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Squatting With Patellar Tendinopathy
Squatting With Patellar Tendinopathy
This article is going to start from the ground up, going over tendon
structure, function, and adaptive capacity, as well as theories of pathology,
rehabilitation principles, and ways to maintain a training stimulus while
addressing the problem. While I obviously think this is important to gain
insight into the “whys” behind the process, I acknowledge not everyone
wants to go back to physiology 101. Feel free to skip ahead to the practical
recommendations if you want; I did my best to make it a self-contained
section. If you’re feeling particularly rushed, you can even jump straight to
the summary below and use the remainder of the article as a reference (no
judgment).
Source: http://jbjs.org/content/87/1/187
Interestingly, the mechanical behavior of a tendon is dependent upon the
type of stress applied (4, 5, 40). When exposed to stresses, their ability to
stretch and recoil serves a protective role for the attaching musculature,
allowing for the delay and reduction of total force (5). Previous studies have
demonstrated that under most conditions, stretching of the tendon is out of
phase with the adjoining muscle fibers. During eccentric contractions,
lengthening of the muscle-tendon unit (MTU) is initially accommodated for
almost exclusively by the tendon while the muscle fibers remain the same
length (or even shorten). Subsequently, the tendon then recoils as it releases
the absorbed energy to skeletal muscle, causing elongation of the contractile
fibers. Importantly, the rate at which energy is stored in the tendon is
significantly greater than the rate of energy release to the muscle – sparing
musculature from high power stressors while prolonging the muscle’s
ability to maintain optimal length-tension relationships required for force
expression or dissipation.
Additionally, these dynamics change based upon the intensity and rate of
the applied load due to a tendon’s viscoelastic characteristics. Like viscous
materials, tendons display time-dependent mechanical characteristics in
which they become stiffer as the rate of loading increases. This enables the
tendon to tolerate a wide bandwidth of velocities with relatively small
changes in length between conditions. Like elastic structures, tendons also
display time-independent characteristics in which the intensity of the stress
drives length changes regardless of the application rate, allowing for greater
muscular power (and subsequent movement economy) upon recoil. These
two seemingly distinct qualities are present within the same structure in
varying proportions based upon the specific task constraints. During the
early eccentric contraction, fluid is forcefully pushed out of the tendon,
resulting in high viscous resistance. Constant tension (and tissue
compression) does not allow for the return of fluid prior to concentric
muscular action, leaving the elastic qualities of the tendon to predominate
during the concentric phase (4, 40). In totality, this introduces the complex
behavior tendons display. Their adaptability is vital to our success as a
species, as the ability to buffer stressors of varying magnitude and rate
allow for amazing variability in human movement without major adverse
responses (4, 5, 6, 40).
The primary focus of this article is going to be the patellar tendon, due to its
propensity for injury within the sport of powerlifting. The patellar tendon
attaches to the inferior pole of the patella (knee cap) and the tibial
tuberosity (bony protrusion at the top of your shin). Although the majority
of the patellar tendon fibers do not directly attach to the quadriceps
musculature, they act functionally as a tendon in conjunction with the
quadriceps tendon. In this role, the patellar tendon serves to facilitate action
of the knee extensors to allow for optimal pull on the tibia during dynamic
movement (7).
Source: https://en.wikipedia.org/wiki/Patellar_ligament#/media/File:Gray345.png
Scientists estimate that the patellar tendon can
withstand between 10,000 to 15,000 N of force, which
equates to approximately 13-19x body weight for an
80-kg individual (8). To provide context, Nisell and
Ekholm conducted a study where they mathematically
estimated patellar tendon loads during the barbell
squat (250 kg squat performed by a 110 kg lifter). They
demonstrated peak forces only reached 6,000 N – far
below the expected failure threshold (9).
Not all tendons serve the same functional role. Tendons are classified into
two distinct categories: positional tendons, which act to predominantly
position limbs, or energy-storing tendons, which act more as springs to
allow for more efficient movement. The patellar tendon is an energy-storing
tendon due to its specific functional role and altered physiological
properties. In order to effectively store and return energy efficiently, the
patellar tendon has higher elastin content, lower absolute levels of collagen,
and a higher relative proportion of Type III collagen versus Type I (Type III
has lower stiffness, allowing for improved extensibility and recoil) when
compared to positional tendons (2). Additionally, energy-storing tendons
display significantly lower levels of collagen turnover, resulting in a half-life
of approximately 200 years (important concept for rehabilitation purposes
to be discussed later).
