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School of Health Science, Ramon Llull University, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Australian Institute of Sport, Canberra, Australia" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Faculty of Health Sciences, La Trobe University, Victoria, Australia" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Gestión de la carga en las tendinopatías: progresión clínica para tendinopatías de Aquiles y rotuliana" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1188 "Ancho" => 1583 "Tamanyo" => 122145 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Programme to incorporate progressive load to the tendon.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Achilles and patellar tendons are commonly affected by tendinopathy, which are overuse injuries characterized by localized tendon pain with loading and dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">I understand tendinopathy as pain and dysfunction not related to the pathology, and knowing that there isn’t a direct connection between structure, pain and dysfunction, a classification based on the structure is called into question. The interaction between structure, pain and function hasn’t been completely understood. One can find regions in the tendon which are in different stages at the same time. The clinical presentation is a hybrid of reactive and degenerative pathologies, where the structurally “normal” part (in the regular image modalities) has a reactive response, and there is a silent degenerative part of the tendon, mechanically and structurally incapable of transmitting tractive load, and this leads to overloading the normal part of the tendon. The tendon pain is partially related to the function, to the tendinopathy, diminishing muscle strength and motor control which, at the same time, reduces the function. The function in this context refers to the muscle's ability to produce the appropriate strength so that the tendon can accumulate and release energy for the sports movements. However, one can find function changes when there is a structural pathology, independent from the pain.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Both are common among athletes and Achilles tendinopathy may also affect sedentary people. Injury to these tendons can severely impact upon sports, recreational and everyday activities.<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">1–3</span></a> The prevalence of patellar tendinopathy is high in sports characterized by high demands on speed and power for the leg extensors (i.e. volleyball and basketball).<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">5</span></a> In the general population, the incidence of Achilles tendinopathy is 1.85 per 1000. In the adult population (21–60 years), the incidence is 2.35 per 1000. In 35% of the cases, a relationship with sports activity was recorded.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Tendinopathy is commonly associated with tendon pathology. Pathological features of tendon pathology include altered cellularity (increased or decreased), break down in the extracellular matrix (ground substance accumulation, disorganized collagen, neurovascular ingrowth).<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">7</span></a> Endocrine tenocytes and nerve endings release biochemical substances that are thought to have a role in tendon pain (e.g. substance P).<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Eccentric musculotendinous loading has become the dominant conservative intervention strategy for Achilles and patellar tendinopathy over the last two decades. Eccentric loading involves isolated, slow lengthening muscle contractions. Systematic reviews have evaluated the evidence for eccentric muscle loading in Achilles<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">9–13</span></a> and patellar<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">14,15</span></a> tendinopathy, concluding that outcomes are promising but high-quality evidence is lacking.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">16</span></a> Eccentric loading may not be effective for all patients (athletes and non-athletes) affected by tendinopathy.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">17</span></a> It is possible that in athletes, eccentric work is an inadequate load on the muscle and tendon. A rehabilitation program aiming to increase tendon load tolerance must obviously include strength exercises, but should also add speed and energy storage and release.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> The aim of this paper is to document a rehabilitation protocol for Achilles and patellar tendinopathy. It consists of simple and pragmatic exercises designed to incorporate progressive load to the tendon: isometric work, strength, functional strength, speed and jumping exercises to adapt the tendon to the ability to store and release energy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This article would be the first step for an upcoming multicenter randomized controlled trial to investigate its efficacy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The development of a rehabilitation plan for any individual with tendinopathy requires complex clinical reasoning, with reference to the pathoanatomical diagnosis and the functional requirements of the person. Tendinopathy and subsequent rehabilitation will vary considerably depending on the site of the pathology (i.e. insertional or mid-substance), the stage of the tendinopathy, functional assessment, fitness level of the person, contributing issues throughout the kinetic chain, comorbidities and concurrent presentations.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">19</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Scientific literature suggests that the pathogenesis of Achilles tendinopathy is heterogenic. Several risk factors and interactions between them have been identified. Both extrinsic (e.g. overuse) and intrinsic factors may predispose to injury.<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">20–22</span></a> These include lipid levels, genes, metabolic disorders, age, circulating and local cytokine production, genre, biomechanics and body composition.