Bad case of patellar tendinopathy: “There was no increase in loading in the previous weeks, nothing had changed, and the guy had just a very severe case of patellar tendinopathy. He was a volleyball athlete, a very high jumper, and then I looked into the physical exam and he had a massive dorsiflexion restriction this guy had a history of several ankle sprains ankle sprains. He had a very weak gluteal muscle. His landing was very very stiff… He has important kinetic chain issues that if I don’t address those, even if I do progressive loading for the quads, there’s no way he’s gonna come back and not develop the same condition.”
Limitation in dorsiflexion leading to more patellar tendon stress: “It’s counterintuitive if you think about it.”
“When you have a dorsiflexion restriction, it is a risk factor for patellar tendinopathy, less than 36 degrees. And then you look into why that is, you have a systematic review that actually showed that people with less dorsiflexion, they have less knee flexion and less hip flexion when they land and they have a higher ground reaction force because of that because they don’t dissipate the load in the form of movement, which is what they’re supposed to do. If their joints are moving, they will eccentrically contract their muscles, they will dissipate the load. But if you don’t have those movements, that dissipation of load, the ground reaction force just goes straight up and it has to be dissipated by either the passive tissues, the tendons, the cartilage, or it’s just gonna become heat. So it has to go somewhere. The ground reaction force is relentless. It has to be dissipated by somebody. So if the movement is not happening down there, it’s going to cause an overuse condition sooner or later.”
“We’re interested in looking into actually identifying the cause of the restriction. It can be restricted because of an ankle sprain and the joint is stiff, so you have to mobilize that. Or it can be stiff because of a muscle shortening, a tight muscle, the soleus is very tight. So you have to stretch that. Some people even have neuro-conditions like the tibialis nerve, the medial plantar and lateral plantar nerve can also be sensitized and cause dorsiflexion restriction. In those cases, you have to treat that with neurodynamics and neuro mobilization.”
“If you don’t have the dorsiflexion movement, the calf muscles don’t engage with an eccentric contraction as much to dissipate the load. So the load has to go up and the quads will have to do all the work, especially if the hips are not doing much.”
“If the person is landing very stiff with the trunk very much upright, the quads are doing all the work. With landing, I was expecting to see quadriceps avoidance landing with pain because well if they use the quads they’re gonna feel pain, so they’re gonna avoid that and do trunk flexion. They’re gonna use their ankles more. Nope. They still keep using it [quads] like they’re trapped in a movement pattern using the quads because that’s how they learned to dissipate the load and that’s all they do.”
“In a bilateral landing we saw that it makes a lot of a difference. An increase in trunk flexion decreases the patellar tendon load by one body weight. it’s on average seven times your body weight when you land in your self-selected position with both legs. If you have your trunk upright, it goes up to seven and a half, maybe eight times body weight. And if you do a trunk flexion, it goes down to six, six and a half times your body weight. just a little bit, and it’s like 10 degrees, 15 degrees of trunk flexion.”
“What we do is in phase one, in addition to the isometrics that we do for the quads, because we want to reduce the inhibition, we want to load the tendon, we want the analgesic effect that some people have with the isometrics, heavy load isometrics sustained if possible. We also do a lot of work for the glutes, glute max, a lot of work for the soleus.”
“I teach them variability of movement in landing so I want to teach them how to land in a different way that they’re used to doing because it’s not about this movement pattern is right, this one is wrong It’s about having variability. Otherwise, you just land the same way you load the same same tissues the same way all the time.”
“If they have too much pain in the knee, even the isometric is very painful, sometimes we use electrical stimulation in the quads. We saw that that actually helps load the tendon a little bit more. It also decreases the pain.”
“A lot of people are not willing to stop training for 12 weeks, which is what most protocols typically take. So if you are going to keep training, I need you to train efficiently. I need you to train with variability of movement. To dissipate the load in the different joints of the lower limb, not just on your quads, otherwise you’re going to keep having this overuse every time.
“The problem that some people just want to do calf raises body weight and they think that’s enough and that’s not enough for the soleus. You need to really load the guy.”
“The literature showing bilateral alterations in people with unilateral pain. We don’t want to rupture in my clinic. So we do heavy training for both legs in the beginning already, sometimes unilateral.”
“In the intermediate and second stage, when I started to do heavy slow resistance, and especially before I started doing the plyometrics with them, I really want to work on the soleus with their diagonal vector, because in closed kinetic chain the soleus doesn’t just do plantar flexion, it also extends the knee… So we do a lot of plantar flexion with knee extension in diagonal format so they actually do a lot of emphasis on the soleus in the closed kinetic chain.”
