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        "titulo" => "Gesti&#243;n de la carga en las tendinopat&#237;as&#58; progresi&#243;n cl&#237;nica para tendinopat&#237;as de Aquiles y rotuliana"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Programme to incorporate progressive load to the tendon&#46;</p>"
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    "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&#44; which are overuse injuries characterized by localized tendon pain with loading and dysfunction&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">I understand tendinopathy as pain and dysfunction not related to the pathology&#44; and knowing that there isn&#8217;t a direct connection between structure&#44; pain and dysfunction&#44; a classification based on the structure is called into question&#46; The interaction between structure&#44; pain and function hasn&#8217;t been completely understood&#46; One can find regions in the tendon which are in different stages at the same time&#46; The clinical presentation is a hybrid of reactive and degenerative pathologies&#44; where the structurally &#8220;normal&#8221; part &#40;in the regular image modalities&#41; has a reactive response&#44; and there is a silent degenerative part of the tendon&#44; mechanically and structurally incapable of transmitting tractive load&#44; and this leads to overloading the normal part of the tendon&#46; The tendon pain is partially related to the function&#44; to the tendinopathy&#44; diminishing muscle strength and motor control which&#44; at the same time&#44; reduces the function&#46; The function in this context refers to the muscle&#39;s ability to produce the appropriate strength so that the tendon can accumulate and release energy for the sports movements&#46; However&#44; one can find function changes when there is a structural pathology&#44; independent from the pain&#46;<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&#46; Injury to these tendons can severely impact upon sports&#44; recreational and everyday activities&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">1&#8211;3</span></a> The prevalence of patellar tendinopathy is high in sports characterized by high demands on speed and power for the leg extensors &#40;i&#46;e&#46; volleyball and basketball&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">5</span></a> In the general population&#44; the incidence of Achilles tendinopathy is 1&#46;85 per 1000&#46; In the adult population &#40;21&#8211;60 years&#41;&#44; the incidence is 2&#46;35 per 1000&#46; In 35&#37; of the cases&#44; a relationship with sports activity was recorded&#46;<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&#46; Pathological features of tendon pathology include altered cellularity &#40;increased or decreased&#41;&#44; break down in the extracellular matrix &#40;ground substance accumulation&#44; disorganized collagen&#44; neurovascular ingrowth&#41;&#46;<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 &#40;e&#46;g&#46; substance P&#41;&#46;<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&#46; Eccentric loading involves isolated&#44; slow lengthening muscle contractions&#46; Systematic reviews have evaluated the evidence for eccentric muscle loading in Achilles<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">9&#8211;13</span></a> and patellar<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">14&#44;15</span></a> tendinopathy&#44; concluding that outcomes are promising but high-quality evidence is lacking&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">16</span></a> Eccentric loading may not be effective for all patients &#40;athletes and non-athletes&#41; affected by tendinopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">17</span></a> It is possible that in athletes&#44; eccentric work is an inadequate load on the muscle and tendon&#46; A rehabilitation program aiming to increase tendon load tolerance must obviously include strength exercises&#44; but should also add speed and energy storage and release&#46;<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&#46; It consists of simple and pragmatic exercises designed to incorporate progressive load to the tendon&#58; isometric work&#44; strength&#44; functional strength&#44; speed and jumping exercises to adapt the tendon to the ability to store and release energy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; This article would be the first step for an upcoming multicenter randomized controlled trial to investigate its efficacy&#46;</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&#44; with reference to the pathoanatomical diagnosis and the functional requirements of the person&#46; Tendinopathy and subsequent rehabilitation will vary considerably depending on the site of the pathology &#40;i&#46;e&#46; insertional or mid-substance&#41;&#44; the stage of the tendinopathy&#44; functional assessment&#44; fitness level of the person&#44; contributing issues throughout the kinetic chain&#44; comorbidities and concurrent presentations&#46;<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&#46; Several risk factors and interactions between them have been identified&#46; Both extrinsic &#40;e&#46;g&#46; overuse&#41; and intrinsic factors may predispose to injury&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">20&#8211;22</span></a> These include lipid levels&#44; genes&#44; metabolic disorders&#44; age&#44; circulating and local cytokine production&#44; genre&#44; biomechanics and body composition&#46;<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&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">21&#44;24</span></a> It is also important to take into account the total amount of load in the tendon&#44; both at work and in sport&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">25</span></a> Understanding and addressing these factors may improve the outcomes&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The literature on the rehabilitation of tendinopathy suggests that the most important treatment is appropriate loading&#46;<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&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Each component of the rehabilitation program&#44; in particular loading&#44; must be handled in relation to the nature&#44; speed and magnitude of the forces applied to the muscle&#47;tendon&#47;bone unit in order to achieve the goals of the particular management phase&#44; without causing exacerbation of the pathological state or pain&#46; Exercise prescription can target matrix reorganization and collagen syntheses&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">28</span></a> reduce tenocyte activity&#44; affect tendon compliance<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">29&#44;30</span></a> or have an analgesic effect&#46;<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&#44; measurable structural change does not necessarily correlate with therapeutic outcome&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">33</span></a> Exercise prescription may exert positive therapeutic effects through other mechanisms&#44; such as change in mechanical properties of the tendon&#44; functional strength&#44; innervation&#44; vascularity or perception of pain&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">An accurate diagnosis is essential&#44; imaging tests are helpful&#44; but what really is