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">23</span></a> It is crucial to have a holistic view of the patient and assess the risk factors.<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">21,24</span></a> It is also important to take into account the total amount of load in the tendon, both at work and in sport.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">25</span></a> Understanding and addressing these factors may improve the outcomes.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The literature on the rehabilitation of tendinopathy suggests that the most important treatment is appropriate loading.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a> The continuum model of tendinopathy<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">27</span></a> provides a reasoned basis for considering targeted rehabilitation dependent on current clinical presentation.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Each component of the rehabilitation program, in particular loading, must be handled in relation to the nature, speed and magnitude of the forces applied to the muscle/tendon/bone unit in order to achieve the goals of the particular management phase, without causing exacerbation of the pathological state or pain. Exercise prescription can target matrix reorganization and collagen syntheses,<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">28</span></a> reduce tenocyte activity, affect tendon compliance<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">29,30</span></a> or have an analgesic effect.<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">31</span></a> While matrix reorganization and improved collagen integrity are sometimes considered to be goals of the rehabilitation process, measurable structural change does not necessarily correlate with therapeutic outcome.<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">32</span></a> There is reasonable evidence to refute observable structural change as an explanation of the benefits of eccentric work in tendinopathy.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">33</span></a> Exercise prescription may exert positive therapeutic effects through other mechanisms, such as change in mechanical properties of the tendon, functional strength, innervation, vascularity or perception of pain.</p><p id="par0050" class="elsevierStylePara elsevierViewall">An accurate diagnosis is essential, imaging tests are helpful, but what really is important is a good clinical assessment. Based on the continuum model, we need to stage where the tendon pathology is: reactive tendinopathy, tendon dysrepair, degenerative or reactive on degenerative tendinopathy. The management of the load is the gold standard treatment at all stages. Early load management in a reactive tendon may keep them in the early stages of tendon pathology and limit the progression of their pathology.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Key points to design and manage tendon load progression</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Pain relief and balanced training</span><p id="par0055" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0060" class="elsevierStylePara elsevierViewall">Pain inhibits the athlete using the elastic (energy storage and release) capacity of the tendon, thereby compromising function and performance.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Excessive training volume or too intense training involving the elastic function of tendons may induce tendon overload and are important factors in the onset of athletic tendinopathy.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0070" class="elsevierStylePara elsevierViewall">Repeated training combined with too short resting periods can result in a net degradation of the matrix and lead to overuse injury.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Managing tendinopathy in season centers around load management, these include strategies that control pain, both reducing aggravating loads and introducing pain-relieving loads.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0080" class="elsevierStylePara elsevierViewall">No medication or injectable treatment to date has been shown to alter tissue properties; only tendon load can stimulate remodeling.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0085" class="elsevierStylePara elsevierViewall">The only option for repeated failures to accommodate athletic load is a comprehensive rehabilitation program that can increase the load absorption ability of the tendon.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0090" class="elsevierStylePara elsevierViewall">Loads that reduce pain should be introduced as early as possible. Loading to decrease pain will maintain a load stimulus on the tendon that is critical to maintain cell function and matrix integrity.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8.</span><p id="par0095" class="elsevierStylePara elsevierViewall">In painful (reactive, reactive on degenerative) tendons, isometric contraction with some load decreases pain for several hours.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> These loads can be repeated several times a day, using 40–60″ holds, 4–5 times, to reduce pain and maintain some muscle capacity and tendon load.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> In highly reactive and painful tendons, bilateral exercises, shorter holding time and fewer repetitions per day may be indicated.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> Literature supports the use of isometric work in painful conditions; sustained isometric fatiguing muscle contraction recruits segmental and/or extrasegmental descending inhibition mechanisms. The recruitment of descending inhibition results in mechanical hypoalgesia and increased pressure pain threshold in healthy individuals.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> Although there isn’t a golden standard for tendinopathy rehab,<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">34</span></a> the guidelines (progression protocols) described in this article match the standards that other authors had previously presented and discussed.