Education

• Athletes must be educated on the importance of resting the tendon and not pushing past 3/10 pain on VAS whilst in the reactive phase of a tendinopathy, because symptoms will worsen. The athlete should be educated about how tendons may feel okay during training but may sore the next day. Progressions in loads should be calculated, not to be aggressive and risk a flare up of symptoms – eg planning and measuring the amount of decelerations in a running program.
• Avoid stretching the tendon, through doing quadriceps stretches. Compressive loads can further aggravate a tendon(1). Soft tissue massage and/or acupuncture through the quadriceps and hip flexors can be utilised alternatively to maintain knee and hip ROM.
• Interdisciplinary management: management of tendon pain should be seen as an issue for an interdisciplinary team to solve. As such, it is helpful to discuss the situation with a physician and dietician as they can administer some ibuprofen, high dose of fish oil and green tea. This may help decrease tendon pain(7).

Ongoing Management

• Managing tendinopathies in-season is about trying to explore the correct balance of unloading the tendon without causing a detraining effect on the tendon. Daily pain monitoring as discussed provides useful information about tendon responses to load. Use of the VISA-P (Victorian Institute of Sport questionnaire) may also be useful.

Programming

Reactive tendon response is the main cause of in-season pain, so the key intervention should be aimed at reducing loads. Load modification can be programmed specifically to relieve tendon pain:

• Programming should periodise an athlete’s week into high, low and medium-load days, to respect the tissue adaptation from demanding sessions where increased elastic loading is present.
• High-load days include increased amounts of stretch shortening cycle (SSC), such as field sessions including training where there may be a lot of running, jumping and mechanical load.
• Medium-load days include specific tendon strength program and/or a less demanding field/running session.
• Low days-load include isometric holds only.

Programming an athlete’s week with PT during the in-season phase can be challenging not only because you’re managing the athletes symptoms but also because of other factors such as recovery from a game and external factors such as match schedules. A typical week is outlined above in Table 3.

Strengthening The Tendon & Kinetic Chain

During the competition phase of the season it is hard for symptomatic PT to become completely symptom free and to achieve strength gains. The following program in Table 4 takes time and depends on the irritability of the tendon. A less than 3/10 pain level should be the threshold and exercises should not progressed if this level of pain or higher is present.

Exit Criteria

Before being able to jog, the athlete must be pain-free walking, on stairs and be able to perform the following programme AND have a pain score of less than 4 out of 10 pain post session/next morning when performing a SL decline squat:

• Decline SL squats on wedge to parallel (x 4 reps each side) with a pain score of less than 3/10;
• SL calf raises – x25 reps each side;
• DL skips (30 secs on/off x 5reps); Alternate skips (40 secs on/20 secs off x 10reps);
• DL hopping/landing progressing to SL hopping/landing sequences (including forward, lateral and multi-directional hopping);
• Running progressions on an Alter-G treadmill (if available) progressing from an entry level of 70-100% weight bearing;
• The introduction of running must be calculated, progressive and programmed to include high, low and medium days as discussed;
• Tendon daily monitoring must be completed and be a guide for progressing the athlete through the above exit criteria, running progressions and training.