Adaptability:
Now that some background information has been presented, we can get to
the important part: if and how we can alter the physical properties of
tendons. Central to this premise is the concept of
mechanotransduction. Mechanotransduction, by definition, is the
mechanism by which cells convert mechanical stimuli into cellular
responses (10). Cells are sensitive to forces such as shear, tension, and
compression, and they respond accordingly through cellular proliferation,
migration, tissue repair, altered metabolism, and even stem cell
differentiation and maturation (10). Thus, in essence, stress is the language
our cells speak, serving to stimulate both positive and negative change.
Tendon cells are no exception, sensing and responding to stressors in their
surrounding environment. Load is a primary stressor which our tendons
detect and functions as a vehicle to drive rehabilitative efforts.
The inner portion of a tendon is formed during years of peak growth (during
time of puberty) and is essentially not renewed thereafter. Therefore, when
exposed to sufficient load, the subsequent changes observed in tendon
structure are almost exclusive to the outer periphery of tendons (13).
Source: Kjaer M, Bayer ML, Eliasson P, Heinemeier KM. What is the impact of
inflammation on the critical interplay between mechanical signaling and biochemical
changes in tendon matrix?. J Appl Physiol. 2013;115(6):879-83
The non-homogenous response to loading contributes to a lower absolute
ceiling of adaptability in tendons when compared to musculature.
Additionally, in the metabolically active segments of tendons, the tissues
also display lower relative adaptive capacity than skeletal muscle due in part
to oxygen consumption levels calculated to be approximately 7.5x lower
(15). This may paint a bleak picture for our ability to modify tendon
structure an appreciable amount, but several recent systematic reviews
demonstrate meaningful effects of loading on tendon structure. Primarily,
three key features of tendons have been studied in response to acute and
chronic loading: tendon mechanical (stiffness), material (Young’s Modulus),
and morphological (cross-sectional area, level of molecular cross-linking)
properties (11,12). Stiffness refers to the ability to resist deformation, and
Young’s modulus refers to stiffness when tendon dimensions are taken into
account (12). Alterations in material properties are believed to be the acute
response to tendon loading, with significant increases noted within the first
several months of training (increased stiffness reportedly ranging from 26%
to 85%), and changes in morphological qualities are believed to be the
chronic adaptation after years of training (increased cross-sectional area
reportedly ranging from 1.5% to 36%) (12).
Tendinopathy
Classically, tendon pathologies were separated into two discrete conditions
referred to as tendinitis and tendinosis. Both were considered “overuse”
injuries with the former representing an acute, inflammatory condition and
the latter representing a degenerative condition. Inflammation’s role in the
disorder has been questioned recently, with evidence suggesting that while
there are an increased number of inflammatory cells present in pathological
tendons, the response observed is not in line with a traditional
inflammatory response and the presence of inflammatory markers does not
necessarily support inflammation as the primary event or key driver of
tendon pathology (16, 17). This revelation, in conjunction with the totality of
evidence, led away from the belief that these conditions are mutually
exclusive. Therefore, the more generic term “tendinopathy” is preferred over
the aforementioned terminology.
Dr. Jill Cook, a leading researcher in the field, proposed that tendinitis and
tendinosis are different aspects of the same complex continuum and has
organized tendinopathy into three distinct phases: 1) reactive tendinopathy,
2) tendon dysrepair, and 3) degenerative tendinopathy (16, 20). A reactive
tendinopathy is believed to be an acute, reversible process brought about by
a rapid increase in mechanical loading. The tendon swells due to an increase
in water retention and is proposed to be a protective response to reduce
stress along involved collagen fibers (20, 21). Tendon dysrepair is suggested
to follow if loading exceeds tendon capacity for a substantial period of time.
Here, we continue to see increased fiber diameter, but the tendon matrix
begins to breakdown and there is evidence of neural and vascular ingrowth.
Finally, a tendon reaches a degenerative state, characterized by further
collagen disorganization, advanced matrix breakdown, and increased fiber
thickness.
