(a)

(b)

Figure 3: Scans of a normal Achilles tendon in the transverse plane (a) and the sagittal plane (b). (J. Antflick, Tendon Performance, 2013)

100

90 80 70 60 50 40 30 20

10 0

(a) Distance along tendon (cm) I MTJ Right Left 100

90 80 70 60 50 40 30 20

10 0

(b) I Distance along tendon (cm) MTJ

Figure 4: Graphical presentation of the ultrasound echo-types (indicating tissue health) along the length of typical healthy Achilles tendons from the insertion (I) to the musculotendinous junction (MTJ) of the right (a) and left (b) Achilles tendons.

pain on single-leg heel-raise and single leg hops. This information is used to adjust and modify tendon load to ensure the tensile loading capabilities of the tendon is not exceeded and the tendon remains pain free. This enables athletes, their clinicians and coaches to make informed and effective decisions about the capacity for training and performance. Research has demonstrated that UTC is valid, reliable and is sensitive at detecting a tissue response to load (4,5).

REHABILITATION Complete removal of tendon load is catabolic for a tendon and only very short periods would be advocated in reactive tendons (6). It has been widely accepted that appropriately progressed loads to the tendon will maintain and/or remodel the tendon matrix (7). Over the last ten years there has been significant attention to eccentric exercises with some promising results in tendinopathy. However, the appropriateness for managing in-season tendon pain is questioned when combined with a high training and/or competition load (8,9). Isometric exercise is a useful

28

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Green % Blue % Red % Black %

Right

Left 1.50

2.23

29.35 66.93

Right 0.90 1.73

23.48 73.89

Figure 5: The different echo-types present in the ultrasound image can be quantified and displayed as a bar graph to give a clear representation of the percentages of the healthy and damaged tissues present in the tendon. (J. Antflick, Tendon Performance, 2013).

adjunct for reactive tendon complaints and can be used for pain modulation in-season while still maintaining some load stimulus. Cook & Purdham (10) suggest sustained holds for 40–60 seconds, repeating 4–5 times several times a day. Such exercise is thought to recruit descending inhibitory mechanisms, resulting in mechanical hypoalgesia and increased pressure pain threshold (11,12). UTC is also

being used to monitor the response of the tendon matrix to medications, shockwave therapy and injectables. Watch this space! There is limited evidence to suggest that isolated eccentric programmes offer superior clinical outcomes in comparison to combined loading programmes. The exact mechanisms underpinning clinical improvements seen with rehabilitation

sportEX medicine 2014;61(July):26-30

Percentage

Percentage of echo-types %

Percentage