Infographic: Loading Programs for Patellar and Achilles Tendinopathies


Eccentric Training and Lower Limb Tendinopathy:

  • Athletic overuse injuries of the patellar and Achilles tendons are common
  • Eccentric muscle training is a popular conservative treatment approach
  • Up to 45% of patients do not respond to eccentric-only loading treatment

Common Loading Approaches to Tendinopathy Treatment:

  • Eccentric-concentric, progressing to eccentric-only
  • Eccentric-concentric, heavy slow resistance (HSR)
  • Eccentric-only

Research Questions:

  • What is the quality of the evidence in studies comparing loading programs?
  • What are the non-clinical outcomes associated with clinical outcomes?/span>

Research Methods:

  • 32 studies reviewed
  • 10 studies compared loading programs
  • 28 studies investigated potential mechanisms
  • 6 studies did both


  • There is limited evidence that eccentric-only loading is superior to other loading programs
  • There is equivalent evidence for Silbernagel Combined loading for Achilles treatment, and greater evidence for HSR loading for patellar treatment
  • Improved neuromuscular performance was the only mechanism consistently associated with improved clinical outcomes
  • HSR loading and Silbernagel Combined loading both had equivalent or higher evidence compared to eccentric-only loading

In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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