Tendon Loading Program for Long Distance Runner

Lauren Jarmusz, PT, DPT
Orthopedic Physical Therapy Resident
Orthopedic and Sports Medicine - Physical Therapy Department
Stanford Healthcare
March 22th, 2017
Insertional Achilles Tendinopathy: Tendon Loading
Program for a Long Distance Runner

Pt reports left heel/achilles tendon discomfort began when training
for a marathon in Dec 2015. In March 2015, his heel "discomfort"
progressed to heel pain after pt rapidly increased training schedule.
Since March 2015, pt had trialed a few different PT clinics, but has not
experienced significant relief.
PT NPV: February 6th, 2017
Radiology: MRI May 2015, per MD. report, “achilles tendinopathy”
MD Referral Dx: Left Heel Pain

PLOF: When not training for a marathon, runs 8-12 miles every other
day and 20miles on sat. Runs on pavement, wears off the shelf insoles
for pes planus.
CLOF: Running 4-6 miles every other day- Pushing through ankle pain
(4/10 max), but unable to train at higher mileage secondary to achilles
pain. Pain begins at ½ mile and continues throughout run.
GOALS: Return to running (training for marathons) without pain

Aggravating Factors Easing Factors SINNS
• Running > ½ mile
• Descending Stairs
• Standing > 30min
• Avoiding Agg. Activities
• Wearing boot with daily
ambulation if Irritated after
running
Severity: Low, max 4/10 pain
Irritability: Moderate, Irritated for 1 day post run
Nature: Localized & Sharp
Stage: Chronic (since March 2015)
Stability: Stable, Irritated by known mechanical factors.
Systems Review:
 CardioPulm (clear)
 Neuro (clear)
 Integumentary (clear)
 GI/Urinary (clear)

Objective Relevant Findings
MMT (Bilat.) • HF, Glute Med, Glute Max, Posterior Tib, Peroneals, Plantarflexors  4/5 *Global Core & LE Weakness
• Dorsiflexors  5/5 Quads, HS  4+/5
ROM (deg) Left: Talocrural DF  neutral; Talocrural PF  40; Subtalar Inv. 20; Subtalar Ever.  5
Right: Talocrural DF  7; Talocrural PF  40 Subtalar Inv. 20 Subtalar Ever.  8
Muscle Length
(Bilat.)
(+) Elys (L>R); (+) Modified Thomas Test (HF, ITB, Quads) L>R ; (+) SLR (R- 75deg; L-65deg); max Gastroc-
soleus shortening *muscle length restrictions t/o entire LE
Jt Play Left: Max hypomobility talocruel jt (AP glide): Grade 3 Assessment; mod-max hypomobility subtalar
eversion: Grade 3 Assessment.
Right: Mod hypomobility talocruel jt (AP glide): Grade 3 Assessment; min-mod hypomobility subtalar
eversion: Grade 3 Assessment.
Functional
Testing
• Dynamic knee valgus with single leg squat (L>R)
• Decreased squat range secondary to impaired DF range
• SL Heel Raise: unable to maintain longitudinal arch upon eccentric heel descent
Palpation (+) TTP calcaneal insertion of achilles tendon 1; (-) TTP retrocalcaneal bursa; (-) TTP mid achilles tendon.
Static Foot
Assessment
Bilateral: neutral forefoot and rearfoot, pes planus, pronated, decrease in midfoot locking mechanism.
Dynamic Foot
Assessment
Excessive pronation noted with ambulation throughout gait cycle secondary to ankle equinus (L>R); no re-
supination from mid-stance to heel off.

1. Insertional Achilles tendinopathy (+)
2. Midsubstance Achiles tendinopathy (-)
3. Retrocalcaneal bursitis (-)
• Acute Achilles tendon rupture (-)
• Partial tear of the Achilles tendon (-)
• Irritation or neuroma of the sural nerve (-)
• Os trigonum syndrome (-)
• Accessory soleus muscle (-)
• Systemic inflammatory disease (-)
Differential Diagnosis 2
* Clinical Practice Guidelines: Achilles Pain, Stiffness, and Muscle Power Deficits: Achilles Tendinitis, JOSPT 2010
Google Image