Source
In clinical findings, the hallmark features of patellar tendinopathy across all
three stages include pain localized to the inferior pole of the patella and
load related pain that increases with the demand on the knee extensors. To
differentiate a tendon disorder from other sources of similar symptoms, it
should be noted that there is rarely pain in resting states and we typically
see a dose-dependency of pain, with increased intensity or rate of loading
associated with increased reports of pain (18). Again, I am not condoning
self-diagnosis of the disorder. If your condition aligns with these symptoms,
or there is any pain beyond normal aches associated with training, I would
seek a medical provider.
Practical Implications
Tendon Rehab
Training Considerations:
Each of the upcoming variables impact total stress upon the involved
tendon in varying capacities. Finding the right balance while ensuring you
are addressing qualities you wish to develop is a difficult process. The best I
can offer is education on several factors believed to be important. I will
leave the nuts and bolts of programming up to you on an individual basis.
Training Volume
The stress applied to tendons is not isolated within the four walls of the
gym and this concept demands particular consideration for tendons of the
lower body, such as the patellar tendon, which are required for locomotion.
Stresses associated with daily demands typically represent a small absolute
value of our tendon’s capacity. However, in pathological tendons, these
same stressors represent a significantly higher relative percentage of that
capacity and may have a critical impact upon your ability to train. The daily
fluctuation in additional load is hard to quantify and account for, rendering
it difficult to walk the fine line of your MRV within session. Additionally, the
magnitude of difference in adaptations observed between performing the
MRV and those seen using a more conservative volume is speculatively not
large enough to overcome the detriment of overshooting your tendon’s
current capabilities.
Note the
different biomechanical positions of the knee at the bottom of each squat variation.
Photo from: http://www.thebarbellphysio.com/squat-assessment-checklist/
Great resource for clinicians working with athletic populations.
In conjunction with modifying your squat selection, the benefit of
accommodating resistance should be intuitive. The ability to progressively
load the squat as you rise from the bottom position can be useful to
maximize the training effect without excessively loading tendons in their
most susceptible position. It should be noted that bands and chains are not
equal in this respect. When controlling for other variables (such as intensity
and velocity), it has been demonstrated that forces on the patellar tendon
during the eccentric portion of a squat are 15-35% greater than the
concentric (8). Thus, using a traditional band-resisted setup may be
counterproductive because this accentuates the downward pull during the
lowering phase. Chains or a reverse-band configuration are probably the
superior option here for altering the resistance throughout the
movement.
Finally, it is commonly hypothesized that solely performing compound
movements may not adequately stress the involved tendon due to conscious
or subconscious compensatory strategies (18). This may be as blatant as a
deviated movement pattern to shield sensitized tissues or could be as
insidious as the neural protective adaptations outlined above. Therefore, it
is probably best to include some form of isolated leg extension towards
the end of your training session to ensure adequate loading of the
involved musculotendinous unit. Be sure to account for this when
determining your appropriate training volume
Training Intensity
Training Velocity
Speculatively, high loading rates have also commonly been viewed as a risk
factor for tendon damage and have been proposed to be an important
modifiable variable to consider when performing resistance training (7, 8,
18). Fortunately, Earp et al. conducted a study using barbell back squats to
gain insight on tendon dynamics (and subsequent stress) when velocity
demands are changed. They had participants perform back squats using 60%
1RM either using a deliberate tempo (2 s eccentric, 1 s pause, 2 s
concentric), a self-selected pace without a pause, or perform a maximum-
speed jump squat. Viscous qualities of the tendon unit allowed for very little
difference in tendon lengthening early in the eccentric contraction despite
large fluctuations in speed. However, rate of tendon loading was greater in
the high-velocity conditions during this period – leading to greater force
through the tendon during the late eccentric phase and early concentric
phase comparatively (40). This knee angle, as noted above, is the most
mechanically vulnerable position for the tendon and high levels of stress
within this specific posture pose a substantial concern for overloading a
pathological tendon. Based on this knowledge, it may initially seem
appealing to remove all high-velocity training from your program. However;
this should come as a tough pill to swallow, considering recent
evidence suggests training at your maximum velocity is a valuable stimulus
for improved muscular strength and hypertrophy. Luckily, a closer look
provides room for optimism.