To start the discussion on the assessment and management of lower limb tendinopathy, Dr Malliaras identified the poor correlation between tendinopathy pain and imaging, and tendinopathy pain and altering biomechanics of the body. He also highlighted the key to exercise is high load and slow movement. The actual type of contraction is less important. In the past eccentric training formed the foundation of any tendon rehabilitation program.

To summarise his approach, he cared less about imaging tendons, choosing specific exercises or stretching. His mantra is Pain and Function. This means assess the Pain and focus on Function. If pain is less than 3/10 and does not last for 24 hours, continue to exercise. If the assessment shows symptoms greater than these parameters, switch to Load management. Load management means reduce the load on the tendon until it settles e.g. change the cadence and stride length of walking and reduce the number of steps in a day. He does support the use of NSAID and ice at this stage. I think more for pain relief than anything else.

If pain allows, isometric training is started. When Load testing shows an increase in load tolerance, isotonic training and high load and slow movement training begins. Running and sport can start as long as the parameters discussed earlier are adhered to.

The types of loads to be achieved with his slow exercises are very high e.g. Leg press >1-1.5 x body weight, soleus strengthening >1-1.5x body weight, and leg extension 40-60kg. These are all single leg exercises and performed with a tempo of 3-0-3 seconds.

The total time to treat these types of conditions can range from months to years. Trying to eradicate the pain in weeks is not a realistic timeframe. If the pain does not react to mechanical forces as normally expected, we can propose a centralised mediated pain response now exists. The pain these tendinpathies will often present with eg. morning pain in the Achilles, sitting pain in the hamstring, night pain for Gluteal or stair climbing pain with patella, can stay present long into the rehabilitation process, and often will be the last symptoms to change. Having 3/10 pain is permissible, instead focus on progressing strength training.

Returning to sport is much more demanding and will require fast and high load training. Dr Malliaras has a variable hop program, which is performed once per week, along with sports training. There is also high loads with exercises such as the split lunge, step up and leg press. Also sprint drills with split jumps and kettle bell swings. The principle is to progressively load the tendon and expose it to similar forces it would get with sport. He is an advocate of testing global strength through the lower limb and has his specific kinetic chain tests.

The evidence supporting the use of steroid injections, PRP and Shock wave therapy are weak. It is clear exercise therapy, in the manner described above, is the mainstay of treatment, and Dr Malliaras has presented an excellent evidence based course.

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