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![s. During the measurements of tendon properties, the
G of TA was measured to investigate the antagonist
e activity of TA (coactivation level). To determine the
mal activation of TA, a maximal dorsiflexion isometric
ction was performed at the same angle (90- of ankle
We normalized the mEMG value of TA with respect
mEMG value of TA at the same angle when acting as
onist at maximal effort.
atistics. Descriptive data included means T SD. A
ay ANOVA with repeated-measures [2 (groups) Â 2
imes)] was used to analyze the data. The F ratios for
effects and interactions were considered significant at
05. Significant differences among means at P G 0.05
detected using a Tukey post hoc test.
ULTS
Resistance
versus
SSC
• 12
weeks
of
resistance
training
vs
plyometric
training
– Tendon
s;ffness
increased
volumes of weight
training
with
the plantar flexor muscles
muscle
sed significantly 4.9 T 2.3% for PT (P = 0.003) and
2.8% for WT (P = 0.002), respectively (Table 1). No
cant difference in the relative increase of muscle
– Jump
and WT (P = 0.379). There
e was found between PT performance
increased
no significant differences in the relative increase in the
with
plyometrics
e volume among MG, LG, and SOL (Fig. 1).
ermore, no significant change in the Achilles tendon
was found between both the protocols (Table 1).
MVC value increased significantly by 17.3 T 21.7%
T (P = 0.017) and 19.3 T 13.6% for WT (P = 0.003),
tively (Table 1). There was no significant difference
relative increase of the MVC value between the two
Kubo
2007,
Markovic
2007](https://image.slidesharecdn.com/23-131104080652-phpapp02/75/Peter-Mallarias-Research-Fellow-LaTrobe-University-and-Queen-Mary-University-of-London-Clinical-Director-Complete-Sports-Care-18-2048.jpg)
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Peter Mallarias. Research Fellow, LaTrobe University and Queen Mary, University of London. Clinical Director, Complete Sports Care
This document outlines the rationale and evidence for incorporating stretch-shortening cycle (SSC) exercises into rehabilitation for tendinopathies beyond eccentric exercise alone. SSC exercises like plyometrics can help restore tendon stiffness, force production capacity, and neuromuscular function that are often deficient in tendinopathy patients. Clinical studies show SSC rehabilitation programs improve outcomes for Achilles and patellar tendinopathy and allow many patients to return to their previous level of sport. While more research is still needed, SSC training appears to offer benefits like increased rate of force development and improved jump performance over resistance or walking/running programs alone.
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Peter Mallarias. Research Fellow, LaTrobe University and Queen Mary, University of London. Clinical Director, Complete Sports Care
- 1. Return to sport progression: beyond eccentric exercise Dr Peter Malliaras
- 2. Outline • Stretch shorten cycle • Ra;onale and indica;ons in tendinopathy rehabilita;on • Evidence • Prac;cal considera;ons and return to sport
- 3. Stretch-‐shortening cycle (SSC) = walk, run, jump
- 4. SSC components Tendon s;ffness Force producing capacity Structural eg fibre type, architecture Neuromuscular eg RFD Joint and leg s;ffness Sprint / jump performance Farley 1993, Komi 2000, Roberts 2002, Brughelli 2008, Hobara 2008, 2010, Harrison 2004
- 5. Stretch-‐shortening cycle (SSC) • Greater performance – Tendon recoils faster than concentric muscle – Increase EMG – muscle poten;a;on, reflex • Greater efficiency – Length-‐tension, force-‐velocity – Passive energy -‐ tendon Finni 2000, Komi 2000, Finni 2006, Hof 1983, 2002, Fenn 1924, 1924b
- 6. SSC and tendinopathy • Tendinopathy associated with SSC – Sport, posi;on, volume, frequency • High forces, strain • Loading rate, energy absorp;on – Influence on tenocytes? Zwerver 2011, Lian 2005, Malliaras 2008, Ferred 1986
- 7. Achilles tendinopathy deficits • Neuromuscular deficits – Reduced tendon s;ffness – Reduced rate of force development – Reduced hopping distance Wang 2012, Arya 2010, Child 2010