<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">18,34,35</span></a> During the strength training sessions, the patients can use metronomes or phone apps, which provide a better control of the number of repetitions of each exercise. Adding these external stimuli has proven to maximize the effects of the workout and to prevent relapses<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">34–36</span></a> and it must be taken into account.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9.</span><p id="par0100" class="elsevierStylePara elsevierViewall">Moderate to heavy loads with slow machine-based weights rarely cause pain.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> These exercises should be completed in the mid to inner range of the muscle-tendon unit to reduce compression at the tendon insertion.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Measuring tendon response to load</span><p id="par0105" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10.</span><p id="par0110" class="elsevierStylePara elsevierViewall">Provocative tests and objective scoring methods should be used to monitor tendon pain. As the VISA scales give substantial scores on pain during high-level activity, they are not responsive to short-term change and are best used on a month-to-month basis. Pain behavior the day after loading is the critical load response test. The athlete can monitor tendon response to training loads by completing a simple loading test every day at a similar time (avoid early morning except in the Achilles where morning pain and stiffness can be a good guide to progression).<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">11.</span><p id="par0115" class="elsevierStylePara elsevierViewall">Perhaps it is the magnitude of the structural tendon response to a load what matters, as this appears to occur before pain arises or changes. An instrument that could quantify the response of a tendon to load would mean a huge advance in the management of tendinopathy.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Prevention of tendon rupture. Evidence for changing tendon structure: aerobic training, synthesis of collagen and rest time</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">12.</span><p id="par0125" class="elsevierStylePara elsevierViewall">Kannus and Józsa examined 891 spontaneously ruptured tendons histologically and found that 864 (97%) of them had degenerative changes.<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">37</span></a> If there's degeneration and tendon overload for a prolonged period, the whole tendon can become degenerative and may fail completely.<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">38,39</span></a> Avoiding these pathological changes is the main prevention to prevent rupture of the Achilles tendon.<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">40,41</span></a> So, in addition to improving the pain and the functional-capacity load tolerance, we must maintain or improve tendon structure to prevent tendon rupture.<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">27</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">13.</span><p id="par0130" class="elsevierStylePara elsevierViewall">Mechanical loading seems to induce changes in gross morphology, mechanical properties as well as biochemical parameters of tendon tissue.<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a> It appears that both intense and regular exercise raise human collagen synthesis (Langberg et al., 1999,<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">43</span></a> 2000,<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">44</span></a> 2001<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">45</span></a>; Miller et al., 2005<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">46</span></a>), which suggests that human tendon tissue is more metabolically active in response to activity than what was previously believed.<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a> Intense exercise increased the formation of type I collagen during the recovery process, which suggests that intense physical loading leads to some kind of adaptation.<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">48</span></a> Intense exercise in humans is followed by an increase of collagen synthesis and degradation. Over the first 24–36<span class="elsevierStyleHsp" style=""></span>h, this response results in a net loss of collagen, but this is followed by a net synthesis 36–72<span class="elsevierStyleHsp" style=""></span>h after exercise.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a> An increased collagen synthesis is consistently observed as a part of the tendon adaptation response to mechanical loading,<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a> however the integration of new collagen into the matrix has not been shown. The COOH-terminal propeptide of type I collagen (PICP) is an indicator for collagen type I synthesis. PICP initially decreased after exercise and an increase in this marker of collagen synthesis was detected 72<span class="elsevierStyleHsp" style=""></span>h after exercise.<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">48</span></a> In healthy humans, both synthesis and degradation increased after 4 week of physical training, whereas after 11 weeks only the collagen synthesis, and not the collagen degradation, was chronically raised.<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">48</span></a></p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">The idea that the tendon can hypertrophy in response to mechanical loading suggests that there is a net formation of connective tissue.<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a> Both long-term (years) and relatively short-term (months) loading induce tendon hypertrophy. The degree of hypertrophy is rather small and seems to occur only in certain tendon regions.<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a> However, this appears to be true only in young people as collagen turnover after the age of 17 years is limited (Heinemeier et al., 2011).<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">14.