important is a good clinical assessment&#46; Based on the continuum model&#44; we need to stage where the tendon pathology is&#58; reactive tendinopathy&#44; tendon dysrepair&#44; degenerative or reactive on degenerative tendinopathy&#46; The management of the load is the gold standard treatment at all stages&#46; Early load management in a reactive tendon may keep them in the early stages of tendon pathology and limit the progression of their pathology&#46;</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&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Pain inhibits the athlete using the elastic &#40;energy storage and release&#41; capacity of the tendon&#44; thereby compromising function and performance&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</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&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</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&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Managing tendinopathy in season centers around load management&#44; these include strategies that control pain&#44; both reducing aggravating loads and introducing pain-relieving loads&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">No medication or injectable treatment to date has been shown to alter tissue properties&#59; only tendon load can stimulate remodeling&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</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&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Loads that reduce pain should be introduced as early as possible&#46; Loading to decrease pain will maintain a load stimulus on the tendon that is critical to maintain cell function and matrix integrity&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">In painful &#40;reactive&#44; reactive on degenerative&#41; tendons&#44; isometric contraction with some load decreases pain for several hours&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> These loads can be repeated several times a day&#44; using 40&#8211;60&#8243; holds&#44; 4&#8211;5 times&#44; to reduce pain and maintain some muscle capacity and tendon load&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> In highly reactive and painful tendons&#44; bilateral exercises&#44; shorter holding time and fewer repetitions per day may be indicated&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> Literature supports the use of isometric work in painful conditions&#59; sustained isometric fatiguing muscle contraction recruits segmental and&#47;or extrasegmental descending inhibition mechanisms&#46; The recruitment of descending inhibition results in mechanical hypoalgesia and increased pressure pain threshold in healthy individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> Although there isn&#8217;t a golden standard for tendinopathy rehab&#44;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">34</span></a> the guidelines &#40;progression protocols&#41; described in this article match the standards that other authors had previously presented and discussed&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">18&#44;34&#44;35</span></a> During the strength training sessions&#44; the patients can use metronomes or phone apps&#44; which provide a better control of the number of repetitions of each exercise&#46; 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&#8211;36</span></a> and it must be taken into account&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Moderate to heavy loads with slow machine-based weights rarely cause pain&#46;<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&#46;<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&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Provocative tests and objective scoring methods should be used to monitor tendon pain&#46; As the VISA scales give substantial scores on pain during high-level activity&#44; they are not responsive to short-term change and are best used on a month-to-month basis&#46; Pain behavior the day after loading is the critical load response test&#46; The athlete can monitor tendon response to training loads by completing a simple loading test every day at a similar time &#40;avoid early morning except in the Achilles where morning pain and stiffness can be a good guide to progression&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">11&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Perhaps it is the magnitude of the structural tendon response to a load what matters&#44; as this appears to occur before pain arises or changes&#46; An instrument that could quantify the response of a tendon to load would mean a huge advance in the management of tendinopathy&#46;<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&#46; Evidence for changing tendon structure&#58; aerobic training&#44; 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&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Kannus and J&#243;zsa examined 891 spontaneously ruptured tendons histologically and found that 864 &#40;97&#37;&#41; of them had degenerative changes&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">37</span></a> If there&#39;s degeneration and tendon overload for a prolonged period&#44; the whole tendon can become degenerative and may fail completely&#46;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">38&#44;39</span></a> Avoiding these pathological changes is the main prevention to prevent rupture of the Achilles tendon&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">40&#44;41</span></a> So&#44; in addition to improving the pain and the functional-capacity load tolerance&#44; we must maintain or improve tendon structure to prevent tendon rupture&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">27</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">13&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Mechanical loading seems to induce changes in gross morphology&#44; mechanical properties as well as biochemical parameters of tendon tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a> It appears that both intense and regular exercise raise human collagen synthesis &#40;Langberg et al&#46;&#44; 1999&#44;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">43</span></a> 2000&#44;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">44</span></a> 2001<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">45</span></a>&#59; Miller et al&#46;&#44; 2005<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">46</span></a>&#41;&#44; which suggests that human tendon tissue is more metabolically active in response to activity than what was previously believed&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a> Intense exercise increased the formation of type I collagen during the recovery process&#44; which suggests that intense physical loading leads to some kind of adaptation&#46;<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&#46; Over the first 24&#8211;36<span class="elsevierStyleHsp" style=""></span>h&#44; this response results in a net loss of collagen&#44; but this is followed by a net synthesis 36&#8211;72<span class="elsevierStyleHsp" style=""></span>h after exercise&#46;<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&#44;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a> however the integration of new collagen into the matrix has not been shown&#46; The COOH-terminal propeptide of type I collagen &#40;PICP&#41; is an indicator