Podcast #115: Achilles & Patellar Tendons with Jarrod Antilock


“With a hamstring injury, you’re out, you can’t perform… whereas a tendinopathy, you can kind of warmup, so we found it was more a performance-limiting disease.”

“There are genetic predispositions to tendinopathy… our aboriginal is very highly prone to patellar tendinopathy.”

“Because they’re not competing every weekend, we really could make quite a difference in their seasons [track and field]… three loading sessions per week is very difficult [NBA].”

“There are Nigerian backgrounds, some Caribbean backgrounds, that are more prone to tendinopathy.”

“You can’t just nail it down to one thing [tendinopathy and genetic predisposition].”

“If we look at the lumbar spine, if you’re over the age of 40, you are likely to have awful imaging and you might not have pain… the load magnitudes are very different, it’s a different structure, there are many tissues that attenuate force before you get to the lumbar spine whereas at the Achilles, other than the FHL and tib post, there is nothing that can attenuate force other than the Achilles tendon.”

“You are likely to experience tendinopathy, pain, discomfort, or worse, if you have areas of echogenicity within the tendon… conversely, if you are sedentary and you don’t sprint, jump, run regularly, then the need to have a normal tendon is not entirely necessary.”

“You have 56 bodyweight a second when you’re sprinting [in the Achilles]. The lumbar spine doesn’t get anywhere near that. So the need for normal structure is really important when you are a high functioning athlete.”

“When there is altered structure, you can pretty much near guarantee (if they’re a high functioning athlete) at some point, they will develop symptoms.”

“Tendons change, they try to adapt to their load stimulus the best they can.”

“Does a normal tendon experience tendinopathy or rupture? No. But there are caveats to that:”

  • fluoroquinolone (they are very unpredictable)
  • plantaris-related tendinopathy

“I see a lot of fluoroquinolone-induced tendinopathy and ruptures.”

“The stiffness qualities of the plantaris are much higher than the Achilles. My analogy is more akin to a garrote… A wire, when you bring it up against somebody’s throat… essentially, the plantaris rubs and causes irritation along the medial Achilles.”

“The understanding of the plantaris in the United States is probably not as well understood as it is in Europe.”

“Plantaris, we see a lot, out of maybe 10 patients, we might see 3, maybe 4 plantar is-related.”

Plantaris: “It’s anatomy is very different in different people… if it attaches to the medial facet, you might not have symptoms, if it attaches on the posterior facet behind the Achilles (wrapping around it), then you probably will have symptoms.”

“Plantaris-related mid portion Achilles tendinopathy is very common, it’s probably more common than we would have thought previously.”

“We think that, because people get tendinopathy, we all of a sudden take away their load, we know that can be catabolic for the tendon, maybe we need to still keep a load stimulus in but just modify things a little bit.”

Getting a tendon healthier: “First a foremost, it’s mechanotransduction, so it’s really a load stimulus… loading is key to changing tendons. Regular, consistent loading trying to get to a heavier, higher strain rates (upwards of 6%) is really really important.”

“Alcohol has quite a profound effect on tendons and inflammation.”

“Not everyone adapts the same way.”

“To keep a tendon healthy it’s consistent loading, progressive loading, with a load stimulus that is without peaks and troughs.”

“The isometrics that I think have some really good evidence are high strain isometrics for 3-5 seconds… I think anything beyond that is opinion are heresy.”

“Heavy, slow resistance is absolutely crucial for not only tendon health but also the MTJ and the other side of the tendon which is the muscle.”

“I call it the medicine for the tendon which is a load stimulus and that usually looks like heavy slow resistance.”

“For patellar tendon, it’s just a lot of quad loading repeated high volume.”

“Single-leg knee extension, single-leg leg press, and then a squat variation (front, back, goblet, split)… but starting with volume.”

“The mechanism of that [high volume] is elevated collagen turnover rate, and that is the reason for the volume.”

“It doesn’t fit perfectly along strength and conditioning principles but the goal is to condition the muscle, the MTJ, and the tendon, but also to change this collagen turnover rate.”

