What is tendon?
Tendon is a type of tissue in the body. Tendons are elastic structures that connect our muscles to the bone. They transfer force from our muscle contractions to create bodily movements. Tendons are made of very resilient and tightly packed collagen fibres that run parallel to each other. Tendons are so tough that it takes an incredible amount of force to rupture a tendon. This tough yet elastic structure allows the tendon to store and release energy and act like a stiff spring to produce explosive movements.
What is tendinopathy?
Before we dive more into tendinopathy, we need to discuss what it means. Tendinopathy refers to the pain and function of a person’s tendon rather than a specific pathology. We should move away from using terms such as tendinosis or tendinitis, which is associated with the inflammatory response, and change our treatment approach. We need to move away from RICE (Rest, Ice, Compression, Elevation). Before we delve into effective tendon rehabilitation, let’s discuss different types of tendon pains, causes and rehabilitation protocols.
The most common cause of tendon pain is overload or overuse. The most common activities that will cause tendinopathy is explosive load using elastic energy in movements such as jumping, change of direction, acceleration, deceleration, sprinting, repetitive fast movements etc. The pain presents once we start to overload and or overuse a tendon above its capacity to tolerate the load.
The most common signs of tendon pain are:
- You can usually point to the pain with one or two fingers
- There may be pain in the morning, but movement reduces the pain
- Isometric exercise at correct load reduces the pain
- At the beginning of the exercise there is pain, but with movement either pain stays the same or reduces. However, the next day pain is worse.
What are the most common tendon pains?
We most commonly see the two lower limb tendinopathies: patella tendon and Achilles tendon. Patella tendon pain is mostly prevalent among young jumping athletes such as basketball and football players. We also see a few explosive strength athletes with lower limb tendinopathy. For example, a powerlifter who needs to explode out of the bottom position during squat training.
Most clients complain about patella tendon pain during explosive movements such as jumping, deceleration and change of direction. In comparison, Achilles tendinopathy is prevalent among all ages, genders and from both the athletic and general populations. Say a sprinter takes a few weeks off from training during off-season where the tendons start to decondition and lose their normal capacity to withstand a sprinter’s training load. However, they return to training with the same amount of load as before their off season will likely present Achilles tendon pain. Another example is an older adult who decides to book a holiday where they will be walking 15-20 km in their brand-new trekking shoes without any training. They might be likely to present with Achilles tendon pain. It is very likely that both of these individuals will develop tendon pain within a week. With the popularity of strength and physique sports we are starting see more biceps and triceps (elbow end) tendinopathy as well. Many strength and physique athletes love fast pulling or pushing movements. In these instances, they may not feel any pain for a while. However, within a couple of years these athletes can develop significant biceps or triceps tendon pain.
What not to do!
Let’s discuss what not to do to for tendinopathy rehabilitation first. The number one rule of tendinopathy rehabilitation is to avoid rest. When it comes to tendinopathy rehab, LOAD IS KING. However, I recommend starting with isometric load where the tendon is under load but without movement. Any tendon with pathology will have a good portion of healthy tendon that needs to be loaded to condition its load capacity. However, we need to be cautious about pain. Pain is your body telling us something about the load it is resisting. The next big thing to avoid is stretching. Stretching has been shown to have no impact on tendon rehabilitation. It can feel good for 15-20 minutes after stretching due to temporary desensitisation of the mechanoceptors (sensors that measure stretch and tension). This does nothing to increase load capacity of the tendon, and once someone returns to the activity that caused the pain in the first place, the pain will return. We always avoid using imaging (MRI, CT etc) and scary language to diagnose tendinopathy. A significant portion of the population can have some kind of tendon pathology present in their MRI or ultrasound but will not have any pain. We always want to treat the person sitting in front of us, not the image. When it comes to tendinopathy rehabilitation, patience is really the true virtue. Allow your tendon to develop its load capacity so it can do what you want it to do. The main thing to remember here is that, any intervention that does not improve your tendon load capacity required for your sport or function, will not help your tendon pain in the long term. The answer is ‘STRENGTH’.
Strength training for tendon rehab.
Not all types of strength training are best for tendon rehabilitation. As Dr. Andrew Lock says, ‘The right exercise for the right person and at the right time’. Isometric exercise is the best approach at the beginning stage of the rehabilitation. Isometric exercise is when a part of our body is resisting against a force without any movement. For example, holding a dumbbell halfway through the biceps curl movement for 15 seconds. Tendons love load, but they hate fast, explosive movement. You can almost immediately start loading a pained tendon with isometric load as part of your rehabilitation. The only exception is a ruptured tendon.