Pt. Presents with signs and sx. consistent with left insertional achilles
tendinopathy. Primary PT movement impairment: Pronatory
Movement Dysfunction. Pt’s primary impairments include: ankle
equinus restricted talocrural DF, excessive pronation t/o gait cycle, LE
muscle length restrictions, impaired midfoot locking mechanics,
proximal & distal LE and core weakness, and running motor control
abnormalities.
PSFS: Running  7
LEFS: 73

Fair: secondary to chronicity (chronic - march 2015) and location (insertional) of
structural impairment.
Study Patient Population Prognosis
Hutchison et al.
Clinical Practice
Guidelines 1
Athletic; acute- subacute
midsubstance achilles tendinopathy
71% - 100% of pts return to
their PLOA with min- no
complaints
Alfredson et al. 
Eccentric Achilles
Tendon Loading
Program 3,8,9,10
chronic insertional achilles
tendinopathy
32% of pts returned to PLOA
with min- no complaints
Rees. et al 
Management of
Tendinopathy 4
nonathletic patients with Achilles
tendinopathy
despite a high compliance rate,
eccentric training produced
good results in < 60% of
patients

Pathological Impairments
Cook et al. “Is tendon pathology a continuum? A pathology model to explain the
clinical presentation of load-induced tendinopathy”
Cook et al. “Revisiting the continuum model of tendon pathology: what is its merit in clinical
practice and research?”

3 Stages of Tendon Pathology5
Reactive Dysrepair Degeneration
• Non-inflammatory cell
response
• metaplastic change in the cells
and cell proliferation.
• No change in neurovascular
structures
IMAGING :
• Increase in diameter
• no/minimal increased signal
CLINICAL :
• Acutely overloaded tendon
• Tendons chronically exposed to
low levels of load (detrained
athlete returning from injury)
• Same as reactive
• matrix breakdown
• Increase in vascularity and
neuronal ingrowth
IMAGING:
• increased matrix disorganization
• increased signal
CLINICAL:
• Thick tendon with localized
changes in one area of tendon
• Older pt’s may develop with
lower loads
• Significant matrix breakdown
• cellular death
• Filled with vessels and neuronal ingrowth
• Little capacity for reversibility
IMAGING:
• Significant hypoechoic regions
• Numerous and larger vessels present
CLINICAL:
• Chronically overloaded tendon
• 1+ focal nodule areas with or without
thickening
• Hx: repeated bouts of tendon pain, resolved,
but returning as tendon load changes.
• Rupture possible

STAGE: Tendon
Dysrepair/ Degneration5
TREATMENT:
Address both functional
and pathological
impairments
Cook et al. “Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?” 6

Malliaras et al. “Achilles and Patellar Tendinopathy Loading
Programs: A Systematic Review” 2013 7
• There is little clinical or mechanistic evidence for isolating
the eccentric component when utilizing tendon loading
program for achilles tendinopathy
• Clinicians should consider eccentric-concentric loading
alongside or instead of eccentric loading in achilles and
patellar tendinopathy

There is no convincing clinical evidence to demonstrate that
isolated eccentric loading exercise improves clinical outcomes
more than other loading therapies.
However, the great variation and sometimes insufficient reporting of
the details of treatment protocols may hamper the interpretation of
what may be the optimal exercise regime with respect to
parameters such as load magnitude, speed of movement, and
recovery period between exercise sessions.
Couppe et al. "Eccentric or Concentric Exercises for
the Treatment of Tendinopathies?“ 14 2015

Week 1: New Patient Initial Evaluation
HEP
1) Bilateral heel lift with slow eccentric descent 3x15, 2x/day
2) Gastroc/Soleus Stretch, towel under arch, 2x30s, 2x/day
3) Quad Stretch, 2x 30s, 2x/day
4) Hip Flexor Stretch, 2x 30s, 2x/day

Week 2 Focus 1. Gain DF ROM
2. Progress Tendon Loading Program
Subjective Pt had been compliant with gastroc soleus stretching
2x/day. Pt compliant with tendon loading program,
completed 3-4x/week 2x/day. Pt reports if he completes
stretching each morning, he has not been experiencing
pain descends stairs during day.
Objective - Pt noted 2pt (Baseline 0/10 today) increase in achilles
tendon discomfort with SL heel raise with 5 sec
isometric hold at top (3x15).
- DF (preintervention) neutral (post intervention) 5deg
HEP 1) unilateral & blateral heel lift with 5sec isometric hold
3x15, 2x/day
3) AROM DF, towel under arch, 2x30s, 2x/day
4) Quad & HF Strech, 2x30s, 2x/day

