a close-up of a person wearing black shorts and a red sock gripping the front of their upper thigh with one hand, standing next to a metal fence by water.

Dr Jon Houghton – Tendon Injuries – Injury Rehab Network

The second of two Injury Rehab Network events in June with BASRaT featured a presentation from Dr Jon Houghton, Consultant in Sports Medicine and Rheumatology, Fortius Clinic. The online event took place on the evening of Wednesday 18th June with 270 sports rehabilitation practitioners in attendance.

Dr Houghton discussed Tendon Injuries. The recording is available to watch here.

Dr Jon Houghton, Consultant in Sports Medicine and Rheumatology, Fortius Clinic

Dr Jon Houghton is one of the UK’s most senior and respected figures in Sport and Exercise Medicine and Rheumatology. He has extensive elite sport experience and regularly consults for multiple Premiership teams, the ECB, RFU, the UK Sports Institute and Olympic athletes. He treats elite athletes, city workers, weekend participants, adolescent sports injuries, and those in middle and later life aiming to remain active.

He worked at the Defence Medical Rehabilitation Centre Headley Court for eight years, running the lower limb rehab unit before moving into full-time sports and private practice, initially at London Bridge Hospital and then joining Fortius Clinic in 2016, where he leads the elite sport service.

His specialist interests include tendon pathology, bone stress injuries, hip and groin pain, and inflammatory arthritis. In 2017, he initiated a complex lower limb tendon clinic alongside Mr Jarrod Antflick and the surgical team at Fortius Clinic, which regularly treats national and international athletes. He also leads an elite bone stress clinic utilising the latest imaging and medical therapies.

His broader clinical experience covers upper and lower limb overuse and running injuries, Pars fracture, adolescent overuse injuries, exercise-induced leg pain, and injury rehabilitation. His rheumatology work includes bone stress, gout, and inflammatory spinal and joint conditions, particularly in young or athletic individuals.

Dr Houghton has worked for the Football Association of Wales since 2010 and as Chief Medical Officer since 2013, including during Euro 2016, Euro 2020, and the 2022 World Cup. He has been Lead Doctor for Surrey County Cricket Club since 2015, including Championship wins in 2018, 2022 and 2023, and served as team doctor for the Oval Invincibles Hundred Tournament champions in 2021, 2022 and 2023.

Tendon Injuries

athlete holding lower limb injury

The speaker discussed the management of Achilles and patellar tendinopathy in elite athletes. He introduced the team he works with at the Fortius Tendon Clinic, including Jarrod Antflick, Mr Sam Church, Prof. James Calder, Mr Sanjay Anand, and Mr Ioan Tudor.

He explained how learning from elite sport is transferable to the general population and helps advance practice across all levels.

The session covered how difficult or high-demand tendon cases benefit from a multidisciplinary team (MDT) approach. Topics included risk factors, imaging, loading, case studies, and surgical options.

He emphasised that Achilles tendinopathy is not uniform and encouraged practitioners to consider:

Insertional vs mid-portion
Inflammatory vs mechanical
Overload vs metabolic
Athletic vs sedentary

The structure of the Fortius Clinic team was outlined, including consultants in sport and exercise medicine, rheumatology, and physiotherapy. The team takes a structured approach and uses advanced imaging. Advice is provided on loading strategies, return to play, and access to interventions, with surgical support also available.

Achilles Differentials

Thirteen differential diagnoses were considered about Achilles injuries. A broader historical view was encouraged, including factors such as training load, volume, intensity, and whether there was a specific moment of injury. Differential diagnoses may relate to conditions such as psoriasis, colitis or iritis, and family history should be considered.

Metabolic factors are increasingly relevant with greater participation across age groups and increased awareness of the benefits of physical activity. Other considerations include hypercholesterolaemia, hyperuricaemia, diabetes, menopause, and exposure to fluoroquinolones. Dr Houghton carries out inflammatory/metabolic screening to aid diagnosis.

Imaging Techniques – Ultrasound

UTC (Ultrasound Tissue Characterisation) imaging is used to assess Achilles injuries. The probe travels along a tracker collecting transverse images every 0.2mm over 12cm at a consistent speed. The probe is fixed within the tracker to standardise depth, gain settings, and transducer angle/tilt.

UTC enables assessment of tendon tissue health and is used for diagnosis, load management, surgical planning, and visual communication with patients.

Tendon Loading: The Basic Premise

a person squatting outdoors with a purple exercise resistance band looped around their thighs above the knees, wearing grey trainers and black shorts with orange accents.

Referencing research by Kjaer et al. (2009), the speaker explained how tendon loading promotes collagen synthesis. Rehabilitation should include heavy and slow resistance exercises, avoiding early compression-based loading. Suggested exercises include leg press, squat, and hack squat.

Case Studies

Three athlete case studies were presented.

24-year-old international footballer: Experienced calf tightness and tendon thickening, with increased lateral calf stiffness over 10 days. Substituted 38 minutes into a game. Management included PRGF injections, immobilisation boot for 10 days, then a progressive resistance programme. The player returned to full training after eight weeks.
29-year-old international rugby forward: Presented with six weeks of mid-portion Achilles pain and morning stiffness. UTC imaging identified medially located pain with plantaris effect. Managed with triple therapy (Etoricoxib, Doxycycline, Omega 3), Ostenil Plus injection, and a heavy, slow-loading programme.
Professional European Tour/LIV golfer: Reported three months of Achilles pain. Treatment involved high-dose NSAIDs (8 weeks), Doxycycline (4 weeks), and Voltarol plasters. Progressed from medium to heavy slow resistance exercises.

Achilles Tendinopathy – Plantaris Release

Surgical techniques by Prof. James Calder were discussed, including non-insertional debridement. Plantaris friction syndrome is identified as a clinical issue in some athletes, with surgical treatment involving mini-open excision and release of ventral adhesions.

What about the Patella Tendon?

Patellar tendon injuries often show slow improvement. PRP/PRGF injections may offer limited benefit, and surgical recovery can be prolonged. One issue surgeons face is the limited research available compared with ACL surgery. However, arthroscopic minimally invasive guided debridement has been shown to improve pain, function and structure.

Summary and Reflections

Advice shared at the end of the session included:

High-demand tendon issues benefit from an MDT approach
Maintain a broad differential diagnosis – don’t overlook rare causes
UTC offers valuable insights
Loading is the core of effective treatment
Surgical options may be necessary
Elite athlete data can help inform wider practice
Exercise prescription takes time

Acknowledgements

Thanks were extended to colleagues at the lower limb tendon clinic, including James Calder, Jarrod Antflick, Sam Church, Sanjay Anand, and Ioan Tudor-Jones.

Further Information

Find more about Dr Jon Houghton at the Fortius Clinic Website.

Q&A

Jon kindly answered questions put forward by practitioners who attended the session. You can see the presentation recording here.

Presentation Recording

The recording of Jon’s presentation is available to watch here.

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