Today I will discuss a stage-based approach to the rehabilitation of tendon pain. We will break down the process into four stages, which reflect the framework discussed by Jill Cook in her research. Let’s remember that first, we must identify and remove the triggering load in order to reduce pain in the acute phase.
Stage One
The goal is to reduce the patient’s pain level, which will allow them to start engaging in the rehab process. Then, we start focusing on strength gains to increase their load-bearing capacity. In stage one, isometric exercise is a good beginning but we must assess the patient’s response. If the pain does not decrease over the first few days or weeks, we need to double-check our differential diagnosis. At this stage, we should always try to stay away from compressive loads in order to reduce pain quickly. We will start with heavy loads (weight) and slow movements, if any. Remember, heavy weights and isometrics or slow movement do NOT represent “Heavy Tendon Loads” but they are “Heavy Muscular Loads”. The starting load will be determined by the patient’s capacity (desk job vs. athlete). A simple prescription target is to get our patient to complete five reps of an exercise for a 45s hold. We will adjust the load as needed if it is too easy or too hard for the patient as well as assess their 24-hour response. If the response is positive, we will progress the load slowly as we grow through stage 1. If the response is negative, we should repeat the process with a lesser load.
Note: Research is showing us that reducing the time under tension is not the best way to achieve the goals of stage one. Therefore, adjusting the load or weight the patient is sustaining is a better option than reducing the time of the hold.
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