In our team meeting last week we discussed a case of patella tendon pain that was being stubborn to the conventional approach to tendon management. But before you say it out loud, what is conventional management of tendon pain?
And I guess that is what got us talking about the nuances of tendon function, the individual profile of the patient that we were discussing and the prospect of how we were going to look to address the issue with this patient. This patient is an elite level weightlifter with a history of degenerative patella tendon pain, particularly when catching in the deep reception positions of the lifts (knee heavily flexed). The thing that made this interesting from a presentation point of view was that the position itself was not painful. Full deep and heavy squatting did not bring on the pain and neither did propulsive jumping tasks such as box jumps or counter-movement jumps. It seemed very specific to the catching position synonymous with full depth clean and snatch lifting tasks.
One of our team members had followed a typical pursuit of isometric loading, through range strength tasks and increasing velocity of movement, including jump tasks to elicit tendon loading. And for all intent and purposes it was working. That is to say that this patient was getting better at these tasks, with very little to no pain and was measuring well above the majority of sporting populations. As a side note working with extremely strong and powerful people requires a level of analysis because often they far out strip other patients that you measure despite being a poor measure for them. But alas, each time they returned to a full session of weightlifting at full depth, they started to develop pain throughout the session.
Based on this, we felt that we had to get in the weeds with regards to the management for this patient. We went on a discussion and exploration of some concepts that are discussed but not as regularly as they probably should be with speed power athletes. And that is namely the capacity to absorbed very high eccentric forces at very high velocities. Now I know coaches and medical staff that work in these areas are probably scoffing, knowing that this is where they spend most of their time developing skills and capacities, but typically in tendon pain management, the extent to which this is discussed is less than ideal.
The properties that become extremely important for managing these movements are typically associated with very early Rate of force development features. That is the ability to eccentrically and concentrically produce forces in under 200ms or so. And whilst weightlifting is an extremely explosive sport, the forces produced still typically occur at rates that exceed the 200ms to produce. This means that for this athlete, they have typically never worked on this capability outside the catch position and we hypothesize that their lack of capability here is leading to both compression and force overload of the patella tendon.
So what have we done?
We have shifted some of their rehabilitation and in collaboration with their coach, added in an increase in the speed of eccentric loading, added in high velocity jump and landing tasks that require very high RFD features and looked to gradually expose this athlete to greater depths of knee range whilst doing so.
We are yet to see the fruits of the changes, but the early signs appear to be promising. The biggest thing that we took out of this case was the idea that sometimes when you are dealing with edge cases, you need to get into the weeds, understand the ergonomics of the task and look to develop the specific skill sets that the tissue and system will be exposed to. And I say this completely without judgement, if you are unsure about the biomechanics and nuances of a task, do not be afraid to speak to those who understand it better than yourself, including the athlete and their coach. You will only get better if you truly understand the task.