[Physio Explained] Load progression in rehab for patella tendon injuries with Dr Teddy Willsey

In this episode, Dr. Teddy Willsey discusses a research paper on load progression for the patellar tendon and its impact on rehabilitation. We explore key exercises like the split squat, rear foot elevated squat, bilateral squat, and forward heel tap, along with how to adjust plyometric exercises for optimal tendon loading. Dr. Willsey also discusses how the paper categorizes exercises into Tier 1, Tier 2, and Tier 3, providing a structured approach for clinicians to improve patient outcomes.

👉🏻 See Teddy’s full Research Review here - https://physio.network/reviews-willsey1

Dr. Teddy Willsey is a sports medicine focused physical therapist and private practice owner in Rockville, Maryland. Teddy has an interest in working with high level athletes and return to sport rehab. In addition to practicing PT, Teddy speaks and teaches publicly, writes and blogs regularly, and posts on social media daily.

Reference to article: Silva R, Song K, Hullfish T, Sprague A, Silbernagel K, Baxter J (2024) Patellar Tendon Load Progression during Rehabilitation Exercises: Implications for the Treatment of Patellar Tendon Injuries. Med Sci Sports Exerc, 56(3):545-552.

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Transcript

SPEAKER_02 0:05

When you jump more slowly, when you're performing a plyometric, you can load your patellar tendon a little bit more. So let's say you're measuring somebody and they're really thinking about how they want to jump. You might tell them to jump more deeply and really bend their knees. That would be more challenging on the patellar tendons. Whereas if you had somebody jump more similar to on a jump rope, that would be more of a shallow jump on the knees, not as much patellar tendon loading.

SPEAKER_00 0:32

In this episode, we talk to Dr. Teddy Wilsey about a great paper that he's recently reviewed for the Physio Network Research Reviews. It's all about patellar tendon load progression. And in this episode, Teddy talks us through the paper. He talks us through the goods and the limitations. But overall, we have a really good discussion around how we can take some of these findings and put it straight into our practice, looking at really good exercises and how we can implement them best into the practice that we have with our patella tendon patients. Now, Dr. Teddy Wilsey is a sports medicine focused physical therapist and private practice owner in Rockville, Maryland. And Teddy has an interest in working with high level athletes and return to sport rehab. In a So to learn more about these research reviews and how they can make keeping up to date so much easier for you, do click in the link in the show notes now. I'm James Armstrong and this is Physio Explained. Teddy, great to have you on the podcast. We're going to be talking about a really interesting paper that you've done a research review for PhysioNetwork on. So thank you so much for coming on.

SPEAKER_02 1:56

Yeah, absolutely, James. Thanks for having me. Glad we were able to put it together.

SPEAKER_00 1:59

Yeah, definitely, definitely. So, Teddy, tell us a little bit about this paper that you've done the research review on. Give us an idea of the title and the aims of this paper.

SPEAKER_02 2:08

Yeah, so the paper, the title of it is Patellar Tendon Load Progression During Rehabilitation Exercises. implications for the treatment of patellar tendon injuries and the lead authors, Rodrigo Silva and company. Some of the papers that they are attempting to, or the aim of the papers, they're attempting to quantify patellar tendon loading during various exercises. It's a paper that's centered around using force plates. So they're only looking at closed chain exercises. So it's important to understand a limitation of the paper, which obviously the authors discussed, which is this was only one kind of one type of exercise. They didn't have things like a leg press or a leg extension, anything like that. What they're doing is they're having people do a variety of exercises in both single leg, double leg, different constraints, different positions, and they are measuring and quantifying their load. They use biomechanical markers on the body in combination with force plates. So they're looking at knee excursion, knee over toe distance, and they're using different equations to try to put together those numbers and rank all the exercises. That's the end product of the paper is the ranking of the exercises. And if we jump to the very top exercise, it is the forward heel tap. So you're standing on a low box on one leg, and then you reach forward with your other foot, tap the heel lightly on the ground, trying to not put too much weight on there, and then come back. And we understand the forward heel tap to be a challenging exercise. It's one that's popularized on social media recently. Knees over toes and different movements like that really explore this movement. They do it on a decline slant board, different positions, different weight loading positions as well. As a physio, do you need to jump to that exercise when you say, okay, I have somebody with patellar tendinopathy and I need to load them? My thought is no, that's kind of like the top of the pyramid. Some other exercises that the paper discussed were things like a rear foot elevated split squat, a bilateral squat. And interestingly, they also looked at plyometrics. And one of the findings here that we were discussing is when you jump more slowly when you're performing a plyometric, you can load your patellar tendon a little bit more. So let's say you're measuring somebody and they're really thinking about how they want to jump. You might tell them to jump more deeply and really bend their knees. That would be more challenging on the patellar tendons. Whereas if you had somebody jump more similar to on a jump rope, that would be more of a shallow jump on the knees, not as much patellar tendon loading. And for certain people, maybe if you had them jump for maximal height, that might be a stiffer jump, just depending on what their jumping strategy is. So that's just one thing that I think is worthwhile to consider here. The paper talks about ACL reconstructions as well. We see a lot of ACLs with patellar tendon autografts. And so by virtue of that graft, we are seeing a lot of patellar tendinopathy or patellar tendon reconstruction type of patients. And when that population is performing their jumps, You can get really a large range in their pain response and their comfort level and their performance depending on how they actually execute the jump. So they might be really compensating on what we see like a stiff leg, right? If you look at biomechanical studies of people after ACL reconstruction or patellar tendon issues, they have a stiffer leg. They don't allow the knee to bend and absorb force as much. And that's because they don't want to use that patellar tendon. They don't want to take advantage of the elastic and the stiffness that we need from it. Instead, they just try to make the whole leg as stiff as possible to not really bend the tendon or use the tendon very much. So if you are to try to promote tendon loading for that type of patient, you might actually have them jump with a little bit more intentional knee bend.

