How to Heal Tendinosis: 3 Treatment Methods that Promote Healing
Tendinosis results from the degeneration of tendon collagen due to repetitive overuse, not inflammation, making anti-inflammatory treatments ineffective. Effective treatments include physical therapy, strengthening exercises, and techniques like ultrasound or shockwave therapy to promote collagen production, tendon healing, and recovery.
In this article, we'll dive into what sets tendinosis apart from tendinitis, exploring the causes and symptoms of each. We'll also discuss the most effective treatments for tendinosis, including exercises and therapies that can help restore your tendon strength and function.
If you're struggling with tendon pain, understanding the right approach to treatment can make all the difference in your recovery.
What is Tendinosis?
Tendinosis is a common musculoskeletal condition that accounts for nearly 50% of all sports-related injuries. A tendon is fibrous connective tissue, called collagen, that attaches muscle to bone and allows for the transmission of forces.
This condition is the degeneration of the tendon's collagen in response to repetitive tasks that the tendon is not strong enough to handle. Importantly, it is not associated with inflammation and anti-inflammatories are ineffective at this stage.
You may have heard of tendinitis, which is what tendinosis is called when the tendon pain is acute (it's been less than 2-4 weeks since it started hurting) and inflamed. They're managed differently! Tendinitis responds well to rest, ice, and NSAIDs versus Tendinosis treatment, which we'll discuss below.
Do I have Tendinitis or Tendinosis?
Tendinitis
- has been present for 2-4 weeks
- exquisitely tender to palpation
- highly irritable
- red/warm
- exceptionally sensitive and painful to everyday, non-strenuous activities
- holding empty pots, walking, going down stairs
Tendinosis
- has been present for 4+ weeks
- can be harder to provoke
- increased load is painful
- holding heavy pots, running, hiking steep incline
- increased load is painful
- pain during or after these activities
3 Research-Backed Tendinosis Treatments
1. Eccentrics
For tendinosis, research supports active treatment over surgery. Unlike an acute sports injury, where rest and immediate care are crucial, tendinosis requires a more gradual and active approach to recovery. One such type of active treatment is eccentrics, which is the lengthening of the muscle as load is applied to it, helping to strengthen tendon tissue.
If this sounds like gibberish, let's take a bicep curl with 5 lbs as an example.
When the arm is straight with the weight in hand, and you start bending your elbow to curl the weight, this is the concentric, or shortening of the muscle. Slowly lowering the weight back down is the eccentric part of the exercise.
Generally, research suggests that slow eccentrics bring a higher load to the tendon tissue and therefore a higher remodeling stimulus that breaks the cycle of tendon breakdown and begins to repair.
Depending on the body part, the eccentric exercise will look different. A Biceps Tendinosis will look similar to the exercise described above. Tendinosis in the patellar tendon will involve a squat variation where the knee comes over the toe, or perhaps using a decline board.
Common treatment for Achilles tendon injuries involves heel raises, often using a stair, while lastly, a “Tennis Elbow” will involve using slow decelerations with hand weights. You can design an eccentric exercise for any body part. Just take the concentric exercise and reverse it slowly and with load!
Successful routines vary from 3 sets of 15 repetitions (also notated 3×15) 2 times per day to 10 times, 6 times per day, most of them exercise into low levels of pain (on a 0-10 scale, around a 3-4/10). The speed of the contraction should be slow and controlled, anywhere from 3-5 seconds.
Our Recommendation:
Active treatment using eccentric exercises can be highly effective for treating tendinosis. Focus on slow, controlled movements that lengthen the muscle under load, as this promotes tendon healing. Perform exercises specific to the affected tendon, such as squats for patellar tendinosis or heel raises for Achilles tendon.
Aim for 3 sets of 15 repetitions multiple times per day, working through low levels of pain that subside within 12–24 hours, and gradually increase the weight weekly if symptoms allow.
2. Heavy Slow Resistance Training
Heavy Slow Resistance Training (HSRT) is similar to eccentric exercises in how they improve tendinosis symptoms, with both showing equally positive results in studies by the American Journal of Sports Medicine.