Week 3
Focus 1. Review HEP
2. Initiate functional deficit strength training
3. Progress tendon loading program
Subjective Pt reports increase compliance with tendon loading program- 2x/day
3(15) and HEP. Ran 5-6miles (Monday-Wed) without Achilles related
pain, but does note he feels more fatigue in his Proximal LE
musculature. Pt purchased shoes with increased arch support for daily
ambulation- pt. reports new shoes have made ambulation more
comfortable.
Objective - Pt noted 2pt (Baseline 0/10 today) increase in achilles
tendon discomfort with SL heel raise with 5 sec isometric
hold at top (3x15).
- DF (preintervention) neutral (post intervention) 5deg
HEP 1) Unilateral heel lift with 3 sec isometric hold)- 15lbs 3x15,
2x/day & Bilateral heel lift with 5 sec isometric hold
3) AROM DF, towel under arch, 2x30s, 2x/day
4) Quad Strech, 2x30s, 2x/day
5) Side Plank, 4x30, 1x/day

Week 4 (1 hr)
Focus 1. Running Assessment
2. Progress tendon loading program
3. Progress functional deficit strength training
4. Initiation of return to running protocol
Subjective Pt reports his achilles had been feeling significantly
better and therefore he trialed 9 miles of running.
Experienced -mod heel pain following run.
Objective Re-Assessment (no manual intervention)
DF (KF) 14deg
DF (KE) 10deg (improvement from neutral)
HEP • All exercises completed in clinic
• Tendon loading protocol 1x/day, 3x15
• Stretching 2x/day, 2x30s
• Proximal LE/Core Strength training, 5x/wk, 1x/day

Progressive Achilles Tendon Loading Strengthening Program 11

Progressively increase the
demand on the tendon by
controlling the intensity,
duration, and frequency of
Achilles tendon loading.
Prior to Running:
• minimal (0-2/10 pain) with all
ADLs.
Important Concepts:
• Rehabilitation program must be
continued daily while running
• 2 to 3 days of recovery between
heavy Achilles tendon–loading
activities. 12,5
Return to Running Concepts 12
Silbernagel et al: A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation

Week 6 (Wk 5 -> off)
Focus 1. Provide exercises to specifically address running
mechanic impairments
2. Progresses running distance (per sub. Report)
3. Review Tendon Loading Program
Subjective Pt reports that he ran 5-6 miles 3x/week (Mon, Fri,
Sunday). Pt reported achilles pain during first 1/2
mile of running but resolved following first 1/2
mile. Pt. Reported no pain following run.
Objective - Muscle Length: Max restriction L > R --> HF, Rec
Fem, Gastroc/Soleus
HEP • All exercises completed in clinic
• Tendon loading protocol 1x/day, 3x15
• Stretching 2x/day, 2x30s
• Proximal LE/Core Strength training, 4-5x/wk,
1x/day

Week 7
NOTE:
Pt arrived to PT appointment 20 minutes late. Therefore, billed PT treatment was not
completed.
Spoke with patient about running progression. Pt. Reported achilles tendon soreness
for 2 days (with ambulation and stairs) following 12 mile run (no pain experienced
during run).
Pt able to tolerate 9 miles of running with minimal tendon pain (<2/10) following run.
Pt educated to wait 2-3 days following high intensity runs to allow for appropriate
tendon regeneration/healing

Exercise MS Impairment Addressed Running Biomechanical Impairment Addressed
Tendon Loading Program Pathology of Achilles
Tendinopathy
Pain in heel
DF AAROM
(overpressure program)
Restricted DF secondary to
Talocrual Jt. Hypomobility
Lack of DF t/o gait cycle
Gastroc- Soleous
Stretching
Restricted DF secondary to
muscle length restrictions
Lack of DF t/o gait cycle
Rectus Femoris & HF
Stretching
Restricted Hip Extension Lack of Hip Ext in terminal stance; vertical trunk
alignment
Side Plank Abdominal and Glute Med
Weakness
Vertical trunk alignment; decreased knee window
Step Down Eccentric Quad Control
Weakness
Decreased knee flexion in loading response
Squats Glute Max Weakness;
Eccentric Quad Control
Weakness
Decreased knee flexion in loading response;
Decreased Hip Extension in terminal stance