- 8. Silbernagel 2007 902 • Con;nued sport v no sport first 6 weeks 100 90 VISA-A-S score • Con-‐ecc, eccentric, faster-‐ power Silbernagel et al 80 70 60 50 • Greater drop CMJ & hop quo;ent 6 months 40 0w 6w Exercise 3m 6m 12 m Active rest Figure 1. Mean VISA-A-S scores with 95% confidence interval, at 0 and 6 weeks and at 3-, 6-, and 12-month evaluations. VISA-A-S, Swedish version of the Victorian Institute of Sports Assessment–Achilles questionnaire. There were significant (P < .05) correlations between the initial VISA-A-S score and the improvements in VISA-A-S 10 on Achille individ may ha ity of li potenti activity ing per allowed their s could n trainin tendino No phy monito Visnes It ca of trea groups represe for the no defi the fun The occurs can be centage Kvist,14
- 9. Patellar tendinopathy deficits • Greater jump height – Precede and aier pain onset if ac;ve Cook 2004, Lian 2003, Visnes 2013 • Less peak quadriceps torque (uni vs controls, bi) • Less peak jumping power, work Bisseling 2007 Clinical presenta;on varies Crossley 2007
- 10. Landing strategy • Ver;cal vs horizontal – Higher PT force • Previous PT, asymptoma;c – eg less PF, knee flexion spike jump landing – eg less hip flexion stop jump Fig. 6. Lower limb alignment during the horizontal and vertical landing phases of a stop-jump movement at initial foot-ground contact (IC) and at the time of the peak patellar tendon force (FPT). Note the more posterior direction of the vertical ground reaction force Bisseling 2 altered Edwards 2010, 2010b, 2013, vector and the008 tibial alignment during the horizontal landing phase compared with the vertical landing phase. hip joint of the s suggested was a s whereby with mo et al., 199 2007; Bis landing contribu observed patellar t angles 4 to greate patellar 2006). G has been tendinop Purdam, greater h phase m the total posterior horizont result of adaptatio amount compress 1998). It the expe which m ultimatel & Purda Despit landing
- 11. Systematic review ofAT & PT Loading programs Limited evidence that eccentrics are superior to other loading Malliaras et al 2013
- 12. Alfredson Type of exercise Eccentric Sets, reps Frequency Stanish &Curwin Eccentricconcentric Faster eccentricconcentric Silbernagel HSR Eccentricconcentric Eccentric Faster eccentricconcentric Balance exercise Plyometric Eccentricconcentric 3x15 3x10-20 Various 4 x 15 to 6 Twice daily Daily Daily 3x/week Progression Load Speed then load Volume Type of exercise Load Pain Enough load to Acceptable if within Acceptable if be painful in third defined limits was not worse set after Enough load to achieve up to moderate pain Sports Medicine Systema;c Review, Malliaras et al 2013
- 13. Clinical SCC loading • Romero-‐Rodriguez 2011 – n=10, 50% ac;ve in sport – Patellar tendinopathy – Improved VISA 86% – No increase jump height • Flywheel training, eccentric cycling – Increased leg spring s;ffness Elmer 2011
- 14. SSC training • Jumping – – – – Ver;cal Forward Hurdle Drop jumps 20-‐70cm step • Power training – Squat jumps • Bounding
- 15. What can SSC rehabilita;on offer? • Increased rate force development (RFD) – Burgess 2007, Kyrolainen 2005, Kubo 2007, Wu 2009 • Improved jump performance – Burgess 2007, Kyrolainen 2005, kubo 2007, Houghton 2013, Foure 2009, Taube 2012, Wu 2009
- 16. Tendon s;ffness • Inconsistent outcomes – Increases (e.g. Wu 2009, Burgess 2007) – No change (e.g. Kubo 2007, Houghton 2013) • No change aier walking, running programs (e.g. Hansen 2003, Kubo 2008)
- 17. Tendon s;ffness • Burgess 2007 – Warm up then 60-‐80 maximal drop jumps – 2 sessions/week, 6 weeks = 840 jumps • Kubo 2007 – Warm up then 50 drops jumps, 20cm – 4 sessions/week, 12 weeks = 2400 jumps
