Core practice readings

Achilles Tendinopathy (Review - Peter Malliaras, 2022)

• Assessed outcomes include VISA-A questionnaire results as well as pain and disability levels
• Graded exposure is more effective than eccentric exercises
• Suggested progression includes isometrics -> isotonics -> plyometrics -> return to sport
• Aim for heavy slow resistance training with full dorsiflexion range of motion, because this is the highest Achilles load
• Load management with good calf strength is key to decrease chances of re-injury
• Education on treatment rationale and risk factors is key
• Describe that recovery may be long; mild pain is possible for 6-12 months
• Heel wedges, taping, or shockwave could be beneficial adjuncts to treatment

Bone Stress Injuries

• Load management and unloading are required, but don't unload for too long as bone loss can be induced from deconditioning
• Strict non-weight bearing for a long time eg 6-8 weeks in a walking boot is not needed
• Treatment should be based on symptoms, not a specific time period
• Education regarding healing and pain is key
• Any pain, regardless of activity or rest, means mechanical or chemical irritation; loading must be modified
• The goal is pain free gait, possible via partial weight bearing with crutches or cushioned shoes
• Maintain fitness by using cross training modalities with low load while monitoring symptoms
• Screen for Relative Energy Deficiency in Sport (RED-S) to prevent recurrence
• Low-intensity pulsed ultrasound and OP medication are options, but unlikely outside professional settings
• Address muscle function and strength continually to prevent future issues
• Target muscles near the bone stress injury (BSI), and provide global strengthening for return to sport (RTS)
• Treatment and management vary slightly based on if the BSI is tibial or metatarsal
• Running isn't osteogenic, so re-introduce that last by starting with low-load elliptical, then progress to overground running with acceptable symptoms
• Jumping exercises encourage bone loading and should be added after recovery, reducing the risk of the bone stress injury recurring

Sever's Disease (James M. Smith; Matthew A. Varacallo, 2024)

• Heel pain in children and young athletes (8-15 years old with immature skeletons) comes from microtrauma to the growth plate from the Achilles tendon
• It is typically self-limiting, with activity modification as the key treatment
• Physical exam may involve pain with passive ankle dorsiflexion
• Pain can be triggered when manually compressing the posterior calcaneus medial and lateral and when on tiptoes
• If pain persists after 4-8 weeks with conservative measures, rule out other causes with imaging
• Treatment includes load management, daily ice, heel cups or lifts, calf stretching, and strengthening to reduce Achilles load

ROAST - Rehabilitation-Oriented Assessment

• Things to consider include the mechanism of injury, previous history of ankle sprains, weight bearing status (to rule out fracture using Ottawa Ankle Rules), and clinical assessment of ligaments

PEACE and LOVE (Blaise Dubois, Jean-Francois Esculier, 2020)

• Acronym for soft tissue injury acute care
• After injury: avoid Heat, Alcohol, Running, and Massage
• Immediately: Protect the injured area by resting it; avoid excessive rest
• Elevate the limb above the heart to decrease swelling
• Avoid anti-inflammatories, since suppressing inflammation might help acute pain, but could worsen long-term outcomes
• Compress the area using bandages or taping to limit tissue hemorrhage and intra-articular edema
• Educate the patient about load management, active rehab, and injury timelines
• Load the area by resuming Activities of Daily Living (ADLs) as soon as symptoms allow, because optimal loading (without exacerbating pain) promotes repair, remodelling, and building tissue tolerance
• Stay Optimistic, this is associated with improved outcomes, when a patient has a positive outlook
• Vascularization: start pain free cardiovascular exercises in the days following the injury to increase blood flow and boost motivation
• Exercise to promote rehab and recovery

Plantar Heel Pain (High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up)

• One intervention group used gel heel cups with plantar stretching. The other used gel heel cups along with high- load strength training
• The strength training group did unilateral calf raises with their big toe in extension (Windlass mechanism) which progressed over 3 months, performed every other day
• An important measurement point was determining the change in score on the Foot Function Index (FFI), where a MCID or Minimal Clinically Important Difference = 7 points; also consider plantar fascia thickness and first step pain
• The strength group had better FFI improvement after 3 months but the difference between groups wasn't significant at 1, 6, or 12 months though (5-7 points)
• Pain was less in the strength group (significant) at 3 months; but there were no differences between them at other measuring points
• Treatment satisfaction was higher and there weren't any adverse events in the strength group (except DOMS)

