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Why Tendons
[04:42] “I kind of like problem solving and solutions, and I think that the whole tendon scene, where you’re looking at strain… it’s very technical… it’s almost like a sub-portion of engineering when you’re looking at these tendons and how they respond to load.”
Surgery vs. Non-Operative
[07:20] “If I’m wanting to return to that kind of high intensity, accel, repeated sport, I think I’d have an Achilles tendon repair as well if I was to rupture it.”
[07:55] “I think the research supports that the outcomes aren’t that much different in the general population, ’cause it’s probably more about how committed you are to your rehab than the surgery at the start.”
It Starts With the Surgery
[09:15] “The big thing in these ruptures, which you don’t really have to deal with in your tendinopathies, is the risk of Achilles tendon lengthening.”
[09:35] “We know the tendon responds to load, and that’s the only real way we can communicate with the tendon.”
[10:00] “If you haven’t got a good surgery already and you’re coming out of that with a long tendon, then your rehab is a much more difficult, long process.”
[10:30] “A lot of surgeons describe Achilles repairs as just sticking two ends together. And it’s the only time I’ve ever heard a surgeon being humble, is when they talk about Achilles tendon repairs. I don’t think it should be that simple.”
[11:30] “If you do your classic repair, your soleus subtendon ends up healing, or even one week post-op, so before we’ve started any loading, ends up being about twenty-five percent longer than the other side. So it never gets restored. So even in rehab I’m talking about not doing damage and lengthening it. Well, it’s long before we start rehab.”
[12:20] “You’re being really gradual with your progressions, and it gets to a point where your bent-knee plantarflexion testing just plateaus. And I mean a plateau is at 1.2, 1.3 times body weight, which… a good athlete should be above two.”
Individualizing Early Rehab
[13:30] “I think we’re guilty of kind of giving a one-size-fits-all approach in our Achilles tendon rehab, especially in the weeks post-op… It doesn’t matter whether you’re a hundred and forty kilos or seventy kilos, whether you’re strong going into the surgery, whether you have other comorbidities. It’s this surgeon did this operation, so you’ve six weeks, eight weeks, ten weeks in the boot.”
[15:30] “If you’re not looking for this, you won’t find it. So it’s about finding out who actually can tolerate it and who can’t, and progressing based on that.”
Earning Your Way Out of the Boot
[16:30] “I’m less fussed about whether you’re six weeks post-op or twelve weeks post-op, and a little bit more interested in, well, have you tolerated what we need you to tolerate in order to be able to walk.”
[17:00] “If we walk normally, we’re usually taking about three times body weight through the Achilles tendon… so 500 newtons just won’t cut it.”
[17:30] “If we have a 30-degree plantarflexion wedge, it’s removing… about 70% of that walking load from the Achilles tendon. And as we go towards flat, it’s removing about 30%.”
[18:15] “One of the biggest mistakes I see people making is they go, we’ve had this really complex rupture and it’s a really heavy guy who has all these other things going on, and it’s been six weeks, so he’s coming out of the boot. And you see them lumping around the place, limping, and you’re kind of saying, what’s the point?”
[18:45] “Even if your programming is a huge volume of calf raises, so we’ll say you do 10 sets of 15 reps… still it’s 150 reps at less than the load you need to take when you walk. If you walk, you’re gonna walk probably a thousand steps that day… And you take three times body weight on each step.”
[19:15] “Why not just put them back in the boot and spend an extra couple of weeks and load them properly?”
[21:00] “I don’t want to sound too conservative here. I’m pretty aggressive in my tendon rehab… We’re loading pretty heavy, pretty sensibly but pretty heavy in the gym. But we’re just setting the threshold higher to come out of the boot.”
[21:20] “If we look at what’s optimal for that tendon in terms of load, it’s probably not going to be walking around all day. It’s probably going to be a shorter bout of intense exercise with a period of rest, and then another shorter bout of intense exercise with a period of rest.”
[22:45] “If we send ten Achilles tendon patients back to the surgeons with these angry long tendons after rehab, they’re gonna start saying that again. So it’s on us to kind of pitch that at the right level and make sure we’re not doing harm.”
Weight Bearing and Wedges
[23:50] “If they’re not able to take 30% of the load by six weeks, we’re in trouble trying to get them out a couple of weeks later.”
[25:00] “The thing that a lot of people miss here is the configuration of the wedges really matters… What the step and the wedge actually encourage is not ankle plantar flexion, it encourages midfoot plantar flexion.”
[26:30] “If you are not in a Vacoped, make sure the wedges you have are kind of a straight line from the front to the back, and there’s not this kind of a flat step where your heel lies.”
Boot to Shoe
[27:20] “If you’re in a boot, even if it’s flat, it removes thirty percent of the load you need to take when you’re walking. So then to transition to a shoe, you can have this sudden jump in load by thirty percent.”
[27:50] “We’ll actually start going, right, you can wear a shoe, but only in rehab… The next week you can wear a shoe, but only indoors… and the next week you can wear it everywhere, but… if you go over a thousand steps, either sit down or put the boot back on.”
