response! 

  • 2L up tall on toes to squat – dynamic force absorption. 
  • 2L squat to toes – dynamic force production. 
  • 2L in-place pogos – slowly increase reps, height, and distance moving forward. 
  • Two-inch run in place – slowly increase reps, height, and distance moving forward. 
  • Progress to bounding – transition from one leg to the other. 
  • Progressing to hopping – SL.  

 

Notes: Make sure we address vertical forces and horizontal forces while challenging all 3 planes.  Increase their tolerance to the repeated “spring like action”. This is a crucial stage and we must be careful with our exercises and load prescription. Start with a low rep count and grow as needed depending on the 24-hour response.  

 

Stage Four

Returns to activity and training. Check 24-hour response! 

  • Start with a progressive return to running volume/intensity while allowing sports activities with low-level plyometrics.  
  • Progress to live change of direction/cutting and progress to moderate level of plyometric sports activities. 
  • Full return to training.  

 

Notes: Make sure we manage how much the athlete is doing in the team environment. Start with every-other-day participation in order to check their 24-hour response and allow for recovery between sessions. 

 

Patella Tendon Programing 

You should also approach patella tendon programming in one to four weeks per stage, depending on the severity of the tendinopathy and the patient’s goals. 

 

Stage One

Stay within 0-90 degrees of knee flexion (KF) positions. Check 24-hour response! 

  • Two-leg Knee extension (KE) – 60 deg. – five reps of 45s hold. Progress to 30deg. 
  • @ 60 degrees KF – five reps isometric hold for 45 seconds. KE machine is a great tool. 
  • Progress to 45 and 30 degrees of KF. 
  • Progress to single-leg (SL) and repeat the process.  
  • Spanish Squat – progress from 60 deg to 90 deg of KF – five reps @ 45s hold. 

 

Stage Two

Slow eccentric & concentric tempo. Check 24-hour response! 

  • 2L to SL – isotonic slow tempo on KE machine.
  • Start at 90 deg to full extension – five seconds concentric, five-second hold followed by five seconds eccentric. 
  • Leg press – isotonic slow tempo.
  • Build to 1xBW then 1.5xBW.
  • Split stance – heavy load on front leg 80/20 BW split with vertical tibia.
  • Slow tempo from 20 deg of KF to 45 deg of KF. Progress to 60 and 90 deg of KF.  
  • Progress to loaded knee drive over toes into DF. 

 

Stage Three

Start to add speed. Plyometrics. Increase tendon load. Check 24 hour response! 

 

  • 2L up tall on toes to squat – dynamic force absorption. 
  • 2L squat to toes – Dynamic force production. 
  • Jump – mini jumps to box to hurdles. 
  • Start with low KF angles and progress to deeper KF loading angles. 
  • Increase reps, height, and distance. 
  • Two-inch run in place – slowly increase reps, height, and distance moving forward – 10 reps. 
  • Progress to bounding = transition from one leg to the other. 
  • Progress to hopping = SL.  

 

Notes: Make sure we address vertical forces and horizontal forces while challenging all 3 planes.  Increase their tolerance to the repeated “spring like action”. This is a crucial stage and we must be careful with our exercises and load prescription. Start with a low rep count and grow as needed depending on the 24-hour response.  

 

Stage Four

Returns to activity and training. Check 24-hour response! 

  • Start with a progressive return to running volume/intensity while allowing sports activities with low-level plyometrics.  
  • Progress to live change of direction/cutting and progress to moderate level of plyometric sports activities. 
  • Full return to training.  

 

Notes: Make sure we manage how much the athlete is doing in the team environment. Start with every-other-day participation in order to check their 24-hour response and allow for recovery between sessions. 

 

Thank you all for reading. Please share your thoughts or questions! 

 

* Information from this blog series was drawn from the Barça Innovation Hub Course – Lower-limb tendinopathy merged with my personal experience on tendinopathy return to play.