for collagen type I synthesis&#46; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">48</span></a> In healthy humans&#44; both synthesis and degradation increased after 4 week of physical training&#44; whereas after 11 weeks only the collagen synthesis&#44; and not the collagen degradation&#44; was chronically raised&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a> Both long-term &#40;years&#41; and relatively short-term &#40;months&#41; loading induce tendon hypertrophy&#46; The degree of hypertrophy is rather small and seems to occur only in certain tendon regions&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a> However&#44; this appears to be true only in young people as collagen turnover after the age of 17 years is limited &#40;Heinemeier et al&#46;&#44; 2011&#41;&#46;<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&#46;</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 &#40;Magnusson and Kjaer&#44; 2003<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">49</span></a>&#59; Kongsgaard et al&#46;&#44; 2005<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">50</span></a>&#41;&#44; which indirectly reflects a region-specific hypertrophy in response to long term loading&#44;<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&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">15&#46;</span><p id="par0145" class="elsevierStylePara elsevierViewall">The potential region-specific adaptation to running appears to be far greater in men than in women&#46; The ability of the tendon to adapt to regular loading is attenuated in women&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">16&#46;</span><p id="par0150" class="elsevierStylePara elsevierViewall">A similar increase in collagen synthesis is seen that is independent of exercise volume &#40;repetitions&#41;&#44; which suggests that there is a ceiling effect in collagen synthesis&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">17&#46;</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 &#40;eccentric&#44; isometric or concentric&#41; supports the belief that the collagen protein synthesis response is regulated by fibroblast strain&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">18&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall">With regard to tendon mechanical properties&#44; increased tendon stiffness is generally observed in response to large volumes of loading&#46;<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&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Studies suggest that appropriate loading during rehabilitation of tendinopathy is the most important treatment method&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">19</span></a> Exercise prescription can target matrix reorganization and collagen synthesis&#44; reduce tenocyte activity&#44; affect tendon compliance or have an analgesic effect&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">15</span></a> Each component of the rehabilitation program&#44; in particular loading&#44; must be handled in relation to the nature&#44; speed and magnitude of the forces applied to the muscle&#47;tendon&#47;bone unit in order to achieve the goals of the particular management stage &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; without causing an exacerbation of the pathological state or pain&#46; When planning a rehabilitation strategy&#44; it is crucial to find an approach that addresses the re-education of muscle function instead as considering the tendon as an isolated unit&#46; While early stimulus of the muscle tendon unit is typically focused on isometric muscle activation&#44; which may include muscle stimulation&#44; most programs advocate the progression to higher loads as guided by symptom presentation&#46;<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&#44; adjusting tendon load through faster eccentric work prior to starting skill specific re-education such as landings&#44; before introducing sports specific challenges such as sprinting and cutting&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">19</span></a> Consideration of the cortical effects of exercise on the motor cortex are critical&#46;</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&#46; 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&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Removing the cause of reactive or reactive on degenerative tendinopathy &#40;usually unaccustomed load&#41;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2&#46;</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&#46;</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&#46;</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&#46;</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&#47;or mechanical properties of the tendon</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">6&#46;</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&#46;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Load management &#40;reductions&#41; removes the cause of reactive or reactive on degenerative tendinopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">23</span></a> Assessment and modification of the intensity&#44; duration&#44; frequency and type of load is the key clinical intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">23</span></a> Intensity seems to be the most important feature&#59; therefore this is the first factor we should modify by removing intensity peaks &#40;i&#46;e&#46; sprinting&#44; sets&#44; Fartlek&#44; fast changes of direction&#44; explosive jumping&#41;&#46; Frequency is a very flexible value that we can use to adapt the load &#40;more or less resting hours between workouts depending on the pain level of the next day&#41;&#46; Volume seems to be the less aggressive feature&#44; if there is enough time of rest among workouts&#44; therefore at early stages we can keep the volume of training and change intensity and frequency&#46; If pain increases the day after the workout we need to assess if the person should maintain regular training or adapt their training&#46; Sometimes the athlete may need a different approach than the rest of the group &#40;alternate days&#44; half track&#44; specific work&#44;&#46;&#46;&#46;&#41;&#46; The change on the Numeric Pain Scale &#40;NPS&#41; value the day after the workout tells us if the load is tolerated&#46; Daily NPS&#58; NPS should not raise on the loading test the day after training&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">2&#46;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Isometric exercises reduce the pain in the early phase of rehabilitation or while managing an athlete in season&#46; Isometrics must be heavy &#40;up to 70&#37; maximal voluntary isometric contraction&#41; for the musculotendinous unit and be held for a long time &#40;up to 45<span class="elsevierStyleHsp" style=""></span>s&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">51&#44;52</span></a></p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">3&#46;</span><p id="par0225" class="elsevierStylePara elsevierViewall">How the tendon responds to the training volume and rest periods indicates if the amount of load is within the load that the tendon can safely handle&#46; During early stages of rehabilitation high energy storage loads should not be repeated in less than 48<span class="elsevierStyleHsp" style=""></span>h&#46; Adapting the training according to the NPS observed the next day&#58; If