When rehabbing tendons...

[Therealredding]

When rehabbing tendons, how closely show the rehab exercise resemble then movement that causes you pain?

For example, my knees are most painful when my feet are close together and my toes are pointing forward which means my knees are doing forward. So getting up out of a chair can be painful. For rehab I’ve chosen the leg press and out of habit I’ve taken the foot placement I use for low bar squats, which means my knees go out to the side. Should I be taking a foot placement that more resembles the movement that cause me the most discomfort by moving my feet in on the press?

My thinking is that if I want to desensitize my knees to a particular movement (knees going straight forward) I should be trying to mimic that movement with my exercise selection.

Am I on the right track or am I over thinking things again?

[Matthew_Rupiper_PT]

Here some thoughts: take them with a grain of salt. I’m sure Austin, Derek and Michael may have more insight.

Looking at common research for “tendon” rehab (air quotes to suggest some nuance and uncertainty with the idea of truly targeting the tendon, or whether the tendon is actually the reason why someone is having pain): achilles, rotator cuff, patellar tendon, etc there are some that have used a “targeted” approach and others have used a generalized approach.

For example:
Many achilles rehab studies use an isolated heel raise program. It is done in both progressive eccentric or con/eccentric protocols. Both have shown benefit.

For the rotator cuff, some evidence shows using the lateral raise alone in a progressive manner may benefit. Some researchers have proposed loading the painful movement in a progressive fashion. Other studies have used a more global scapular/rotator cuff program.

For those with anterior knee pain, you’ll find some research trying to isolate the tendon with a decline eccentric squat, others using heavy slow resistance training with a leg press, squat and hack squat. These have shown benefit.

To me, the evidence leans/suggests progressive loading appears to be the common denominator whether the loading is isolated/specific or generalized to the proposed tissue problem. Having an eccentric component stands out to me. Clinically I default to standard progressive loading protocols. If an isolated movement is not tolerated, I’ll take a generalized approach. As that becomes tolerated, I’ll move into a more isolated approach (single leg heel raise, single leg knee extension, lateral raise), while maintaining the heavier loads of generalized movements (squats, presses, rows, etc)

Since you’re the one dealing with this predicament: use the basic scientific method on yourself. Trial of period of very isolated, specific movements and assess your response. Trial of period of more generalized movements. See what works for you. The evidence suggests both approaches can be effective.

[Therealredding]

@Matthew_Rupiper_PT

Here some thoughts: take them with a grain of salt. I’m sure Austin, Derek and Michael may have more insight.

Looking at common research for “tendon” rehab (air quotes to suggest some nuance and uncertainty with the idea of truly targeting the tendon, or whether the tendon is actually the reason why someone is having pain): achilles, rotator cuff, patellar tendon, etc there are some that have used a “targeted” approach and others have used a generalized approach.

For example:
Many achilles rehab studies use an isolated heel raise program. It is done in both progressive eccentric or con/eccentric protocols. Both have shown benefit.

For the rotator cuff, some evidence shows using the lateral raise alone in a progressive manner may benefit. Some researchers have proposed loading the painful movement in a progressive fashion. Other studies have used a more global scapular/rotator cuff program.

For those with anterior knee pain, you’ll find some research trying to isolate the tendon with a decline eccentric squat, others using heavy slow resistance training with a leg press, squat and hack squat. These have shown benefit.

To me, the evidence leans/suggests progressive loading appears to be the common denominator whether the loading is isolated/specific or generalized to the proposed tissue problem. Having an eccentric component stands out to me. Clinically I default to standard progressive loading protocols. If an isolated movement is not tolerated, I’ll take a generalized approach. As that becomes tolerated, I’ll move into a more isolated approach (single leg heel raise, single leg knee extension, lateral raise), while maintaining the heavier loads of generalized movements (squats, presses, rows, etc)

Since you’re the one dealing with this predicament: use the basic scientific method on yourself. Trial of period of very isolated, specific movements and assess your response. Trial of period of more generalized movements. See what works for you. The evidence suggests both approaches can be effective.

Thanks for the info Matthew, that sounds pretty much in line with what I’ve heard from BBM. In my knee rehab I’ve been doing high rep progressive tempo work on the leg press and single leg extensions.

The reason I though to ask about mimicking the painful movement was because my pain was improving during a knee movement like a squat (knees going out to the side), but the more forward my knees go (like getting up out of a chair) the more pain I get.

Ill play around and see what happens

[Derek_Miles]

I’m going to echo what Matthew said. When dealing with symptoms there is often a spectrum between working around and working through issues. Rarely is the answer to only work around because specificity of training dictates that we need to practice a task in order to best perform a task. That does not mean that any more often do we need to just work through a problem. It really does come down to striking a balance between the two and this answer of what determines that balance is going to be different for different people. If you find a movement you can tolerate, do that movement, but reintroduce or test the one you couldn’t do from time to time. There is no perfect “if p then q” algorithm to this.

[Therealredding]

@Derek_Miles

I’m going to echo what Matthew said. When dealing with symptoms there is often a spectrum between working around and working through issues. Rarely is the answer to only work around because specificity of training dictates that we need to practice a task in order to best perform a task. That does not mean that any more often do we need to just work through a problem. It really does come down to striking a balance between the two and this answer of what determines that balance is going to be different for different people. If you find a movement you can tolerate, do that movement, but reintroduce or test the one you couldn’t do from time to time. There is no perfect “if p then q” algorithm to this.

So like you had me do with my shoulder and low bar squats.

So maybe start leg press with a narrower foot placement for the early easy sets and then move to a foot placement that produces less knee pain for the heavier sets and try to transition to the closer footing as things improve?

[Matthew_Rupiper_PT]

I have had folks (construction workers, catchers in baseball, post-op tendon repairs, ACL reconstructions, etc) that do a lot of low work while squatting do just that; progressively work into a tip-toe squats or heel raised front squats intentionally shoving the knees forward. To me as a PT, it was about showing them it was safe to do, as opposed to getting stronger, but either way, they were able to return to the task.