PSFS: Running  8 (7@ NPV)
LEFS: 75 (73 @ NPV)
• Not MCID
• Improvements In:
• Performing hobbies, recreational, sporting activities
• Making sharp turns while running fast
Functional Improvements:
• Running 9 miles with minimal/no pain during and after run
• No Achilles pain descending stairs throughout day (except 1st few
steps in morning)
• No longer using boot to relieve Achilles pain when flared up

• Progression to Phase 3 and 4 of Progressive Achilles Tendon Loading
Program
• Continued return to running progressions to 26 miles
• Continued progressions addressing functional deficits:
▫ Weak Core & Proximal LE Musculature
▫ Weak Distal LE Musculature (intrinsic foot musculature & extrinsic
longitudinal arch support musculature)
▫ LE Muscle Length Restrictions
▫ Maintain and improve talocrural DF gains.
▫ Motor control gait training: return to symmetric midfoot striking pattern
Expected Continued Progressions

• Achilles Tendinopathy: treat pathology and pt’s functional deficits
• Clinicians should consider eccentric-concentric loading alongside or
instead of eccentric loading in achilles and patellar tendinopathy
▫ May improve pt. compliance - protocol completed 1x/day instead of 2x/day
• Relate biomechanics from MOI to treatment (ie: assess running to
determine cause of tendinopathy)
Summary & Clinical Applications

1. Hutchison, A.-M., et al. "What is the best clinical test for Achilles tendinopathy?" Foot and Ankle Surgery 19(2): 112-117.
2. Carcia, C. R., et al. (2010). "Achilles Pain, Stiffness, and Muscle Power Deficits: Achilles Tendinitis." Journal of Orthopaedic & Sports Physical Therapy 40(9): A1-
A26.
3. Jonsson, P., et al. (2008). "New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study."
British Journal of Sports Medicine 42(9): 746-749.
4. Rees, J. D., et al. (2009). "Management of tendinopathy." American Journal of Sports Medicine 37(9): 1855-1867.
5. Cook, J. L. and C. R. Purdam (2009). "Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy."
British Journal of Sports Medicine 43(6): 409-416.
6. Cook, J. L., et al. (2016). "Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?" Br J Sports Med 50(19): 1187-
1191.
7. Malliaras, P., et al. (2013). "Achilles and Patellar Tendinopathy Loading Programmes." Sports Medicine 43(4): 267-286
8. Alfredson, H., et al. (1998). "Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis." The American Journal of Sports
Medicine 26(3): 360-366.
9. Alfredson, H. and J. Cook (2007). "A treatment algorithm for managing Achilles tendinopathy: new treatment options." British Journal of Sports Medicine 41(4):
211-216.
10. Alfredson, H. (2003). "Chronic midportion Achilles tendinopathy: an update on research and treatment." Clinics in Sports Medicine 22(4): 727-741.
11. Silbernagel, K. G., et al. (2007). "Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a
randomized controlled study." Am J Sports Med 35(6): 897-906.
12. Silbernagel, K. G. and K. M. Crossley (2015). "A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and
Implementation." J Orthop Sports Phys Ther 45(11): 876-886.
13. Gabbett, T. J. (2016). "The training-injury prevention paradox: should athletes be training smarter and harder?" Br J Sports Med 50(5):
273-280.
14. Couppe, C., et al. (2015). "Eccentric or Concentric Exercises for the Treatment of Tendinopathies?" J Orthop Sports Phys Ther 45(11): 853-
863.
Citations

Tim J Gabbett: The training-injury prevention paradox: should
athletes be training smarter and harder
Take Away:
• To minimize injury risk, practitioners should aim
to maintain the acute:chronic workload ratio
within a range of approximately 0.8–1.3.
• limit weekly training load increases to <10%.
Conclusion: Excessive and rapid increases in
training loads are likely responsible for a large
proportion of injuries. However, physically hard
training develops physical qualities, which in turn
protects against injuries. This paper highlights the
importance of monitoring training load, including
the load that athletes are prepared for (by
calculating the acute:chronic workload ratio), as a
best practice approach to the long-term reduction
of training-related injuries
Return to Running Concepts 13

Alfredson Eccentric Exercise Program 3,8,9,10

Points:
- insertional vs midsubstance respond different to
treatment
- important to address movement impairments and
pathology of insertional tendinopathy
- Return to running progressions: intensity, duration, fq
- May return to PLOF!

Tendon Loading Program for Long Distance Runner

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