NPS increases keep 72<span class="elsevierStyleHsp" style=""></span>h rest between workouts&#44; if NPS does not increase&#44; keep 48<span class="elsevierStyleHsp" style=""></span>h rest between workouts&#44; if NPS decreases it is possible to increase the frequency or intensity of high load training&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">4&#46;</span><p id="par0230" class="elsevierStylePara elsevierViewall">To Increase load capacity of the tendon up to that required by the person by improving either structural or mechanical properties of the tendon&#44; we must increase load absorption ability of the musculotendinous unit and the kinetic chain&#44; through progressive loading&#46; Mechanical properties of tendon&#44; including tendon compliance&#44; are improved later in rehabilitation by retraining landings&#44; running&#44; changing pace or direction&#44; jumps &#40;energy storage loads&#41;&#46; Eccentric exercises incorporated in all the loads proposed in this paper seems to be the best way to stimulate remodeling of tissue&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">5&#46;</span><p id="par0235" class="elsevierStylePara elsevierViewall">The ultimate goal is that the athlete should be able to use the elastic capacity of tendon and have regained function of the kinetic chain suitable for performance&#46; Functional exercises and individual technical exercises that involve high loads at maximum speed&#44; to apply high force and achieve high velocity&#44; maximum expression of force in sports where tendon have to show their ability to store and release energy in functional and asymptomatic form&#46;</p></li></ul></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Monitoring effect&#58; load dosage and pain management according to pain level the day after the training Numeric Pain Scale &#40;NPS&#41;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Numbered scale from 0 to 10&#44; where 0 means lack of pain and 10 the highest imaginable level of pain&#46; The patient chooses the level that better suits his symptoms&#44; knowing that 7 means an exaggerated pain resulting in modified function&#46; It is essential to correlate pain during training with change on the loading test the next day &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Exercises progression</span><p id="par0245" class="elsevierStylePara elsevierViewall">This is an example of progression&#44; which would vary depending of the goals of each patient&#46; Goals are different for an elite volleyball player and a weekend warrior&#46; The program must be unique to each individual&#44; since the needs of each person are also unique&#46; The highest demanding parts of this program only apply to high performance level of competitive sports &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">1&#46;</span><p id="par0250" class="elsevierStylePara elsevierViewall">On early stages&#44; we keep a daily isometric work&#58; 4&#8211;5 isometrics&#44; holding 40&#8243; &#40;from 30 to 60&#8243;&#41; and resting at least 1<span class="elsevierStyleHsp" style=""></span>min and up to 2<span class="elsevierStyleHsp" style=""></span>min between each&#44; 3 times a day&#46; High loads provide best results&#46; The load needs to be high but avoid muscle fatigue&#46; Muscle vibration during the execution of the exercise means that we are approaching fatigue and that the load is excessive&#46; The exercise needs to be stopped at that moment and we will take that time &#40;being 20&#8243;&#44; 30&#8243;&#44; 40&#8243; or any other amount&#41; as a reference for progression&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0255" class="elsevierStylePara elsevierViewall">Do I feel pain for the next few hours&#63; No<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>maintain and gradually increase the time you hold the isometric contraction or the load if I stay below or equal to pain level 4 for 2 or 3 days&#46; Yes<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>reduce the time you hold the isometric contraction<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">2&#46;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Progression&#58; start slow isotonic exercises on alternate days&#46; 4 sets of slow concentric&#8211;eccentric&#44; 6&#8211;8 repetitions of 4&#8220;concentric<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#8221; eccentric&#46; Increase the load &#40;2<span class="elsevierStyleHsp" style=""></span>kg&#44; 4<span class="elsevierStyleHsp" style=""></span>kg&#44; 6<span class="elsevierStyleHsp" style=""></span>kg&#8211;12<span class="elsevierStyleHsp" style=""></span>kg&#41;&#46; Rest 30&#8243; between sets&#46; Once a day&#44; on alternate days&#46; We keep the isometric work&#44; alternating slow dynamic exercises &#40;one-day isometric work&#44; next day slow dynamic work&#44; next one isometric&#44;&#46;&#46;&#46;&#41;</p></li></ul></p><p id="par0265" class="elsevierStylePara elsevierViewall">Do I feel more pain the next day&#63; No<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>increase the load in slow dynamic exercises every 2 or 3 days when I stay below or equal to pain level 4 for 2 or 3 days&#46; Yes<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>reduce the load in slow dynamic exercises<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">3&#46;</span><p id="par0270" class="elsevierStylePara elsevierViewall">Then increase the speed with functional exercises when base strength is adequate</p></li></ul></p><p id="par0275" class="elsevierStylePara elsevierViewall">Do I feel more pain the next day&#63; No<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>increase the speed in functional exercises every 2 or 3 days when I stay below or equal to pain level 4&#46; Yes<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>reduce the speed in functional exercises&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Maintain the strength exercises<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">4&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Progression&#58; add fast dynamic exercises every three days&#46; 3 sets of fast concentric-eccentric contraction &#40;explosive&#41;&#44; 6&#8211;8 repetitions&#46; Rest 2<span class="elsevierStyleHsp" style=""></span>min among sets&#46; Once a day&#44; every three days&#46; Alternating fast dynamic work with slow dynamic and isometric work&#46; &#40;One day fast dynamic&#44; the next day slow dynamic&#44; the other day isometric&#44; then again fast dynamic&#44;&#46;&#46;&#46;&#46;&#41;</p></li></ul></p><p id="par0290" class="elsevierStylePara elsevierViewall">Do I feel more pain the next day&#63; Yes<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>reduce the number of energy storage exercises&#46; No<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>increase the number of energy storage exercises every 5&#8211;6 days</p><p id="par0295" class="elsevierStylePara elsevierViewall">Maintain the strength exercises</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0300" class="elsevierStylePara elsevierViewall">Achilles and patellar tendinopathy are the most common tendinopathies of the lower limbs&#46; The ideal treatment to manage these tendinopathies doesn&#8217;t exist&#46; There is a need for further research to resolve which is the best therapeutic strategy to help those patients who suffer from tendinopathies&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">On