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 of AT & 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
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 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
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
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
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