“We have a lot of people who have a very strong fasciculations when they’re contracting their quads. You ask them to do an isometric, heavy isometric, and their quad is all over the place shaking. And we don’t want that plyometric stimulus in the tendon in the initial stages. So we either do the Berlin method contractions with a shorter duration when we see that, or we do electrical stim, which is my go-to nowadays.”
Electrical stimulation: “I like the medium frequency currents, you also have the shorter, the low frequency current too that works very well. You do big electrodes in the ⁓ motor point of the rectus femoris, one in the vastus medialis, heavy contraction as heavy as possible, as high intensity as they can tolerate, and they do the isometric contraction in addition to that. So you can either do a close chain exercise like the the Basas Spanish squat at the same time as you do that or you can do what is typically my go-to for the first stage an open kinetic chain knee extension machine unilateral you do that at the same time you are stimulating the quads to get that really nice contraction reducing the inhibition and getting the long duration contraction without that fasciculation that I really don’t want in the initial stage.”
“When they’re getting that really heavy electrical stimulation for the quads, they kind of forget about their knee pain. They kind of shift their focus, their attention away from their knee pain. So it’s very interesting to see how some people that cannot tolerate even isometric loads, they tolerate that a lot better with the electrical stem for the quads. It’s a very strong stimulus. They focus on what’s going on in the quads and they just forget about their knee pain.”
“Sometimes we get a little bit too carried away and then their pain in the next day gets worse. So I asked them to do the testing, the loading test the next day, and their pain was very manageable and then it becomes very high. So you have to be careful of that. But other than that, it’s a very, very powerful tool for us to use in the initial stage.”
“You can clearly see that the load increases substantially with the e-stim. Which makes sense because you have inhibition, the muscle is not really pulling as hard as it could, so you just give a very powerful electrical stimulation to the muscle to help it load more and since we know the tendons are mechanosensitive, it needs the load it needs the strain.”
“The Berlin method has very little research with pathological tendons. That’s the only problem. That’s the only issue I have. Because they only have one very small study looking into people with pain. The rest, everything that Arampatzis group did was with healthy tendons. And they did see that if you don’t have enough strain, if it’s not 90 % of the MVC, you don’t really get the strain that gets into that 4.5 and 6.5 range that ⁓ they talk a lot about, about actually being necessary to get that mechanical stimulus. But ⁓ their studies are only with healthy people.”
“My go-to option is typically the long duration isometric because I really want that time under tension. I want that analgesic effect that we see so often with people after a long duration isometric. But some people can’t tolerate that. And that’s the problem.”
“When you actually apply that [45-second isometrics] into the real world, you see that a lot of people don’t respond as well with long duration. They have a lot of pain. They have a lot of fasciculation in their muscles. So for those guys, I love using the Berlin method because it’s short duration, higher intensity, three seconds on, three seconds off.”
“I typically try to get that done [isometrics] in the beginning of the session when they have a lot of energy, they got the tendon loading properly, and then I focus on the glutes, I focus on the calves, I focus on improving the dorsiflexion range of motion and then we have a whole session just with those aspects of the rehab.”
Fasciculations causing plyometric stimulus on tendons during isometrics: “After we do that long duration, forcefully, the patient can’t really hold that, but they’re like trying for their life to continue the contraction. And the next day they are very often worse. So I’m assuming it’s because we gave the fast contraction stimulus that we already saw in the literature that don’t really get tendon adaptations. The whole plyometric versus slow duration, slow velocity, high intensity. We know that the tendon needs this low velocity to actually adapt more structurally, so yeah, that’s my thought.”
Achilles and electrical stimulation: “Especially in patients that have a lot of difficulty getting that heel raise, we like to do isometric contractions with e-stim in the beginning. So it’s a way of loading the tendon in a stage where they don’t really tolerate all that much.”
Blood flow restriction: “For the upper limb, for positional tendons, I think it makes sense because they don’t really need that much load. They need a a lower intensity of load. They get better with that. But for the lower limb, I’m very skeptical still because of all the research that we have showing that you need high load to get an adaptation… And then we have what Falk Mersmann talks about the imbalance between the muscle and the tendon because the muscle gets stronger but the tendon won’t follow. The tendon will not get the stiffness that it needs in order to tolerate the higher load that the muscle is producing now. So yeah I’m not a fan for lower limb.”
Overstraining the tendon: “I mean you could in a very heavy eccentric contraction but not in isometric. You don’t get enough strain in that isometric contraction that could be damaging.”