- 18. s. During themeasurements of tendon properties, the G of TA was measured to investigate the antagonist e activity of TA (coactivation level). To determine the mal activation of TA, a maximal dorsiflexion isometric ction was performed at the same angle (90- of ankle We normalized the mEMG value of TA with respect mEMG value of TA at the same angle when acting as onist at maximal effort. atistics. Descriptive data included means T SD. A ay ANOVA with repeated-measures [2 (groups) Â 2 imes)] was used to analyze the data. The F ratios for effects and interactions were considered significant at 05. Significant differences among means at P G 0.05 detected using a Tukey post hoc test. ULTS Resistance versus SSC • 12 weeks of resistance training vs plyometric training – Tendon s;ffness increased volumes of weight training with the plantar flexor muscles muscle sed significantly 4.9 T 2.3% for PT (P = 0.003) and 2.8% for WT (P = 0.002), respectively (Table 1). No cant difference in the relative increase of muscle – Jump and WT (P = 0.379). There e was found between PT performance increased no significant differences in the relative increase in the with plyometrics e volume among MG, LG, and SOL (Fig. 1). ermore, no significant change in the Achilles tendon was found between both the protocols (Table 1). MVC value increased significantly by 17.3 T 21.7% T (P = 0.017) and 19.3 T 13.6% for WT (P = 0.003), tively (Table 1). There was no significant difference relative increase of the MVC value between the two Kubo 2007, Markovic 2007
- 19. Pathology changes • Less fluid flow response with loading – Aggrecan Grigg 2012 , Docking 2013 • Reduced s;ffness aier resistance training Kongsgaard 2010 • Neuromuscular adapta;on more realis;c
- 20. Indica;ons for specific SSC? • Con;nued sport possible for some • Quick return to sport within season – Inseason management of symptoms – Return to sport criteria? Pain, training capacity • Spectrum of presenta;ons clinically – Pain / confidence – Kinema;cs eg poor eccentric control, s;ff knee – Performance eg hop distance
- 21. Hop kinema;cs Hop distance
- 22. Low intensity • • • • • • Pain Motor paperns Endurance Jumps Hops – Achilles ++ Box
- 23. Landing strategy • Replicate landing e.g. block jump landing • Land on toes • Soi landing • Hip flexion difficult in volleyball Chmielewsky 2006, Flexion Figure 1 – The Athletic Position in TripleFlanagan 2008
- 24. Landing challenges • Stop jump – eg basketball • Proximal kine;c chain
- 26. Performance • Minimise hysteresis – <25ms contact ;me • Progress intensity but not at expense of speed • Single leg • Ver;cal • Forward • Hurdle Chmielewsky 2006, Flanagan 2008
- 27. • Stable pain, but present • Reasonable kinema;cs • Side to side isolated & compound strength – Leg extension – Leg press – Calf raise When to start?
- 28. How to progress? • Start asap • • • • Every 2-‐3 days -‐ tenocytes? pain? Pain / endurance – 5-‐10 mins Motor paperns – 5x10 Performance – 5x10, 5x5 – Stable pain before progressing
- 29. à Hopping Isometric Kine;c chain Sport à Landing Performance Running -‐hops -‐cudng -‐sprint Isometrics for load Concentric-‐eccentric – isolated Concentric-‐eccentric – compound Eccentric? Return to sport = stable pain, strength, motor paperns, performance
- 30. Summary • Limited evidence for SSC rehab – Look for individual indica;ons • No evidence on return to sport criteria – Pain, strength, movement paperns, performance • Achilles – low intensity, endurance • Patellar – motor paperns Twi$er: @DrPeteMalliaras
- 31. Case 1 • A young talented player with symptoms in the patella tendon (on and off pain during warm up or aier training, beper during ac;vity) during the preseason training • what to do? • con;nue training? adjust training? add treatment? Modify training based on pain response What are the deficits? Address these in parallel
- 32. Case 2 • A very important player during season experience increasing symptoms (pain and stiffness in the morning) in the Patellar Tendon weeks before an important match • What to do ?? Modify load Isometrics High volume injection Other eg heel wedges, tape
- 33. Case 3 • One of your players experiences sudden onset of pain in the inser;onal Achilles tendon during training but only during high loading. • What to do ? Imaging Clinical signs of tear? Fascia crura