the other hand&#44; there is a number of effective exercise programs for Achilles and patellar tendinopathies&#46; Eccentric training is the most commonly used&#46; It was first posed by Alfredson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">53</span></a> Systematic reviews have evaluated the results of eccentric loading of the injured tendon in tendinopathy&#44; concluding that outcomes are promising&#44; but high-quality evidence is lacking&#46;<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">54&#44;55</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">In our experience&#44; the results obtained by athletic patients &#40;professionals and nonprofessionals&#41; in an isolated eccentric exercise program are poor&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Malliaras et al&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">16</span></a> performed a systematic review of studies comparing two or more loading programs for Achilles and patellar tendinopathy&#46; His conclusions recommend bearing in mind the eccentric and concentric exercises&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">There are studies that recommend a Heavy Slow Resistance &#40;HSR&#41; program to treat lower limb tendinopathy&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">56&#44;57</span></a> Keep in mind that the eccentric-exercise training is slow lengthening of a muscle-tendon unit while it is under load and Heavy-slow resistance training is a series of exercises in which each repetition is performed slowly &#40;&#62;6<span class="elsevierStyleHsp" style=""></span>s&#41; for both the eccentric and concentric phase&#46; In these studies&#44; the HSR program achieved the same pain and function improvement &#40;VISA score&#41; than the Alfredson eccentric program&#44; but with a significantly higher patient satisfaction at the six months follow-up&#46; This clinical improvement came with a collagen rise in the HSR group&#46; This data allows us to recommend the HSR program as an alternative to the eccentric workout for Achilles and patellar tendinopathy rehab&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Isometric exercises have been recommended to reduce and treat patellar tendon pain<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">35</span></a> and to initiate muscle-tendon unit loading when the pain limits the ability to perform isotonic exercises&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> Five repetitions of 45-s isometric mid-range quadriceps exercise at 70&#37; of maximal voluntary contraction have been shown to reduce patellar tendon pain for 45<span class="elsevierStyleHsp" style=""></span>min after the exercise and this was also associated with a reduction in the motor cortex inhibition of the quadriceps that was associated with patellar tendinopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">36</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">Some authors recommend including functional activities &#40;like speed and leap exercises&#41; in the tendinopathy rehab protocols for athlete patients&#46; But they haven&#8217;t been implemented in the scientific literature yet&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">58&#44;59</span></a></p><p id="par0335" class="elsevierStylePara elsevierViewall">In this sense&#44; the progressive exercises protocol presented in this article takes into account the isometric and strength exercises &#40;concentric and eccentric&#41;&#46; The innovation resides in the incorporation of functional strength exercises&#44; speed and leaps to adapt the tendon to the ability to store and release energy&#46; In our clinic experience&#44; incorporating these exercises is very important for the patellar and Achilles tendinopathy rehab for athletic patients&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusion</span><p id="par0340" class="elsevierStylePara elsevierViewall">This protocol can be useful to improve symptoms and function in Achilles and patellar tendinopathies&#46; We have shown the exercises and their progression&#44; we have been using this protocol in our clinical practice for the past 7 years&#46; Our patients get positive results&#46; But this is just a protocol&#46; Randomized clinical trials are needed to demonstrate its efficacy&#44; to devise an adequate dose-response model and to determine its long-term effects&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0345" class="elsevierStylePara elsevierViewall">Authors declare that they don&#8217;t have any conflict of interests&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Achilles and patellar tendons are commonly affected by tendinopathy&#46; Injury to these tendons can severely impact upon sports&#44; recreational and everyday activities&#46; Eccentric musculotendinous loading has become the dominant conservative intervention strategy for Achilles and patellar tendinopathy over the last two decades&#46; Eccentric loading involves isolated&#44; slow lengthening muscle contractions&#46; Systematic reviews have evaluated the evidence for eccentric muscle loading in Achilles and patellar tendinopathy&#44; concluding that outcomes are promising but high-quality evidence is lacking&#46; Eccentric loading may not be effective for all patients &#40;athletes and non-athletes&#41; affected by tendinopathy&#46; It is possible that in athletes&#44; eccentric work is an inadequate load on the muscle and tendon&#46; A rehabilitation program aiming to increase tendon load tolerance must obviously include strength exercises&#44; but should also add speed and energy storage and release&#46; The aim of this paper is to document a rehabilitation protocol for Achilles and patellar tendinopathy&#46; It consists of simple and pragmatic exercises designed to incorporate progressive load to the tendon&#58; isometric work&#44; strength&#44; functional strength&#44; speed and jumping exercises to adapt the tendon to the ability to store and release energy&#46; This article would be the first step for an upcoming multicentre randomized controlled trial to investigate its efficacy&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las tendinopat&#237;as de Aquiles y rotuliana son muy frecuentes&#46; Las lesiones en estos tendones pueden afectar severamente a las actividades deportivas&#44; recreativas y cotidianas&#46; En las &#250;ltimas 2 d&#233;cadas&#44; los ejercicios exc&#233;ntricos se han convertido en la principal intervenci&#243;n conservadora para tratar las tendinopat&#237;as de Aquiles y rotuliana&#46; Los ejercicios exc&#233;ntricos no son efectivos en todos los pacientes afectados por tendinopat&#237;as &#40;atletas y no atletas&#41;&#46; Es posible que en atletas&#44; la carga que genera el trabajo exc&#233;ntrico sobre el m&#250;sculo y el tend&#243;n sea insuficiente&#46; Un programa de rehabilitaci&#243;n que tenga por objetivo aumentar la tolerancia del tend&#243;n a la carga debe&#44; obviamente&#44; incluir ejercicios de fuerza&#44; pero tambi&#233;n debe agregar ejercicios de velocidad y ejercicios que aumenten la capacidad para almacenar y liberar energ&#237;a&#46; Este trabajo muestra un protocolo de rehabilitaci&#243;n para las tendinopat&#237;as de Aquiles y rotuliana&#46; Consiste en ejercicios simples y pragm&#225;ticos dise&#241;ados para incorporar carga progresiva al tend&#243;n&#58; mediante trabajo isom&#233;trico&#44; fuerza&#44; fuerza funcional&#44; velocidad y ejercicios pliom&#233;tricos que aumenten en el tend&#243;n la capacidad de almacenar y liberar energ&#237;a&#46; Este trabajo es el primer paso para dise&#241;ar un ensayo cl&#237;nico aleatorizado y multic&#233;ntrico que permita evaluar su eficacia&#46;</p></span>"