Knee: Fat Pad Impingement (The Infrapatellar Fat Pad and Plica Injuries)

• Infrapatellar Fat Pad (IFP) issues usually benefit from physical therapy intervention
• Reduce IFP load via taping, and by improving foot function along with hip strength
• In severe cases, load management may be needed
• General lower limb strengthening with neuromuscular closed chain/weight bearing exercises is key to recovery

Lower Limb Tendinopathy (Ten treatments to avoid in patients with lower limb tendon pain)

• Avoid absolute rest because it decreases load tolerance and tendon stiffness in just two weeks
• Avoid "wrong" prescriptions such as: avoiding compressive loads (lengthened muscle), avoiding elastic/explosive movements in early stages
• Don't depend on primarily passive treatments like shockwave or soft tissue release
• Avoid injections as they result in poor long-term results
• Don't overlook pain; if patient's pain gets greater than 2/10 on daily basis then the program may be too aggressive
• Do not stretch the tendon because this creates a compressive load around it that is irritating
• Don't massage the tendon on a tender irritated tendon because direct massage will make it more painful
• Don't use imaging to assess diagnosis/prognosis/outcomes

Hip: Gluteal Tendinopathy (Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management)

• The most common lower limb tendinopathy, with hip adduction being a key factor
• There isn't strong evidence showing a superior treatment for gluteal tendinopathy; exercise and load management are key conservative approaches
• Reduce compressive forces on the tendon by addressing adduction (in both stretch and compression while sleeping on the side)
• Run the tendon plan as described above, while improving running form by increasing cadence to drop hip adduction

Gluteal Tendinopathy - LEAP Trial (Current and future advances in practice: tendinopathies of the hip)

• As you increase tendon loads via exercise and patient education make sure to avoid large compressive loads
• Use a combination of isometric hip abduction, exercises for improving frontal plane femoral pelvic control, and heavy slow abductor loading with lower kinetic chain conditioning
• The LEAP trial compared education + exercise against cortisone shots (CSI) and "wait and see"; education and exercise had superior results at 8 and 52 weeks in global rating of change

Proximal Hamstring Tendinopathy (Current and future advances in practice)

• Current research is low, so hamstring theories utilize evidence from other tendinopathies
• Load management + patient education + exercises are crucial
• Classic tendinopathy care (isometrics etc.) utilizing a "traffic light system" is used

Acute Hamstring Strains (Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols)

• Two groups: lengthening exercise (L protocol) and conventional exercise (C protocol)
• Primary measurement point was return time to sport with reinjury rate within a year
• The L protocol mainly utilized eccentric lengthening work
• The C protocol utilized more standard exercises with less focus on lengthening
• Each group performed 3 exercises
• Re-injury: 1 C protocol vs. 0 from L protocol
• Return To Sport was much faster in the L group (28 days vs 54 days)

Adductor Groin Strains (Return to Sport After Criteria-Based Rehabilitation of Acute Adductor Injuries in Male Athletes: A Prospective Cohort Study)

• A comprehensive, four-stage protocol emphasizes exercise and return to running
• While doing resistance training pain of 2/10 or less was okay, anything more meant the load was lessened
• Running and strengthening were done at the same time, with criteria for progressing from each phase
• Exercise and run programs have four phases which make up four stages:
• Stage 1 which is the acute and subacute phase contains activity flexibility as phase 1 and early resistance as phase 2, and start SLOW walk to run if symptoms allow
• Stage 2 which is the conditioning phase contains a load progression as phase 3, running movements as phase 1, and slow running/side steps as phase 2
• Stage 3 is the "Sports Specifc Phase" and contains a phase 4 (high load) and then progression can be made by hitting all of the clinically pain free criteria and graduating to the next stage
• Stage 4 is return to sport to maintain strength from the three previous stages with progressive running and cutting (change of direction) exercises while including high speed running and cutting actions