So, what are the protocols of isometric exercise for tendinopathy rehabilitation? The rehabilitation process is guided by a history of the client, where we precisely establish the cause of pain, and the desired function and position of that tendon. The rehab of a 23-year-old male basketball player will look very different to a 42-year-old female marathon runner. When it comes to load selection for isometric exercise, pain is the best indicator. If the pain is less or starts to disappear as the set progresses, then the load is correct. We need to watch the pain for 24 hours. If the next day the pain is less or the same, then we are on the right track. However, if the pain is higher the next day, then we need to either reconsider the load or exercise. Once the isometric exercise has built enough resilience and desensitisation of the pain, we need to introduce slow and heavy resistance exercise with complete pauses at the points of change of direction before we move into the return to sport/life phase. With these exercises we prefer the eccentric phase to be slightly longer than the concentric phase. For example, a lunge squat with 3 counts to the down phase and 2 counts to the up phase. This is where experience and understanding an individual’s goal is very important. We need to select exercise based on function and goal.
Different exercises for different joints.
The most common tendinopathy rehab I have done is patella tendon, and the most common clients are jumping or agility athletes, such as basketball players, different ball players and more recently explosive strength athletes. Leg extension is the best method to isolate the knee joint at the perfect angle. We find somewhere in the middle to outer range of knee extension movement is the best position to load that tendon. We avoid wall sits or leg press machines, because they distribute the load across multiple joints and the load is nowhere near what is needed to build resilience in the patella tendon. If a leg extension is not available, the next best option is a Spanish squat. But it must be done with a belt behind the knees, not a band. We do not want any perturbation to the joint. Load can be added to the Spanish squat just by leaning backwards.
The second most common tendon pain presentation is the Achilles tendon. For this type of tendinopathy, I prefer standing isometric calf raise holds, but both seated and standing slow heavy resistance can be useful. If the pain is closer to the heel, I prefer the ankle joint moving into dorsiflexion but not quite. Meaning your foot is slightly pointing to the ground instead of your shin bone. If the pain is mid Achilles tendon, then we have a bit longer range of angles to play with. I prefer the standing calf raise isometric or slow heavy resistance exercise to be done unilaterally to make sure there is no compensation from the asymptomatic side.
The other common tendinopathy presentations are biceps and triceps. Biceps tendinopathy pain presents during any pulling movement, and triceps during any pushing movement. I find cable machines or bands to be the best tool. Generally, I prefer the joint angle to be more than ninety degrees (the forearm is further away from the arm). But every rule has exceptions. The hand position is very individual, but a common rule is holding the way it hurts. If the pain is most in supine grip, then that’s our hold position.
Rehab protocol.
When it comes to tendinopathy rehab it is very important to precisely identify the cause of pain and the function of the tendon. Isometric exercise will not work if it is not a tendon pain. In some cases, such as elbow bursitis, it will make things worse. Hence, isometric exercise can be a great diagnostic tool to establish tendinopathy.
I have come up with a generalised tendinopathy rehabilitation protocol that you can modify to suit your own needs. This is a general guide only, every rehab should be treated individually.
| Stage | Exercise | Sets/Reps | Duration/frequency |
| 1 | Isometric exercise | 5 sets of 45 seconds at one angle | 2-4 weeks and 2-3 times a day. |
| 2 | Isometric exercise | 5 sets of 10-15 seconds at multiple angles | Can be introduced during week 3 or 4 of stage 1. It will be continuous for maintenance. |
| 3 | Isotonic exercise | 4 sets of 6-8 reps. 2 counts concentric, 3 counts eccentric with a pause at change of direction | Can be introduced during week 3-4 of stage 1 and 2. |
| 4 | Activity specific exercise | Very slow progressive load. The load introduction should be very moderate to trick the tendon to think it is still lifting the same load. | It depends. |
I have not included a return to sport phase. Because it cannot be described in a four-column table. It requires constant monitoring and vigilance from a professional who understands you as an individual, and you are willing to work with regularly to reach your goal.
One last message is to use common sense. What you get out of your tendon will depend on what you invest in it. We need to see beyond the tendon when it comes to rehabilitation. Is there a weakness in the chain that resulted in tendon pain? Was there a movement disfunction? How do we fix that? Otherwise, tendon pain will return.
Remember, strength is the answer. But what type of strength? It depends. Not all strengths are created equal.