Managing tendinopathy in rugby – Part 2

In this article we focus on the common issue of sub-acute or chronic patella tendinopathy in rugby union and rugby sevens athletes.

Following on from our article on managing acute tendinopathy, we discuss the next phase of tendinopathy management in part 2. Longer lasting (sub-acute or chronic) tendinopathy is likely to result in significantly reduced strength and function of the musculo-tendinous unit.

Reversing this decline is essential for the long term health and function of the tendon. In this article we provide two strengthening techniques, both of which follow a similar theme of gradually increasing load while carefully managing pain…

Eccentric Loading

Professor Håkan Alfredson is the godfather of the eccentric loading regime for musculo-tendinous strengthening. This program begins with body weight only, gradually progressing through to heavier loads (10-15RM) as pain and progression allows.

From Alfredson’s work we recommend choosing one of the following eccentric strengthening exercises to be completed every day:

i) Non-Weighted Single Leg Squat – 3 sets x 15 reps each leg

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ii) Weighted SL Squat – 3 sets x 15 reps each leg

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iii) Weighted SL Leg Press – 3 sets x 15 reps each leg

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Heavy Slow Resistance Training

Heavy Slow Resistance training (HSR) has become a very popular rehab option among sports medicine practitioners. In contrast to the every day prescription of eccentric loading, HSR is completed only 2-3 times per week. HSR involves using much heavier weight, building to  70-85%of 1RM at a slower tempo.

‘HSR’ Patella Tendon Program

This program is likely to appeal to those who are accustomed to resistance training, as it can be incorporated into your regular weights training program. This program involves three sessions per week with three key exercises. You should complete four sets of each exercise with 2 minutes rest between sets.  The program lasts a total of 12 weeks.  The number of repetitions are outlined below:

  • 15 repetitions maximum (RM) during week one
  • 12 RM weeks 2-3
  • 10 RM weeks 4-5
  • 8 RM weeks 6-8
  • 6 RM weeks 9-12

During each exercise you should not go below 90 degrees of knee flexion at any time, to avoid compressive loading.  It is also suggested that you count 3 seconds for both the lower (eccentric) and raise (concentric) phase of each exercise.  This means that each individual repetition will take a total of six seconds.

Considering recent research we recommend incorporating one of the following HSR strengthening exercises into your training – to be completed 3x per week:

i) Back Squat – 4 sets x 6-15 reps 

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ii) Hack Squat – 4 sets x 6-15 reps

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iii) Leg Press – 4 sets x 6-15 reps

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It is imperative that when using the HSR training approach, that the prescribed frequency of rehab is followed. The graph below demonstrates that the fine balance between protein synthesis (building muscle / tendon) and protein degradation (breaking down muscle / tendon) must be respected. Optimising the time when you next perform the HSR drills is crucial, to allow for a net gain in protein synthesis (strengthening of the musculo-tendinous unit). This is the reason a prescription of HSR training every 2-3 days is given… to ensure the athlete achieve the 48-72hr recovery time frame required.


Magnusson et al (2010) Protein Synthesis
Protein Synthesis & Degredation – Magnusson et al. (2010)

In summary…

When embarking on a rehab plan for tendinopathy you must be patient! Sadly, there is no miracle cure or quick fix!! Genuine improvements in muscle strength take approximately 6-8 weeks and tendon remodelling takes at least 12 weeks to adapt to a loading programme.

Our take home message is to gradually increase the load on the musculo-tendinous unit, whilst managing the pain accordingly. There is no quick fix, so you must be patient and work to a strict regime. We also stress that tendinopathy is a very complex condition. So if you do have a persistent tendinopathy, we highly recommend seeing a Chartered Physiotherapist or a Sports and Exercise Medicine Physician for further advice and treatment specific to your needs.

Keep your eyes peeled for part 3 where we will introduce our mobility exercises to complement the strength programs for the management and prevention of patella tendinopathy…



Dan Jones


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