“4 sets of 6 or 3 sets of 8 is just not enough, you just won’t get your desired effect… if you’re trying to change a tendon, 3 sets of 8 of one exercise is not gonna tip the scales.”

“Duration (along with magnitude and frequency) is one of the more important variables with building a program… (1s worse than 3s contraction times).”

“You can change stiffness qualities doing plyometrics but are we talking healthy or are we talking non healthy tendons?… the muscular side of the tendon has wittled away… so putting a player that has patellar tendinopathy that has no base strength and putting them through a plyometric program, you’re probably gonna end up back where you were.”

“Tendinopathic tendons function differently, they have other mechanical property deficits that need to be addressed before you can probably push them into faster rate loading.”

Horse tendon regeneration: “They do stand, they sleep standing up, they walk around a lot, they don’t get to sit down like we do, so there’s always a strain or a load stimulus going into their tendons.”

“Some of the [45-second isometric] analgesic loading came from a fibromyalgia paper. Tendinopathy is not fibromyalgia.”

“The load stimulus needs to be high. 45-seconds means it probably wouldn’t be 90% MVC and why are we trying to do 90% MVC? Because this is the effect it has on the stiffness, strain rates, and elastic modulus of the tendon.”

“With the patellar tendon, one has to really ask the question, what’s the morphology at the knee.”

  • Patella Alta: “Those players don’t tolerate knee extension particularly well… so they don’t love knee extension.”
  • Retropatella changes (cartilage changes on the back of the knee): “They’re not going to love knee extension because the compression forces are much higher.”
  • “Knee extension is a great exercise… all exercises are good exercise and all exercises are bad exercises, I think it’s context-specific.”

“I don’t do long-hold isometrics because I’m not convinced that it provides enough usefulness to the athlete, to the tendon, and I would much prefer to get buy-in doing another exercise, a different exercise, where I know that I’m really getting to the nuts and bolts of it.”

Long hold isometrics: “I don’t think that the stimulus is high enough.”

Analgesic effect: “Get on a bike, have a cuddle, do a couple of squats, get on a leg press do 10 reps of something moderately heavy and they’re probably warmed up.”

“I think there’s some really good evidence for BFR for patellar and Achilles.”

“I think the lactate [from BFR] stimulates fibril and collagen production.”

“If you are going to load someone and you wanted high strain rates, they have to go to end range dorsiflexion but also be a long lever, so it would be a standing calf raise.”

“What limits your load on the tendon in a seated position is how much dorsiflexion you can get in to.”

“I’m not sure that just stretching you’re gonna get enough stimulus for the tendon and you’re also not gonna change the muscle by just doing stretching.”

“Tendinopathic tendons increase their cross-sectional area. The tendon itself has this influx of aggregates, proteoglycans, fluid, because it’s trying to increase its cross-sectional area but they can still fail.”

“Normal tendons don’t rupture, there’s always a reason for these tendons rupturing. Whether it be a rapid increase in their training volume or intensity, there’s a tipping point at which a tendon just won’t adapt.”

Tendons being static after 17 years old: “Do we think that that holds true with tendons that we’re trying to change?… if your sample of tendons were non-athletic, non-exercising tendons, then maybe the core won’t change.”

“If we think that tendons don’t change, then why are we seeing tendons normalize and go back to normal function?… if you give them a high enough and a regular enough load stimulus, then core of the tendon will change.”

“I think there are acute tendinopathies… I don’t go down the continuum that was put forward, mainly because it’s a theory.”

Tendinopathy continuum: “They might have paratendinopathy, plantaris-related, linear tear, ventral surface tear, other pathologies around it that probably don’t fit into the continuum particularly well… when you see enough imaging, you kind of forget the continuum and you look at what’s in front of you.”

Advice for average joes on tendon health

For Achilles: “seated calf raise, standing calf raise, 2-3 times per week.”

For patellar: “regular quad loading (leg press, knee extension, squat) heavy, just condition yourself.”

“Keeping your body mass down, it makes the goal of getting to a multiple bodyweight to return to play, much easier… if you’re eating and putting on body mass, it’s like the carrot in front of the donkey.”

“I call 17 year old athletes rubber bands because they’re so springy and bouncy, they can get away with it [changes in load].”

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