[30:15] “It works out fairly small, somewhere less than 15%. But if you’re doing a thousand, two thousand, three thousand steps a day at three times body weight per step, that’s a significant reduction in Achilles tendon load.”
[31:25] “If you push one times body weight through your forefoot, because of that lever, it means your Achilles has to get about three times body weight.”
Loading Frequency
[33:00] “Even an ankle mobilization for something that can only take 500 newtons is a loading session.”
[34:00] “I look at them as an active recovery for your tendon.”
[35:00] “This evening I just want you to put a school bag on your back with maybe twenty kilos in it, and just stand on one leg with your heel off the floor for thirty seconds, and do it four times.”
[36:00] “You have to pick the big rocks… There’s different ways of getting people better, and it’s not the only way.”
Pain and Fear After Rupture
[37:20] “Pain isn’t usually a big issue in your Achilles repair… it’s not usually a limiting factor.”
[38:30] “I think a hundred percent of them had tendinopathy on their histology. Now that doesn’t mean they all had symptoms.”
[39:30] “He’s got the same jump height bilaterally in a drop jump, and he’s a thirty-eight percent deficit in his ankle contribution to that jump. So the tendon isn’t being pushed to the same limit… he’s finding different ways of doing that.”
[40:15] “It’s something that they’ve done a thousand times before, and then one time their tendon just gives up on them.”
Benchmarks Over Calendars
[43:15] “We usually go ten to fifteen percent body weight per week, and a one centimeter increase in their heel raise… per week.”
[43:30] “Usually almost a progression in range controls the progression in output as well, because in an inner range you’re pretty weak.”
[44:00] “If you set your benchmarks right, people will gradually get there, and it won’t be the time that stops you.”
When the Tendon Ends Up Long
[45:01] “I haven’t yet seen somebody having to redo surgery because the tendon’s too long.”
[46:30] “We might cycle to kind of concentric-only type training… almost the opposite of what you do in hamstring training, where you go eccentric to lengthen fascicles. We’ll go concentric only to shorten fascicles.”
[47:20] “People can manage really, really well with stuff that I don’t think they should be able to manage really well with, often.”
[48:45] “You can find a way of coping, whether it’s your gastroc develops more, whether it’s your FHL gets really strong, whether it’s that you actually change how you move a little bit and you use a bit more from your hip and your knee.”
[50:55] “We don’t want to get them to that point where they’re at the end and they’re regretting it, ’cause they’re struggling to get that bulk and that strength back, ’cause their muscle hasn’t got an effective pulley attached to it.”
Range of Motion and Inner-Range Training
[52:30] “If we’ve got an unhealthy tendon, it’ll strain at much, much lower levels of force.”
[54:30] “I don’t think you need high strain in those early stages. I think it’s actually a low level of loading it will adapt that tendon, or certainly in the injured portion.”
[56:00] “If I’ve got somebody who’s healthy, I’m gonna train them in dorsiflexion. But I’m dealing with a lot of people who aren’t healthy. So they can’t tolerate high force… And they’ll adapt from a lower level of force and strain in their tendon.”
[57:50] “Training in an inner range is a really, really nice way of controlling the amount of force output, controlling the amount of Achilles tendon strain to ensure that it’s safe, but still targeting that muscle and getting really good adaptations there.”
[58:15] “Rather than going, just don’t push as hard and do it in mid range, put into an inner range and make work really hard. And you’ll get a better muscle adaptation.”
Exercise Selection
[1:00:05] “We usually start with an isometric, not because… the tendon probably doesn’t know the difference, but it’s a little bit easier to prescribe safely.”
[1:03:15] “Chains don’t work very well on a calf raise, because they get heavier as you lift and you get weaker as you lift.”
[1:03:45] “You need to be able to get from dorsiflexion to neutral… without any assistance. And then you can use assistance to get through that top range… This allows us to kind of overload the strong portion of the lift without completely missing the top portion of the lift.”
Building Up to Running
[1:07:20] “For us, that’s too big a gap from the time you come out of the boot to the time you start running, because the loads that you have to take to run are massive.”
[1:08:00] “We do feel you need a really, really large volume of plyos before you start running.”
[1:08:55] “We set the bar fairly high then for them to start running, so that once they start, they can progress relatively quickly.”
The Biggest Early-Stage Mistakes
[1:09:30] “I think the early stage comes to two things. They either get afraid of lengthening and do nothing, and that’s not good for a tendon, or they don’t know about lengthening and they do too much.”
[1:10:40] “A tendon needs load. Use your sensible approach of progressing it with range and load. Don’t just suddenly jump by forty percent or something. But… they’re the basics of sensible strength training. They’re not something that’s special for an Achilles.”
[1:11:00] “They think getting out of the boot at six weeks means you’ve stolen a couple of weeks in your rehab. You haven’t, unless you’re strong enough to get out of the boot, because you’re still going to spend the rest of the time catching up that strength.”
[1:11:40] “Coming out of the boot early is great if you’re ready. But if you’re not ready, then take your time about it.”
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