Written by Josh Chuah.
Following up from my previous post “Understanding tendinopathy”, this post will cover practical implications of management to help kick-start your recovery process. “Understanding tendinopathy” is quite a heavy read, however, having a good grasp of what tendinopathy is and how it develops is essential, especially if you’re a personal trainer or strength coach that works with athletes, as it is quite a common condition. Dealing with tendinopathy can be frustrating for both the coach and athlete, exercising patience with the rehab process will be crucial as tendon adaptation takes time (you’re probably looking at a period >8 weeks depending on stage). Note: Every individual will respond differently to these protocols. It will very likely take some trial and error to figure out what dosage and modification works best for you.
Is there a root cause?
First question to ask yourself – What is the driving factor for the development of tendinopathy? Was it purely a load spike that caused it or was there something else?
A few contributing factors to think about that I won’t dive into in this post but worth mentioning:
- Squat-related biomechanical factors (Inefficient positioning/technique)
- Quad dominant lifters with jacked up quads but poor-relative hip strength (knee absorbs majority of the load, increased stress over time leading to tendon overload)
- Insufficient ankle range into dorsiflexion (again, knee having to absorb majority of the load)
- Insufficient quadriceps strength (increased strain on tendon)
- Insufficient hip range (flexion, external rotation, internal rotation)
As you can see, there could be a multitude of factors that may contribute to the development of tendinopathy. This may or may not be applicable to you, but worthwhile putting some thought into it. If it does apply to you, it will be a good idea to make it your priority to address these deficits. Side-note: It is important to mention that there is very limited evidence to suggest that “bad” technique will eventually lead to an pain/injury. Many can train with what is considered “bad” form and never experience pain, and people with perfect form can end up injured. What may be considered “good technique” for one is not always “good technique” for another – but this is not to say that efficient technique doesn’t matter in the lifting world. I’ll cover this topic in another post in the future.
Step 1 – Modify training stress
Typically during the early stages of tendinopathy, most will find compressive positions to be quite irritable (ie. Full loaded knee flexion). Just because your knee hurts in a particular range, doesn’t mean that you should avoid loading it altogether. However, It will be wise to limit loading to a range where only minimal/no discomfort is present for the short term.
Some examples of movements to get you started
- Barbell box squats
- Pin squats
- Medium height barbell step up
- Split squats
- Leg press
If your symptoms are particularly mild (eg. minimal discomfort at the bottom of the squat when you get over 80% of your 1RM), applying accommodating resistance via the use of chains or bands will help keep you training hard but symptoms at bay, while actively rehabbing the issue.
Tendons adapt and respond best to high strain sustained for a period of time, rest is not always the answer! (Although, in some cases off-loading for a short term is necessary) Therefore, all rehab movements should be performed with a slow tempo concentrically and eccentrically (eg. 3 seconds eccentric, pause, 2 seconds concentric)
Monitor and track your session to session volume, and weekly volume for lower body movements. Refer to part I under Acute:chronic workload ratio to find out more about tracking load.
Space out high loading sessions by at least 36 hours to optimize collagen synthesis (covered in part 1). Avoid back to back days for loading.
Step 2 – Monitor pain levels
In tendon rehabilitation, any pain levels below 3/10 is deemed as acceptable as long as its tolerable for the individual. Recent research has suggested that pain during exercise is not detrimental for recovery, and some even suggests that it may even be beneficial.
Specifically for tendon rehab, monitor pain levels within training session and also a 24-hour window immediately following session. This will help you have an idea of how the tendon has responded to the load demands in the previous session, it may take some trial and error to find your baseline tolerance. Once you do find your baseline tolerance, start there and progress on from there.
After a training session, you wake up the next morning with 6/10 pain that lasts for 2 days. This would give you an idea that the session itself was likely too much for the tissue to handle. Scale back your volume in the following session and continue monitoring from there. This is where monitoring your volume and frequency will come in handy as you are able to objectively measure your stress rather than play the guessing game.
Step 3 – Building tolerance
Isometrics is typically a great start for building tolerance for tendons, it is generally more tolerable, less fatiguing – especially if used in competition prep phases, simple to do and able to deliver a high strain to a tendon in controlled manners. Furthermore, it’s great to use as a tool to build tolerance in specific angles. Not to mention that most people find that it has quite a good pain relieving effect as well.
Exercises such as the Spanish squat or an isometric hold with the leg extension machine held at 30-60 degrees (mid-range) can be very effective. Personally, I find the Spanish squat more effective as an isometric but the leg extension better as a heavy slow resistance rehab exercise. Again, different people respond to different movements better so the only way to find out, is to give it a go.
- 3-5 sets
- 45 seconds each set pre-lower body session
- May be performed daily depending on irritability and tolerance of individual
Heavy slow resistance (HSR)
As mentioned above, tendon adaptation occurs when exposed to high strain. Multiple tendon researchers found that too little resistance has been shown to be ineffective for tendon rehab.
Heavy slow resistance rehab is basically using a tolerable heavy load (6-8 reps) performed at slow tempo. It may be initiated when the exercise itself produces minimal, tolerable pain (<3/10). Movements can include as mentioned above under “range”, progressing to full range as symptoms improve. Initially, it will be a good idea to pick a single-joint movement to start off with (ie. leg extension) where it specifically loads up the quads and tendon prior to progressing on to multi-jointed movements (ie. Leg press) where multiple other muscles can come in to compensate.
The heel elevated, close stance tempo squat will be a great choice in the later stages of rehab, a multi-joint movement providing high strain to the tendon itself. The higher the elevation, the higher the stress on the tendon. Start off lower prior to progressing to a higher elevation, as the tendon’s capacity to tolerate load increases.
Recommended parameters for HSR movements
- 3-4 sets,
- Fatiguing load
- Depending on irritability of tendon, 15 reps working up to a heavy 6 reps over time
- Slow tempo
- Every 2nd day
Rehab is often more challenging (especially mentally) compared to training itself, and for most, it is all part of the process as you strive to be a better athlete. The body is an adaptable structure, ultimately, you will come out stronger. Apply the recommendations above in training and give it time to adapt and respond. If you feel like you’re stuck and need an opinion, feel free to head to the contact section and send me an e-mail. All the best, and happy training!
- Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol. 2010;6(5):262-8
- Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations (Malliaras P, Cook J, Purdam C, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. J Orthop Sports Phys Ther. 2015;45(11):887-98
- Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409-16
- Smith BE, Hendrick P, Smith TO, et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis Br J Sports Med. 2017; 51(23):1679-1687.
- Kountouris A, Cook J. Rehabilitation of Achilles and patellar tendinopathies. Best Pract Res Clin Rheumatol. 2007;21:295-316