Client performing a squatting exercise to assist in her recovery.

Exercise for Tendinopathy

What Exercise Should I do for Tendinopathy?

Why rest is always the wrong answer

Most clients who present to me with tendon pain have usually told me a story of “I started training for this event, and I was training really hard, and then my Achilles started hurting! So I rested for a few weeks and it felt better, so I naturally returned to training. Then it just came back again, WTF?!” It’s unfortunately far too common for me to hear this story and is a common pitfall that people fall into when trying to manage a tendinopathy themselves. Rest is almost never, ever the right answer to fixing a tendinopathy. Only in very specific circumstances is a short period of rest advised, even then, we will typically want you loading your tendon to some extent.

My tendon is overloaded, so why am I exercising it more Nathan?

It is correct in saying that typically a tendon is overloaded in most presentations to physiotherapists. The story above is the most common, but there could be other presentations such as doing some home improvements over the weekend and using a hammer a lot and developing symptoms of tennis elbow, or playing a few too many holes of golf and developing golfers elbow, or suddenly adding in hill sprints and developing a hamstring tendinopathy. All of these are loads that the tendon is unprepared for, but that it can perform if adequately built up to that loading.

Because the causative load was too high, the answer has to be that we must develop more load tolerance and strength in the tendon for it to withstand that level of load in the future. Otherwise, symptoms will simply become recurrent every time you do that task or level of exercise.

There are differing levels of load on tendons, ranging from simple exercises such as isometrics (calf raise holds, wall squats, bridge holds) where there is a muscle contraction and tendon loading but no movement, all the way through to energy storage and loading exercises (skipping, hopping, decelerating and reaccelerating). Energy storage and loading exercises relate to the tendons capacity to act like a spring, efficient tendons are able to store and release energy quickly.

While tendons act like springs in a sense there is one big difference, and it’s what happens if I hold the spring on tension and what happens to that energy. With a spring I can pull it apart and no matter how long I hold that spring for, when I release it, it will release the same amount of energy. With a tendon, the opposite occurs, the longer I hold that spring for, the more energy I lose. This means my muscular system ahs to work harder to compensate for this lost energy and momentum that my tendon can’t maintain/produce.

Common Tendinopathies

– Patella tendinopathy

– Achilles tendinopathy

– Hamstring tendinopathy

– Rotator cuff tendinopathy

– Tennis elbow

– Golfer’s elbow

– Gluteal tendinopathy

Different Types of Exercise

There are a range of differing exercise and contraction types you can utilise in the management of a tendinopathy, here we will run through some of the commonly utilised exercise regimes, the evidence for them, and how we see they fit in when rehabilitating.

It’s important to remember that tendons often have a 24 hour window of turnaround of symptoms, monitor your symptoms after your gym session to ensure you haven’t loaded your tendon too much. Some soreness is acceptable, and it’s often thought that some pain is better than no pain when rehabilitating a tendon. My limit is often a 4/10 pain that warms up with 30 minutes of waking, I often define a 4/10 pain as being sore but not painful and wouldn’t restrict any activities or make me question doing anything.

Isometric Exercises

Isometric exercises are one of the simplest exercises we can give out for any body part let alone a tendon. An isometric contraction occurs when there is a muscle contraction but no joint movement. Therefore there is no lengthening or shortening of the muscle, and the tendon is not required to produce any high load forces. Research hasn’t been able to be overly conclusive as to the benefits and effects of isometric exercises on tendon pain. However there has been signs that show that isometric loading of a tendon for a sustained period of time, most commonly 5 x 45 second contractions, that we can see a significant reduction in pain coupled with an improvement in function. We are currently not quite able to determine why this change occurs, but theories suggest there is likely a change in the brain occurring. Ebonie Rio, who is a Melbourne based tendon researcher, likens tendinopathies to driving a car with your foot on both the brakes and the accelerator due to the changes at the brain. Clients exhibit a reduction in modulation of force production, but also show increased inhibition of the muscles, isometric may potentially be a short term method for overriding this system while simultaneously loading the aggravated tendon.