</span><p id="par0140" class="elsevierStylePara elsevierViewall">Persons who undergo regular training have a greater Achilles tendon cross-sectional area than other age-matched persons (Magnusson and Kjaer, 2003<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">49</span></a>; Kongsgaard et al., 2005<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">50</span></a>), which indirectly reflects a region-specific hypertrophy in response to long term loading,<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a> possibly during adolescent loading when the tendon is able to adapt structurally to load.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">15.</span><p id="par0145" class="elsevierStylePara elsevierViewall">The potential region-specific adaptation to running appears to be far greater in men than in women. The ability of the tendon to adapt to regular loading is attenuated in women.<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">16.</span><p id="par0150" class="elsevierStylePara elsevierViewall">A similar increase in collagen synthesis is seen that is independent of exercise volume (repetitions), which suggests that there is a ceiling effect in collagen synthesis.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">17.</span><p id="par0155" class="elsevierStylePara elsevierViewall">The fact that pro collagen expression is regulated the same way in the tendon regardless of the type of muscle contraction (eccentric, isometric or concentric) supports the belief that the collagen protein synthesis response is regulated by fibroblast strain.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">18.</span><p id="par0160" class="elsevierStylePara elsevierViewall">With regard to tendon mechanical properties, increased tendon stiffness is generally observed in response to large volumes of loading.<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a></p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Integrating structural effects of exercise into rehabilitation</span><p id="par0165" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">19.</span><p id="par0170" class="elsevierStylePara elsevierViewall">Studies suggest that appropriate loading during rehabilitation of tendinopathy is the most important treatment method.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">19</span></a> Exercise prescription can target matrix reorganization and collagen synthesis, reduce tenocyte activity, affect tendon compliance or have an analgesic effect.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">19</span></a> The way the absorption of energy is distributed across the kinetic chain is important and each tendinopathy requires a holistic approach in terms of rehabilitation.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">15</span></a> Each component of the rehabilitation program, in particular loading, must be handled in relation to the nature, speed and magnitude of the forces applied to the muscle/tendon/bone unit in order to achieve the goals of the particular management stage (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), without causing an exacerbation of the pathological state or pain. When planning a rehabilitation strategy, it is crucial to find an approach that addresses the re-education of muscle function instead as considering the tendon as an isolated unit. While early stimulus of the muscle tendon unit is typically focused on isometric muscle activation, which may include muscle stimulation, most programs advocate the progression to higher loads as guided by symptom presentation.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">19</span></a> Progression beyond the early isolated strength and hypertrophy loading requires functional conditioning of the muscle-tendon unit, adjusting tendon load through faster eccentric work prior to starting skill specific re-education such as landings, before introducing sports specific challenges such as sprinting and cutting.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">19</span></a> Consideration of the cortical effects of exercise on the motor cortex are critical.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Effect of loading on tendon. Goals according to key points</span><p id="par0175" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">1.</span><p id="par0180" class="elsevierStylePara elsevierViewall">Removing the cause of reactive or reactive on degenerative tendinopathy (usually unaccustomed load)</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2.</span><p id="par0185" class="elsevierStylePara elsevierViewall">Reduce the pain through reduction of high loads</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">3.</span><p id="par0190" class="elsevierStylePara elsevierViewall">Introducing isometric loads that reduce pain at early stages</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">4.</span><p id="par0195" class="elsevierStylePara elsevierViewall">Adapt the training volume and resting periods to the amount that the tendon can safely handle at that moment</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">5.</span><p id="par0200" class="elsevierStylePara elsevierViewall">Increasing load capacity of the tendon up to that required by the person by improving the structural and/or mechanical properties of the tendon</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">6.</span><p id="par0205" class="elsevierStylePara elsevierViewall">At the end of the progression the athlete should be able to use the elastic capacity of tendon and have regained function of the kinetic chain suitable for performance</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Methods that lead to goal achievement according to key point</span><p id="par0210" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">1.</span><p id="par0215" class="elsevierStylePara elsevierViewall">Load management (reductions) removes the cause of reactive or reactive on degenerative tendinopathy.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">23</span></a> Assessment and modification of the intensity, duration, frequency and type of load is the key clinical intervention.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">23</span></a> Intensity seems to be the most important feature; therefore this is the first factor we should modify by removing intensity peaks (i.e. sprinting, sets, Fartlek, fast changes of direction, explosive jumping). Frequency is a very flexible value that we can use to adapt the load (more or less resting hours between workouts depending on the pain level of the next day). Volume seems to be the less aggressive