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Reactive tendinopathy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46; The tendon shows no adaptation to load<span class="elsevierStyleHsp" style=""></span>&#8594;<span class="elsevierStyleHsp" style=""></span>back to the load used before the symptoms<br>2&#46; Isometrics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tendon dysrepair&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Progression of strength work&#58;<br>Isometrics<br>2&#46; Slow dynamic functional work &#40;first progressing the strength&#44; then the speed&#41;<br>3&#46; Add endurance as required<br>4&#46; Progressing the compression<br>5&#46; Energy storage and release loads&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Degenerative tendinopathy<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Process of adaptation to load<span class="elsevierStyleHsp" style=""></span>&#8594;<span class="elsevierStyleHsp" style=""></span>load management and exercise&#46;<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Progression of strength work&#58;<br>Isometrics<br>Slow dynamic functional work &#40;first progressing the strength&#44; then the speed&#41;<br>Progressing the compression<br>High load elastic &#40;plyometric work&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Reactive on degenerative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Settle the reactive tendon first and then address the degenerative component&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The reactive tendinopathy settles relatively quickly&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No pain&nbsp;\t\t\t\t\t\t\n
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Original article
Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy
Gestión de la carga en las tendinopatías: progresión clínica para tendinopatías de Aquiles y rotuliana
Alfons Mascaróa,
Corresponding author
amascaro.crb@telefonica.net

Corresponding author.
, Miquel Àngel Cosb, Antoni Morralc, Andreu Roigb, Craig Purdamd, Jill Cooke
a Faculty of Physical Therapy, Lleida University, Lleida, Spain
b High Performance Centre (CAR) Sant Cugat, Barcelona, Spain
c Blanquerna School of Health Science, Ramon Llull University, Barcelona, Spain
d Australian Institute of Sport, Canberra, Australia
e Faculty of Health Sciences, La Trobe University, Victoria, Australia
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The clinical presentation is a hybrid of reactive and degenerative pathologies&#44; where the structurally &#8220;normal&#8221; part &#40;in the regular image modalities&#41; has a reactive response&#44; and there is a silent degenerative part of the tendon&#44; mechanically and structurally incapable of transmitting tractive load&#44; and this leads to overloading the normal part of the tendon&#46; The tendon pain is partially related to the function&#44; to the tendinopathy&#44; diminishing muscle strength and motor control which&#44; at the same time&#44; reduces the function&#46; The function in this context refers to the muscle&#39;s ability to produce the appropriate strength so that the tendon can accumulate and release energy for the sports movements&#46; However&#44; one can find function changes when there is a structural pathology&#44; independent from the pain&#46;<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&#46; Injury to these tendons can severely impact upon sports&#44; recreational and everyday activities&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">1&#8211;3</span></a> The prevalence of patellar tendinopathy is high in sports characterized by high demands on speed and power for the leg extensors &#40;i&#46;e&#46; volleyball and basketball&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">5</span></a> In the general population&#44; the incidence of Achilles tendinopathy is 1&#46;85 per 1000&#46; In the adult population &#40;21&#8211;60 years&#41;&#44; the incidence is 2&#46;35 per 1000&#46; In 35&#37; of the cases&#44; a relationship with sports activity was recorded&#46;<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&#46; Pathological features of tendon pathology include altered cellularity &#40;increased or decreased&#41;&#44; break down in the extracellular matrix &#40;ground substance accumulation&#44; disorganized collagen&#44; neurovascular ingrowth&#41;&#46;<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 &#40;e&#46;g&#46; substance P&#41;&#46;<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&#46; Eccentric loading involves isolated&#44; slow lengthening muscle contractions&#46; Systematic reviews have evaluated the evidence for eccentric muscle loading in Achilles<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">9&#8211;13</span></a> and patellar<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">14&#44;15</span></a> tendinopathy&#44; concluding that outcomes are promising but high-quality evidence is lacking&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">16</span></a> Eccentric loading may not be effective for all patients &#40;athletes and non-athletes&#41; affected by tendinopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">17</span></a> It is possible that in athletes&#44; eccentric work is an inadequate load on the muscle and tendon&#46; A rehabilitation program aiming to increase tendon load tolerance must obviously include strength exercises&#44; but should also add speed and energy storage and release&#46;<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&#46; It consists of simple and pragmatic exercises designed to incorporate progressive load to the tendon&#58; isometric work&#44; strength&#44; functional strength&#44; speed and jumping exercises to adapt the tendon to the ability to store and release energy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; This article would be the first step for an upcoming multicenter randomized controlled trial to investigate its efficacy&#46;</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&#44; with reference to the pathoanatomical diagnosis and the functional requirements of the person&#46; Tendinopathy and subsequent rehabilitation will vary considerably depending on the site of the pathology &#40;i&#46;e&#46; insertional or mid-substance&#41;&#44; the stage of the tendinopathy&#44; functional assessment&#44; fitness level of the person&#44; contributing issues throughout the kinetic chain&#44; comorbidities and concurrent presentations&#46;<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&#46; Several risk factors and interactions between them have been identified&#46; Both extrinsic &#40;e&#46;g&#46; overuse&#41; and intrinsic factors may predispose to injury&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">20&#8211;22</span></a> These include lipid levels&#44; genes&#44; metabolic disorders&#44; age&#44; circulating and local cytokine production&#44; genre&#44; biomechanics and body composition&#46;<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&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">21&#44;24</span></a> It is also important to take into account the total amount of load in the