Common exercise choices for certain tendons may include:

  • Achilles tendon – Single leg calf raise holds
  • Patella tendon – Single leg wall squat, spanish squat, leg extensions
  • Hamstring tendon – Bridges, straight leg pull down, heel digs
  • Tennis elbow (wrist extensors) – wrist extension with weight, shoulder front raises
  • Golfers elbow (wrist flexors) – wrist flexion with weight

Almost all tendons can be loaded in as simple of a way as possible that you shouldn’t need gym equipment, at times though it may be recommended. For example, with a higher level athlete who can tolerate the load, it would be optimal to load an isometric with weight for the added bonus effect of strength gains while performing the exercise.

Concentric Exercises

Concentric exercises occur when the muscle is loaded while the muscle is shortening, the easiest example to think of is a bicep curl. As you bring the weight towards your shoulder, the biceps muscle shortens and contracts to bring the weight up. In all tendinopathy presentations, strength training is key to recovery and preventing recurrence of symptoms. Without a solid strength base to build upon, developing the appropriate strength and loading capacity becomes tougher. Concentric exercises can produce some great results for clients looking to developing strength and tolerance through muscular structures with regular, often 2 x week for tendinopathies, strength and gym training.

Common exercise choices for certain tendons include:

  • Achilles tendon – Single leg calf raises straight and bent knee
  • Patella tendon – Leg extension
  • Hamstring tendon – Hamstring curls, single leg bridges
  • Tennis elbow (wrist extenors) – weighted wrist extension
  • Golfers elbow (wrist flexors) – weighted wrist flexion

Eccentric Exercises

Eccentric exercises are simply the opposite of concentric exercises, whereby the muscle is placed under load when the muscle is lengthening. If we take the same example of the bicep curl, to perform this exercise eccentrically I would often pick a heavier weight, then my opposite hand would help me bring the weight up, and then I would slowly lower the weight down to stress the bicep muscle fibres as they are lengthening. With regards to pure tendon loading levels, there isn’t a significant difference between concentric and eccentric exercises. Eccentric exercises can cause more soreness (DOMS) after a gym session, and may lead to more strength gains. But it’s important to consider how this will fit with the rest of your training and rehabilitation. If you are too sore to perform higher load exercises the next day as you may be prescribed, the potential benefits of eccentric exercises over concentric exercises may diminish.

The second benefit of eccentric exercises is the lengthening effect it has on muscular structures. Research has shown in hamstring muscles, that after performing a training block of Nordic Curls, there is significant improvements in both hamstring strength and hamstring length.

Common exercise choices for certain tendons include:

  • Achilles tendon – Eccentric calf raises to neutral or on edge of step
  • Patella tendon – Reverse Nordic Curls, eccentric leg extension
  • Hamstring tendon – Nordic Curls, GHR machine/back extensions, single leg RDL
  • Tennis elbow (wrist extenors) – eccentric wrist extension
  • Golfers elbow (wrist flexors) – eccentric wrist flexion

Heavy Slow Resistance Training

Heavy Slow Resistance (HSR) training was proposed by Kongsgaard et al in 2009 and 2010 and assessed it’s use in patella tendinopathy cases. It is somewhat the opposite of other protocols such as the Alfredson’s protocol that required 180 reps per day every day, HSR training by contrast is 4 sets of 3 exercises 3 times per week. The protocol progresses from a 15 rep max down to a 6 rep max by the end of the 12 week program. For patella tendinopathy, the authors utilised squats, leg press, and hack squats as their selected exercises.

Plyometrics/Energy Storage and Loading

Plyometrics and energy storage and loading exercises are the highest forms of load on tendons. They require tendons to quickly absorb and release force. Tendons in a way act like big springs, as you pull a spring back the spring absorbs the force, then when you release it that force is exerted. Tendons work incredibly similarly, when you land from hopping the Achilles tendon absorbs a large amount of force. The one key difference between tendons and springs is what happens when that force is held over time. In the example of a spring, you can hold it for half a second or two hours, whenever you release the spring it will have the same amount of energy. Unfortunately tendons don’t have that capacity. As soon as a tendon is required to absorb and then hold force, it begins to lose the energy it once stored.