SPEAKER_00 5:56

Definitely. And I think it's like we've talked about off air as well in terms of it's got to be athlete centred around what do they want to go back to? Are they going to actually need to do that movement as well? In terms of we talked about that single leg decline squat. At what point in that patient's return are they going to need to do that? So therefore, do we really need to jump into that early, early on?

SPEAKER_02 6:18

That's exactly right, James. And with rehab in general, right, we're always working towards a goal and that individual's return to sport demands in general so you know if there's somebody that needs to jump and sprint and run a lot then we are going to have them do something more on the plyometric side and they probably will need to work up to that forward heel tap like you mentioned just because of the overall demands of the sport if there's somebody that's having more of a garden variety tendinopathy but they're a runner let's say and they're doing more endurance activities they're a runner and a cycler Maybe they don't need that forward heel step to the same forward heel tap to the same degree. Maybe that's something that could flare them up or actually kind of impede the healing process if it's beyond their recoverable envelope of function, if you will, if it's beyond where they are right now. Because the biggest challenge that we see with tendon morbidity is large changes or acute changes in the actual workload. So we need a gradual progression, understanding where they are right now, where they want to be.

SPEAKER_00 7:19

Absolutely. And it's pitching that. We mentioned off-air, I've just finished Ebony Rio's practical with Physio Network on Achilles tendons. And it's interesting looking at this paper compared to some of the stuff I've got from that. But again, we know that those tendons don't want to rest. That's not going to be a good idea, but it's about where we pitch that. And as you say, kind of leading up to that tendon morbidity, where is that patient on that continuum?

SPEAKER_02 7:45

Right, exactly. There might be some cases where absolutely we don't want to rest attendant, but there might be some cases where you need to unload it a little bit in order to find that envelope or to find that window that you can then, your entry point, right? The entry point is a term that we use a lot in my clinic and I used a lot in my paper and my analysis of this in general. Because what the authors tried to do with their three tiers was help to provide the clinician with what would be an appropriate entry point. So if we just kind of like quickly fly through the tiers here, tier one starts with walking, a low step up, double leg squat to 60 degrees of knee bend, a step down and a step up on the really low box. I think they used a 10 centimeter step for that one. Tier two, we've got double leg repetitive jumps that are faster, Bulgarian split squat, single leg squat to 60 degrees of knee bend, starts to move up to some lateral jumps, alternating split jumps. There's a lot that are in this tier two range. There wasn't quite as much kind of sensitivity across this middle range for the testing in general. We've got the three second Spanish squat. And the Spanish squat was also one that was very high on here to mention. So that's at the top of tier two. We've also got like a single leg drop vertical jump, single leg repetitive lateral hopping, double leg counter movement jump, and then we get to running. So some of those things are still below running. So I think that it's fair to say that anybody that is running should be able to do everything up to that point. But maybe running could be the hardest thing on their tendons. Maybe they don't need to go beyond that. Then tier three, we've got the single leg maximal forward hop. So you're going to get a lot of knee excursion there, especially on the landing part of it. Single leg repetitive forward hops, kind of like a triple jump test for ACL. Single leg countermovement jump, running and cutting with full speed to a 45 degree cut. Single leg decline squat. Again, that was the the pinnacle, the hardest one there. And that was to 90 degrees of knee flexion. So that's a lot of knee bend for the single leg decline squat. And that's a tough exercise.

SPEAKER_01 9:42

Are you struggling to keep up to date with new research? Let our research reviews do the hard work for you. Our team of experts summarize the latest and most clinically relevant research for instant application in the clinic so you can save time and effort keeping up to date. Click the link in the show notes to try PhysioNetwork's research reviews for free today.