tendon&#44; both at work and in sport&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">25</span></a> Understanding and addressing these factors may improve the outcomes&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The literature on the rehabilitation of tendinopathy suggests that the most important treatment is appropriate loading&#46;<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&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Each component of the rehabilitation program&#44; in particular loading&#44; must be handled in relation to the nature&#44; speed and magnitude of the forces applied to the muscle&#47;tendon&#47;bone unit in order to achieve the goals of the particular management phase&#44; without causing exacerbation of the pathological state or pain&#46; Exercise prescription can target matrix reorganization and collagen syntheses&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">28</span></a> reduce tenocyte activity&#44; affect tendon compliance<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">29&#44;30</span></a> or have an analgesic effect&#46;<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&#44; measurable structural change does not necessarily correlate with therapeutic outcome&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">33</span></a> Exercise prescription may exert positive therapeutic effects through other mechanisms&#44; such as change in mechanical properties of the tendon&#44; functional strength&#44; innervation&#44; vascularity or perception of pain&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">An accurate diagnosis is essential&#44; imaging tests are helpful&#44; but what really is important is a good clinical assessment&#46; Based on the continuum model&#44; we need to stage where the tendon pathology is&#58; reactive tendinopathy&#44; tendon dysrepair&#44; degenerative or reactive on degenerative tendinopathy&#46; The management of the load is the gold standard treatment at all stages&#46; Early load management in a reactive tendon may keep them in the early stages of tendon pathology and limit the progression of their pathology&#46;</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&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Pain inhibits the athlete using the elastic &#40;energy storage and release&#41; capacity of the tendon&#44; thereby compromising function and performance&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</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&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</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&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Managing tendinopathy in season centers around load management&#44; these include strategies that control pain&#44; both reducing aggravating loads and introducing pain-relieving loads&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">No medication or injectable treatment to date has been shown to alter tissue properties&#59; only tendon load can stimulate remodeling&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</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&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Loads that reduce pain should be introduced as early as possible&#46; Loading to decrease pain will maintain a load stimulus on the tendon that is critical to maintain cell function and matrix integrity&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">In painful &#40;reactive&#44; reactive on degenerative&#41; tendons&#44; isometric contraction with some load decreases pain for several hours&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> These loads can be repeated several times a day&#44; using 40&#8211;60&#8243; holds&#44; 4&#8211;5 times&#44; to reduce pain and maintain some muscle capacity and tendon load&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> In highly reactive and painful tendons&#44; bilateral exercises&#44; shorter holding time and fewer repetitions per day may be indicated&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> Literature supports the use of isometric work in painful conditions&#59; sustained isometric fatiguing muscle contraction recruits segmental and&#47;or extrasegmental descending inhibition mechanisms&#46; The recruitment of descending inhibition results in mechanical hypoalgesia and increased pressure pain threshold in healthy individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> Although there isn&#8217;t a golden standard for tendinopathy rehab&#44;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">34</span></a> the guidelines &#40;progression protocols&#41; described in this article match the standards that other authors had previously presented and discussed&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">18&#44;34&#44;35</span></a> During the strength training sessions&#44; the patients can use metronomes or phone apps&#44; which provide a better control of the number of repetitions of each exercise&#46; 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&#8211;36</span></a> and it must be taken into account&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Moderate to heavy loads with slow machine-based weights rarely cause pain&#46;<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&#46;<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&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Provocative tests and objective scoring methods should be used to monitor tendon pain&#46; As the VISA scales give substantial scores on pain during high-level activity&#44; they are not responsive to short-term change and are best used on a month-to-month basis&#46; Pain behavior the day after loading is the critical load response test&#46; The athlete can monitor tendon response to training loads by completing a simple loading test every day at a similar time &#40;avoid early morning except in the Achilles where morning pain and stiffness can be a good guide to progression&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">11&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Perhaps it is the magnitude of the structural tendon response to a load what matters&#44; as this appears to occur before pain arises or changes&#46; An instrument that could quantify the response of a tendon to load would mean a huge advance in the management of tendinopathy&#46;<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&#46; Evidence for changing tendon structure&#58; aerobic training&#44; 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&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Kannus and J&#243;zsa examined 891 spontaneously ruptured tendons histologically and found that 864 &#40;97&#37;&#41; of them had degenerative changes&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">37</span></a> If there&#39;s degeneration and tendon overload for a prolonged period&#44; the whole tendon can become degenerative and may fail completely&#46;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">38&#44;39</span></a> Avoiding these pathological changes is the main prevention to prevent rupture of the Achilles tendon&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">40&#44;41</span></a> So&#44; in addition to improving the pain and the functional-capacity load tolerance&#44; we must maintain or improve tendon structure to prevent tendon