Whenever you observe athletes like triple jumpers, or sprinters, ground contact times are incredibly important. If they held their ground contact time for longer between each step or jump, they would be losing energy on each occasion. Hence, when we consider returning to plyometrics load we need to ensure that the tendon is working efficiently to produce and maintain as much energy as possible. This will both reduce the risk of symptoms recurrence, and improve your performance as an athlete.

Returning an athlete to high level sport without having completed this phase of rehabilitation can be fraught with risk. Ultimately it will mean you are placing a load on the tendon that it is not quite equipped to handle. There are many considerations such as the number of plyometric events (for example steps in a run up to a long jump), the rate at which they occur (ballet is a perfect example because of the tempo at which certain dances are performed), how often the athlete has to perform it (the number of jumps is very different between triple jump and long jump), and the velocity at which the events occur (higher loads will be seen in a triple jumper versus a basketballer). One of the main considerations for Achilles tendon load in particular, is the speed at which the events occur. Progressing from walking to running, and from running to sprinting, all involves significant increases in Achilles tendon load that it needs to be prepared to handle.

Putting it all together to build an exercise program

Building a thorough and complete rehabilitation program for an athlete recovering from tendinopathy can be difficult. Often mid-season it becomes a matter of managing symptoms, maximising performance, and reducing irritability to keep an athlete training during the week. Then it becomes a rehabilitation priority for the off-season.

During the season, a program will often involve a combination of isometrics, concentric and eccentric, and plyometric/energy storage and release. They key is how we program this though to ensure we get the training effects from each without overloading. Most sporting teams at the local level train 2xweek and typically play games on weekends. For an athlete managing symptoms mid-season, we would often decide that training sessions and games become the “high load days”. These are the days when we require energy storage and release loads from the tendon where there is likely to be some irritability. The day after a game, we would perform isometrics as these have been shown to have positive effects on pain reduction and improvements in function.

Determining when to put in strength and conditioning via a gym program will largely come down to how irritable an athletes symptoms are. A less irritable tendon may be able to tolerate a gym session in the morning before completing training, and others may not be able to tolerate that level of load in one day. This would ultimately be the ideal situation as it allows us to perform the higher level loading of training and our strength and conditioning in the same 2 days of the week, leaving 3 days for further prescription of training. On those 3 days we could vary between a range of options such as simple isometrics for highly irritable tendons, to low level energy storage exercises to continue to progress that portion of the rehabilitation in certain athletes.

Low Level Irritability Sample Exercise Program

Monday – Energy Storage Exercises e.g. skipping

Tuesday – Gym/Strength and Conditioning AM session Training Night 1.5hrs PM session

Wednesday – Isometrics and light energy storage loading

Thursday – Gym/Strength and Conditioning AM session Training Night 1.5hrs PM session

Friday – Isometrics only

Saturday – Game Day – 1.5hrs

Sunday – Isometrics only

High Level Irritability Sample Exercise Program

Monday – Strength and Conditioning session

Tuesday – Training Night 1.5hrs incorporating rehabilitation exercises for energy storage

Wednesday – Isometrics only

Thursday – Training Night 1.5hrs incorporating rehabilitation exercises for energy storage

Friday – Strength and Conditioning session

Saturday – Game Day – 1.5hrs

Sunday – Isometrics only

The main difference between these two programs is in the prescription of the energy storage exercises and the amount of rest between different sessions, in particular training during the week. In both examples, the Sunday is designed as a rest day to allow symptoms to settle following the game as this is likely the highest level of load applied to the tendon throughout the week. But the low irritability group is able to transition to higher level loading faster than the high irritability group.

With tendon rehabilitation it is always important to monitor symptoms 24hrs after loading. If symptoms were to increase in the low irritability group the likely regression would be to reduce the loading on the Monday and Wednesday in this example to allow for a greater period of lower level loading throughout the week.

Rehabilitation for a tendinopathy can be a long journey, particularly if you are continuing to play sport and are choosing to manage the symptoms and then rehabilitate completely during the off-season. An accurate diagnosis from a physiotherapist is integral as misdiagnosis can be common, and alternative pathways of management for a tenosynovitis versus a tendinopathy.

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