Rehabilitation and Return to Sports of Lower Limb Tendinopathies

Tendinopathies represent a significant number of injuries in sports. The most commonly affected lower limb tendons are the patellar tendon and the Achilles tendon. In addition to being extremely prevalent, patellar and Achilles tendon disorders may be difficult to manage, since symptom persistence and/or recurrence are common. The high prevalence of these tendinopathies in the athletic population and their impact on the athletes’ sports career highlight the importance of appropriate management, with a comprehensive rehabilitation program. This chapter focuses on the management of athletes with patellar and Achilles tendinopathy, with special focus on return to sport. The clinician should keep in mind that a thorough assessment is the pillar of a successful rehabilitation process. Outcome measures offer the opportunity to benchmark improvement over time and can ensure treatment alliance between the patient and the treating clinician. The evaluated outcome measures should encompass all domains of tendon health, and a thorough patient evaluation should include assessment of symptom severity, tendon structure, psychological factors, functional impairments, and kinetic chain deficits. Exercise rehabilitation is the cornerstone for the rehabilitation of athletes with lower limb tendinopathy. The management of tendinopathy involves different aspects such as education and load management, the modification of factors that influence the athlete’s biomechanics potentially increasing overload, and the implementation of progressive loading exercises. In this context, initial management of the athlete with tendinopathy needs to consider the tendon involved, the kinetic chain, the loading history of the tendon, the irritability and severity of pain, and the athlete’s sport. A large part of education should center around activity modification and pain monitoring, as this offers tools for pain management with the athlete continuing to train and play. In the early stages of rehabilitation, isolated exercises for selectively loading of the affected musculotendinous unit are crucial, to ensure that the tendon and muscle are loaded sufficiently so that adaptation can occur, and to prevent deficits hiding in the kinetic chain. Therefore, in the joints where deficits exist, single joint isolated exercises must be completed prior to progression to multijoint exercises. The target of rehabilitation will gradually shift from strength and endurance to power, which will increase the capacity of the system to cope with training loads in preparation for return to sports participation. At the return to sport phase, a gradual and controlled progression that allows the athlete sufficient time to recover and gives the therapist time to evaluate symptoms seems to be determinant for success. The return to sport decisions should be a collaborative process among all stakeholders, including (but not limited to) the injured athlete, team physician, coaching staff and team managers, strength and conditioning staff, the athletic training and physical therapy staff, and the sports psychologist. Education about the rehabilitation process will help athletes and coaches understand the big picture and adhere to realistic time frame of return to play. In general, athletes with tendinopathy can be expected to return to sport anywhere from 6 weeks to 1 year after the initial presentation of symptoms. The athlete is not considered completely recovered, however, until they have participated in a full season without symptoms.