rupture&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">27</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">13&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Mechanical loading seems to induce changes in gross morphology&#44; mechanical properties as well as biochemical parameters of tendon tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a> It appears that both intense and regular exercise raise human collagen synthesis &#40;Langberg et al&#46;&#44; 1999&#44;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">43</span></a> 2000&#44;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">44</span></a> 2001<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">45</span></a>&#59; Miller et al&#46;&#44; 2005<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">46</span></a>&#41;&#44; which suggests that human tendon tissue is more metabolically active in response to activity than what was previously believed&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a> Intense exercise increased the formation of type I collagen during the recovery process&#44; which suggests that intense physical loading leads to some kind of adaptation&#46;<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&#46; Over the first 24&#8211;36<span class="elsevierStyleHsp" style=""></span>h&#44; this response results in a net loss of collagen&#44; but this is followed by a net synthesis 36&#8211;72<span class="elsevierStyleHsp" style=""></span>h after exercise&#46;<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&#44;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a> however the integration of new collagen into the matrix has not been shown&#46; The COOH-terminal propeptide of type I collagen &#40;PICP&#41; is an indicator for collagen type I synthesis&#46; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">48</span></a> In healthy humans&#44; both synthesis and degradation increased after 4 week of physical training&#44; whereas after 11 weeks only the collagen synthesis&#44; and not the collagen degradation&#44; was chronically raised&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a> Both long-term &#40;years&#41; and relatively short-term &#40;months&#41; loading induce tendon hypertrophy&#46; The degree of hypertrophy is rather small and seems to occur only in certain tendon regions&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a> However&#44; this appears to be true only in young people as collagen turnover after the age of 17 years is limited &#40;Heinemeier et al&#46;&#44; 2011&#41;&#46;<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&#46;</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 &#40;Magnusson and Kjaer&#44; 2003<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">49</span></a>&#59; Kongsgaard et al&#46;&#44; 2005<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">50</span></a>&#41;&#44; which indirectly reflects a region-specific hypertrophy in response to long term loading&#44;<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&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">15&#46;</span><p id="par0145" class="elsevierStylePara elsevierViewall">The potential region-specific adaptation to running appears to be far greater in men than in women&#46; The ability of the tendon to adapt to regular loading is attenuated in women&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">16&#46;</span><p id="par0150" class="elsevierStylePara elsevierViewall">A similar increase in collagen synthesis is seen that is independent of exercise volume &#40;repetitions&#41;&#44; which suggests that there is a ceiling effect in collagen synthesis&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">17&#46;</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 &#40;eccentric&#44; isometric or concentric&#41; supports the belief that the collagen protein synthesis response is regulated by fibroblast strain&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">18&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall">With regard to tendon mechanical properties&#44; increased tendon stiffness is generally observed in response to large volumes of loading&#46;<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&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Studies suggest that appropriate loading during rehabilitation of tendinopathy is the most important treatment method&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">19</span></a> Exercise prescription can target matrix reorganization and collagen synthesis&#44; reduce tenocyte activity&#44; affect tendon compliance or have an analgesic effect&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">15</span></a> Each component of the rehabilitation program&#44; in particular loading&#44; must be handled in relation to the nature&#44; speed and magnitude of the forces applied to the muscle&#47;tendon&#47;bone unit in order to achieve the goals of the particular management stage &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; without causing an exacerbation of the pathological state or pain&#46; When planning a rehabilitation strategy&#44; it is crucial to find an approach that addresses the re-education of muscle function instead as considering the tendon as an isolated unit&#46; While early stimulus of the muscle tendon unit is typically focused on isometric muscle activation&#44; which may include muscle stimulation&#44; most programs advocate the progression to higher loads as guided by symptom presentation&#46;<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&#44; adjusting tendon load through faster eccentric work prior to starting skill specific re-education such as landings&#44; before introducing sports specific challenges such as sprinting and cutting&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">19</span></a> Consideration of the cortical effects of exercise on the motor cortex are critical&#46;</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&#46; 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&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Removing the cause of reactive or reactive on degenerative tendinopathy &#40;usually unaccustomed load&#41;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2&#46;</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&#46;</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&#46;</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&#46;</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&#47;or mechanical properties of the tendon</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">6&#46;</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&#46;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Load management &#40;reductions&#41; removes the cause of reactive or reactive on degenerative tendinopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">23</span></a> Assessment and modification of the intensity&#44; duration&#44; frequency and type of load is the key clinical intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">23</span></a> Intensity seems to be the most important feature&#59; therefore this is the first factor we should modify by removing intensity peaks &#40;i&#46;e&#46; sprinting&#44; sets&#44; Fartlek&#44; fast changes of direction&#44; explosive jumping&#41;&#46; Frequency is a very flexible value that we can use to adapt the load &#40;more or less resting hours between workouts depending on the pain level of the next day&#41;&#46; Volume seems to be the less aggressive