In my last article, I explained how to find a client's Single Leg Squat Load Tolerance - the maximum amount of force that the person can generate without form failure or symptoms. This article explains how to use that information in designing a program for someone with patellar tendonosis by blending Pathology, Load Tolerance, and Staging.
Let's assume that our 44 year old, male weighs 180 lbs. The tests results indicate that his Single Leg Squat Load Tolerance is equal to the force produced by his body weight at Level 6 position on the Total Gym. The angle of Level 6 on the Total Gym produces ( ) % of body weight force for a person of 180 lbs. This is the maximum amount of force for the symptomatic limb.
In most cases, the test will stop due to pain. Let's assume that this is the case in our 44 year old guy. To determine the dosage (the intensity, frequency and duration) for the drills, we need to know one more thing: severity of the symptoms.
Nirschl
developed a staging system for tendonosis that categorizes the severity
of symptoms and functional impairment. He then prescribes exercise
based on the stage.
Stage 0: No pain or soreness
Stage 1: Stiffness or mild soreness after exercise activity. Pain is usually gone in 24 hours.
Stage 2: Mild stiffness and soreness before activity which
disappears with warm up. No pain during activity, but mild soreness
after activity that disappears within 24 hours.
Stage 3: Same as above with mild pain during activity which does
not alter activity, disappearing in 24-48 hours. Counter-force bracing
may be considered here as well as mild anti-inflammatory medication.
Stage 4: Mild to moderate pain before, during, and after
exercise which alters the exercise or activity. ADLs are affected.
Phase 4 is indicative of some level of tendon damage.
Stage 5: Moderate or greater pain before, during, and after
exercise or activity, forcing the patient to discontinue the exercise.
Pain is experienced with ADLs. Usually reflects permanent tendon damage
Stage 6: Phase 5 pain that persists with complete rest. Pain disrupts ADLs, many activities have to be eliminated.
Stage 7: Phase 6 pain with disruption of sleep on a consistent basis. Pain is aching in nature and intensifies with activity.
Phase 5 or greater indicates some degree of tendon damage.
If
the client is a Stage 5 or higher, Nirschl's guidelines are to use
bodyweight resistance and isotonic exercise in a pain-free range of
motion (his original article was for elbow tendonosis). I found this to
be of little help in cases of patellar tendonosis. The motion was too
limited and the loads were too light to produce any significant
improvement. The program consists of 30 repetitions that the client can
perform pain free. This is done daily. Once the client can perform 30
repetitions, on two consecutive days, the load is reduced but the
stress to the tendon is increased by altering either the range of
motion or reducing the mechanical advantage of the muscles. This
process continues until the client reaches a Stage 4 then the frequency
is reduced to three times per week.
The physiologic basis for this approach, according to Nirschl is "to promote a vascular response and increase endurance". However, my understanding from experimental research suggested that one set of 30 repetitions was not enough stimulation for a more avascular tissue like tendon.
Experimental models suggested much higher dosage - in the hundreds of repetitions. For example, one study, using a rat model, found that swimming counteracted the effects of aging and increased the tendon strength better than muscle strength training. The authors concluded that endurance training had an impact on tendon strength but that muscle strength training had little. If this is true, and considering that the number of repetitions in swimming is far beyond 20 or 30, how can you perform hundreds of squats without overloading the tissue and making the client much worse?
You have to alter the training environment. To alter the tendon, you need a high volume of training. This is where the Total Gym comes in. Let's go back to our scenario of the client who has a Load Tolerance of 70 lbs. Let's assume he's a Stage 5 on the Nirschl Scale (Moderate or greater pain before, during, and after exercise or activity, forcing the patient to discontinue the exercise. Pain is experienced with ADLs. Usually reflects permanent tendon damage). We know that at 70 lbs., the tissue is not yet overloaded but if we asked him to perform 50 or 60 or 70 repetitions, he likely would be.
At Stage 5 or higher, we're aiming for 300 to 500 hundred repetitions per session. Let's assume he can perform squats at a pace of about 20 per minute. That's 15 to 25 minutes of squats! Of course, we wouldn't ask him to perform all of the squats at once but it gives you the idea of the volume.
If we're asking him to perform, for example 5 minutes of squats, how much load should we use? Well, 70 lbs. will be too much; that's his maximum. You could use a bilateral squat which would then cut the load in half (35 lbs on each leg). That might work. But, we also need a little fatigue. We need to know that the muscle tugged on the tendon enough and the only way to know that is to achieve a certain level of fatigue. You could use a scale, 0-10 where 10 is extreme fatigue, and aim for 5/10 fatigue at the end of the set.
So, you could start at Level 6 on the Total Gym, bilateral squats, to no more than 90 degrees of motion, five minutes and assess the fatigue both during and after the set. You want to check during the set because sometimes the client, because he is not used to performing squats, will fatigue rapidly. I've had clients, like our example client, reach a 5 or 6 level of fatigue in under two minutes. Watch the pattern of motion - make sure it's well controlled - and inquire about fatigue. I ask,"What is your fatigue level? What number?" Rather than, "Are you fatigued?" Remember the volume: 500 squats at 35 lbs of load is 17,500 lbs of total force.
This process takes a session or two to find the right dosage. Once you have it, some clients will change stages on you faster than you might think. You have to adjust the training to match the stage for maximal progression. This is probably a common mistake - failure to "edge" clients as they move through the stages.
This leads into other areas of the session that I call "coaching". This is about how to get the information you need without being obvious, how to help people make decisions instead of you making them, etc. Staging has a large "subjective" component (which, by the way is not less valuable than things you measure but I digress) and to figure out what stage the client is in, you have to know how they feel. You need to know what the injury is doing to them and how they are reacting to it. For example, the difference between Stage 4 and 5 is mostly the severity of pain and the degree of impact on activities of daily living.There's only one way to find that out. You have to talk. What you say and how you say it is coaching.
Once you reach Stage 4, the program shifts. It moves away from the higher volume and lower loads to higher loads, speeds, and greater motion with fewer repetitions. I'll go over that next time.
And, of course, there are other elements to a comprehensive program including biomechanics, understanding segment links (like how the hip and ankle move, etc) and coaching. But, for now, all I'm focusing on is tissue healing.
If you know the Pathology (tendonosis), Load Tolerance (e.g. 70 lbs) and the Stage (e.g Stage 5), the program design is much easier. Try going through this case without any of this information and then pay attention to how confident (or not) you feel about your plan. I think you'll find that this combination of information makes a significant difference for you.
And, before I get emails about what to do if you don't have the tools, my answer is always the same. Good luck. I quit trying to "make do" a long time ago. But, that's another story. Tools are key. Remember, you have to match the environment to the person and that's what tools do for you.
DK
ref: (Simonsen, E., H. Klitgaard, et al. (1995). "The influence
of strength training, swim training and ageing on the Achilles tendon
and m. soleus of the rat." J Sports Sci 13(4): 291-5.
