Rehab progression

• Rehab progression – Phase I - pain relief:

  • Isometric work, up to 70% MVC (Rio et al 2015, [patellar])
  • Not effective in all (O’Neill et al 2018, [Achilles], Holden et al 2019 [patellar])
• Rehab progression - Phase 2 - build strength:

  • isotonic progression through range
• Rehab progression - Phase 3 - power development:

  • Incorporation of speed and elastic recoil
• Rehab progression - Phase 4 - return to sport

  • Maintenance
  • management of load
• Rehab progression summary

  A) unload

  B) isometric

  C) capacity

  D) pain

  E) isotonic

  F) explosive

  G) strength

  H) endurance

  I) power

  J) functional

  
• Phase 1:

  • Isometric holds 45 - 60 secs x 4 , 4 days a week
  • Use 70% MVC, good to load
  • Pain free positions initially
  • Avoid compression positions
  • Use if isotonic > 3/10 pain
• Phase 2 - Limited range:

  • Aim to develop strength
  • Isotonic exercise – slow (6 secs) and heavy
  • Minimal pain
  • 6 - 10 x 4 for 3 days a week (high load)
  • Or, 15 x 4 done daily (Low load)
• Phase 2 - Progressive range:

  • Improve load tolerance
  • Moving towards function
  • More provocative
• Phase 3:

  • Energy storage and power loading
  • Mostly for athletic populations
  • Minimal pain
  • Speed work into range
  • Development of kinetic chain motor control
  • Volume before intensity
  • 6 - 8 weeks (??concurrent with activity)
• Phase 4:

  • Sports specific activity
  • Gradual increase
  • Overlaps with elements of phase 3
  • Long term maintenance programme advisable/essential beyond resolution of symptoms
• sample rehab protocol

  • Consider dosage = frequency x volume (days per week x sets/reps)
  • Allow time for recovery
  • Repetitive hard days is too much
  • Monitor by 24h response (VAS 0-3 ok, 3-5 caution, 6-10 avoid)
  • Avoid spikes in activity – slow progression, use % of previous load
  • High load for tendons involve SSC components eg jump, hop

  
• What to expect during rehab:

  • Pain - during rehab not as important as reactivity next day
  • Education & expectations - Slow recovery, ensure buy-in and compliance
  • Consider biopsychosocial contribution (fear, threat, etc) in acute/chronic presentation
  • Investigations - Structural change poorly correlated with symptoms, but structure changes – UTC studies
  • Exercise is for muscle as well as tendon (M-T unit)
  • Benefits of exercise go beyond physiological changes locally - strength, sensitivity, confidence, tissue capacity
• Less common adjuncts and alternatives to exercises:

  • Surgery – minimal invasive, outside tendon
  • High Volume Injections
  • Excision
  • Scrapping
  • Plantaris
  • Shock Wave Therapy
• More common adjuncts and alternatives to exercises:

  • Corticosteroids
  • GTN
  • Ice
  • Taping
  • Sclerosing agents
  • Alternative medicine
  • Platelet Rich Plasma PRP