“That’s the biggest mistake I see people doing after an Achilles rupture. I see a lot of people really forcing dorsiflexion, trying to gain range of motion as if that was a problem. Like nobody ever got a restriction in the dorsiflexion range of motion after rupture. It’s the opposite. They heal too long and then you lose performance because of that. People don’t really study that in depth enough, they treat it like an ankle sprain. They want to improve dorsiflexion. They’re concerned about range of motion. And then the tendon just heals too long and you just lost your surgery.”
“I firmly believe, from what I’ve heard and what I read that quadriceps tendinopathy has more to do with compression than it does with tension. So it’s more of a compressive issue, similar to an insertion or Achilles tendinopathy. So we have to be mindful of decreasing compression in the initial stages.”
Quadriceps tendinopathy: “What we typically do in the initial stage is we try to load the tendon by bending your trunk back, leaning back, because that way I get more load in the rectus femoris, which loads more of the quad tendon, but I don’t want to do that in the compression range of motion in the beginning because the tendon doesn’t like compression so that’s the difference between what people I see people doing all the time and what I’ve been doing.”
Patellar vs. Quad Loading Tiers: “We looked into the graphs, the loading tiers are almost identical for the quads and the patellar tendon. So there’s not much difference there.”
“I do isometric contraction with the trunk leaning back in the in the knee extension machine. I like the reverse Nordic exercise for the quads tendon which I don’t use for patellar tendinopathy because I don’t want to compress the patellar tendon against the floor, but for the quad tendinopathy, it makes sense because I want to load it more leaning back.”
“We have a video where we’re looking into the quad tendon and when we’re doing flexion and extension of the knee and you can clearly see it being compressed against the trochlea. When you are above 60 degrees, 70 degrees, that’s when it starts typically… I try to stay away from something deeper than 70 degrees in the initial stage. And I just lean the trunk back to actually load the quad tendon more.”
“I don’t think it makes any sense for you to keep loading them in deep knee flexion in the initial stage when they already have an overuse with a lot of compression in their tendon.”
“A lot of people don’t have any idea of how compressive loads can be bad for tendons. Everybody that came to me with a quad tendinopathy was stretching their quads like crazy because everybody told them they had tightness in their quads, they had to stretch. And then just by removing the excessive compressive load, same thing with the Achilles. Just by doing that, you already decreased their symptoms.”
“In the initial stage you have to stop poking the tendon, stop compressing it against the bone.”
Rectus femoris tendon: “It’s the biggest tendon. It’s the one that is typically also used for ACL reconstruction too. They take that away because it’s a very good, very strong tendon. It’s long. They’re individual. The vastus medialis, lateralis, intermedius and the rectus femoris, they are very separate tendons. And what we see is that the rectus femoris tendons is often the one that is more problematic. So you need to actually load that specific guy a lot more. And we have the fact that it is a biarticular muscle. We have the opportunity to load it more by moving the trunk position, which is something I don’t see people doing as well.”
“Do you want to strain the quad tendon more? You have to lean back instead of leaning forward.”
“A study that we did in my PhD, we found 27% less strength in the gluteus maximus in people with patellar tendinopathy versus controls. So if you have three muscles generating force for your propulsion, you have the calf muscles, the quads and the glutes. If one guy is working 30% less, somebody is going to have to pay the bill. Otherwise you’re going to lose performance. Either you lose your jump vertical heights or the quads or the calves are going to have to work more. So, I mean, there’s no way you can ignore a 30 % weakness in the muscle and not expect something to go wrong. So that’s why we give a lot of emphasis of that and about that in the beginning, initial stages.”
Loading Index: “The single leg decline squat, which is the exercise that everybody used to do is the first exercise in the first day for the patella tendon with the eccentric program, the Alfredson classic eccentric program was the exercise with the highest index, the highest load of all even comparing with single leg jumps, single leg maximal vertical jumps, running, cutting, changing direction, nothing was able to beat the single leg decline squat. So it calls our attention to the fact that this is the exercise that people were giving patients in the first day and they have a pain of eight out of 10. And if our whole premise is to gradually build low tolerance, it doesn’t make any sense for us to start with the exercise with the highest load in the very first day.”
Rehabbing with or without playing sport: “We try to always keep them in sport if we can, but sometimes we can’t… What I tend to do, the rule of thumb that I usually use is what is your pain like the next day?… If the pain is below five in the next day, I tend to allow them to do. I ideally want their pain to happen the next day to stay below three out of 10, but that’s kind of tricky too because a of people will lie to you. They will say that the pain is different than it actually is because they want to keep playing. But it’s a big challenge.”
Keeping them playing: “The idea is to keep them doing what they love to do because, in my experience, that improves the adherence to the intervention versus completely saying you have to stop everything you’re doing. That’s kind of lazy. Everybody does that.”
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