SPEAKER_00 10:04

It's really interesting, actually, because it does transcend other things. You mentioned the ACL reconstruction. So it does make us or allow us to think, OK, well, this patient hasn't had a hamstring graft. They've had a patellar tendon graft. Actually, their entry point to ACL rehab is going to be slightly different. And using the tiers here... It's quite helpful actually in terms of where you might pitch that and where you might pick that out from. And it also fits nicely with what we know about the patellofemoral joint loading as well. As you go further into that knee flexion, we see an exponential growth in compression of the patellofemoral joint. So it fits quite nicely there as well.

SPEAKER_02 10:43

Yeah, it absolutely does. It also kind of fits nicely with one of my biases with the teletennant and ACL rehab in general, James, which is that I generally view some certain jumping exercises as a better entry point than running. And I prefer to work on those for longer to build more resiliency before I have patients running or really pushing up the volume with running. I want them to be able to absorb and create force. And we see here that single leg drop landing, double leg drop landings are lower patellar tendon load than running. But nine out of 10 patients would be surprised if you told them, we're going to have you jump before we have you run.

SPEAKER_00 11:19

Absolutely. Yeah.

SPEAKER_02 11:22

So there's a lot of things that we can do before running, before that forward heel tap that are still going to be very relevant and helpful and therapeutic for the patellar tendon.

SPEAKER_00 11:32

It's proving a really good useful paper within reason as you've mentioned there are limitations and that limitation around open chain exercises or they're not including those. Talk to us a little bit about that Teddy and what your thoughts are around the fact that they've not included that.

SPEAKER_02 11:50

One of the biggest limitations here like you mentioned they didn't include open chain exercises so we're not going to have the leg press and we're not going to have the long arc quad or the leg extension and I think those are probably the two most common movements that you're going to see that were not included. And, you know, you mentioned Ebony Rio. They used those exercises in Peter Meliaris and Ebony Rio and some of their guidelines for tendinopathy in general. And I think that just because of the way that they wanted to grade the scales, and this is kind of like the challenge with research, I think it was just a research problem. They wanted to grade all of these on an equal playing field and utilize the same technology, the force plates, right, the biomechanical markers. And you can't do that with open chain exercises. Everything kind of falls apart. You can't use those same equations and the kind of the mathematical inferences on the back end to quantify load. So inverse dynamics and biomechanics are just kind of naturally limited by some of that 2D to 3D sagittal plane motion as well. So you're not going to get some of the rotational forces at the knees and whatnot because they just looked at everything in two-dimensional form. They use these inverse dynamics equations, and it's very helpful, but we just have to understand that it's one kind of a piece of the equation of the whole thing.

SPEAKER_00 13:03

Yeah, definitely. To finish off and to touch on that a little bit as well is, from your experience and your research and the things you're aware of, where would you say, say, the knee extension would fall into this continuum of tears? Any ideas?

SPEAKER_02 13:18

I always think about it in terms of it depends. Are we doing an isometric leg extension? What degree of knee flexion are we doing? We know that around 60 degrees of knee flexion is probably going to allow the user to exert the greatest force and maybe load the tendon the most. We know that if we did some sort of oscillation or some sort of faster movement, that's going to load the tendon a little bit more. Whereas if you do something isometric or you have a longer ramp-up period, that could potentially make it more comfortable on the tendon. So we're always constrained by pain as well. And that's kind of the fun thing about rehab is we're applying strength conditioning and performance principles through a lens of pain, right? So we have to figure out what's going to actually hurt the person or feel okay for them because the leg extension can be a pretty sensitive movement sometimes when you have patella tendinopathy. But my guess would be that If you were to load it up and have somebody work kind of quickly, you could get that leg extension probably somewhere in that high tier two range. Yeah. Somewhere around maybe a Spanish squat because the Spanish squat has very similar biomechanical and dynamics as the leg extension where you have very little movement of the femur approximately. And it's just kind of distal tibial femoral movement. That's where I think if you were to load up a leg extension, you would get it where it would kind of fall.

SPEAKER_00 14:37

That's brilliant, Teddy. So listeners getting even more than just the paper that you've researched in this episode, which is fantastic. Teddy, thank you so much. I think that the paper is really useful, actually. Obviously, it has its limitations and we've talked off air about it. It is only one study. You know, we take it with a pinch of salt, but I think there's something there for clinicians to take and use in their rehab, for sure.

SPEAKER_02 14:57

Yeah, absolutely. Hats off to the researchers. It was a helpful paper overall and a lot to take away, I think. So I think all research is one piece of the puzzle.

SPEAKER_00 15:05

Absolutely. That big jigsaw that we work in. Teddy, thank you so much for your time. So listeners, if you are interested in reading this research review that Teddy did for the Physio Network, then do jump down onto the show notes and check out the link that you can access these. We look forward to hopefully maybe getting you on again, Teddy, and talking more about tendons and all sorts of other bits in between.

SPEAKER_02 15:29

Absolutely. Looking forward to it.

SPEAKER_00 15:30

Thanks a lot, Teddy. Enjoy your evening. Thanks, James.