Clinical practice is as much about always learning new things as it is about treating and curing our patients. When I look back to my early years in the NHS, when I had my first MSK clinics, I could cringe! Everything was Root based; if patients had a specific foot type, then they “must” have a problem…… and anything beyond a calf stretch was strictly for the Physiotherapists! As I’ve mentioned in previous blogs, I’ve been very fortunate and worked alongside some excellent Physios in private practice, so leaving exercises to Physios has just been the way I’ve always worked….. But is that good enough?

Well no, I guess not! At the end of the day, we pride ourselves on being lower limb “Specialists” so maybe we should think about prescribing exercises as well as orthoses…. after all…. the likelihood is that they will help with our treatment outcomes.

For me, what really changed my mindset on all this was listening to top Physio, Peter Malliaras, speak at Biomechanics Summer School earlier this year, and then again through his webinar a few weeks ago. I think I’d always been put off by talk of intrinsics and extrinsics, and in all honesty, I didn’t want to get it wrong! But listening to Peter’s research made me realise that a lot of the time, it’s more about loading and being aware of your patient’s individual pain threshold.

With particular reference to tendonosis, be it the Achilles, peroneals, tibialis posterior…etc…, recent research has shown that up to 45% of tendonosis patients don’t respond to eccentric muscle strengthening alone (Malliaras et al., 2013).  This is probably because it only concentrates on the eccentric portion of movement, so effectively you’re only strengthening half of the leg function…. In essence, it’s not a natural or real movement.

Exercise programs which incorporate eccentric, concentric and fast loading are thought to be better because they are more reflective of the way in which the leg naturally moves. The “Silbernagel-combined loading program” is certainly worth looking up if you want tips on loading programmes and evidence has suggested that this approach has better outcomes compared to eccentric-concentric calf raises and stretching alone (Silbernagel et al., 2001). One of the reasons for this could be the simple fact that it is a gradual build-up of load which patients would generally tolerate better. Pain, or pain reduction, also acts as a fairly reliable outcome measure; Cook and Purdam (2009) found that treatment outcomes tended to be more effective if pain levels and response to load were considered in the management of tendinopathy.

There is a whole wealth of research out there about tendons, exercises and rehab…. from simple loading programmes right through to the workings of a tendon at a cellular level. All of this can be a bit of a minefield especially when conflicting evidence arises. Pile that in with a busy caseload and it’s no wonder that the average clinician just carries on the way they always have (especially if it works for them!) But the truth is there are a few simple facts which make it a little less scary to start prescribing exercises –

  1. Tendinopathy is unlikely to just go away with rest alone. It’s also unlikely to resolve in the long term with treatments such as massage, ultrasound, injections and shock-wave therapy (in other words, treatments which don’t involve exercise).
  2. Exercise is the most evidence-based treatment (even if the finer details are debated in the literature). However, it is a slow process in terms of your patient getting better.
  3. Different patients have different “Pain Thresholds” (Peter’s term, not mine). Getting your patient on board with what you want to achieve cannot be underestimated! Education, reassurance and setting expectations are just as important as the actual treatments you prescribe.


If you’re reading this blog, the likelihood is that you already prescribe orthoses to your patients to offload whichever structure is painful, but what about rehabbing that structure back to its optimum function? When you look at it like that, prescribing exercises are just as important as prescribing orthoses and in my opinion, these treatments can only complement each other.



  1. Cook, J., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine, 43(6), 409-416.
  2. Malliaras, P., Barton, C. J., Reeves, N. D., & Langberg, H. (2013). Achilles and patellar tendinopathy loading programmes. Sports Medicine, 43(4), 267-286.
  3. Silbernagel, K. G., Thomee, R., Thomee, P., & Karlsson, J. (2001). Eccentric overload training for patients with chronic Achilles tendon pain–a randomised controlled study with reliability testing of the evaluation methods. Scandinavian journal of medicine & science in sports, 11(4), 197-206.