I often recommend a mix of both to my patients, but HSRT only needs to be done 2 to 3 times per week, compared to the multiple daily sessions required for eccentric training. The exercises vary depending on the injured tendon, so let’s use Achilles tendinosis as an example:
- Heel raises with bent knees using the seated calf raise machine
- Heel raises with straight knees while standing on a disc weight with the forefoot with the barbell on your shoulders
- Heel raises with straight knees in the leg press machine
For this protocol, it's important to do the exercises slowly, with controlled movements. All exercises should use both legs evenly, ensuring full range of motion in all joints. One study showed success with a pace of 6 seconds per repetition.
Over time, the number of repetitions decreases as the weight increases, allowing the injured tendon to grow stronger and reduce tendinosis symptoms. This will depend on your injury, current fitness level, and pain tolerance.
Example Rep/Load Scheme:
| Week 1 | Weeks 2-3 | Weeks 4-5 | Weeks 6-8 | Weeks 9-12 |
| 3×15 RM | 3×12 RM | 4x10RM | 4x8RM | 4x6RM |
(RM=Repetition Max)
(RM= Maximum amount of weight that a person can possibly lift for a certain amount of repetitions)
Our Recommendation:
Heavy Slow Resistance Training (HSRT) is another effective option for treating tendinosis, and it only needs to be done 2 to 3 times per week. Focus on exercises specific to the tendon you are targeting, like heel raises for Achilles tendinopathy. Be sure to perform the movements slowly and with full control, aiming for a pace of around 6 seconds per repetition. Tailor the load and frequency based on your injury and current fitness level.
3. Stay Active
“The 2018 Physical Activity Guidelines for the public recommend that able-bodied adults should engage in 150 to 300 minutes of moderate-intensity physical activity, or 75 to 150 minutes of vigorous activity, or equivalent combinations of both.”
Above all, I realize that staying active can be scary when there's pain with movement…but…we know now through neuroscience research that pain does not equal structural damage and tendons need blood flow for healing.
Tendons have an extensive blood flow and synovial fluid network that they rely on for nutrition. If you're not in an acute bout of tendinitis (see above), stay active with other activities that do not significantly provoke your symptoms into high levels of pain (>4 on a 0-10 scale). Or if your chosen activity only creates low-level pain, it's okay to keep doing it!
For instance, large studies using athletes as subjects, allow the athletes to continue their sport while they work through tendon rehabilitation protocols, and they still improved! Staying active is that important! In one tendon study, they state,
“Immobilization reduces the water and proteoglycan content of tendons, increases the number of reducible collagen cross-links, and results in tendon atrophy.”
In other words…. Keep Moving!!!
Our Recommendation:
Staying active is crucial for tendon health, even when managing tendinosis. Tendons need blood flow for healing, but it’s important to engage in activities that do not significantly increase your pain. Continuing activities that aggravate symptoms can increase the risk of more severe complications, such as a tendon rupture.
If you experience only low-level discomfort, it’s okay to continue, as staying active can help your tendons recover and prevent further weakening.
How Physical Therapy Can Help
We understand that developing tendinosis can be a painful and frustrating experience, leaving you itching to get back to your favorite sport while resting up on the sidelines. The uncertainty of how long recovery will take and the fear of re-injury can make it even harder to stay patient.
Working alongside a qualified physical therapist offers a structured approach to recovery, focusing not only on managing pain but also on rebuilding tendon strength and mobility.
At AgilePT, we take a structured approach to help reduce pain, improve strength, and support recovery. With tailored treatment plans designed specifically for your needs based on years of professional, practical experience, you're in safe hands.
If you have any questions at all about your condition, don't hesitate to reach out to a member of our friendly team today to discuss your goals.
Summing up:
Dealing with tendinosis can be challenging, but understanding the condition and approaching treatment with a solid plan can make all the difference. Whether it's through exercises like eccentrics, resistance training, or staying active while managing symptoms, there are proven ways to support the healing process and regain strength.
Remember, recovery is a process, and with the right guidance, you can work through the discomfort and get back to the activities you enjoy. If you're feeling unsure about where to start, a physical therapist can be a valuable resource to help guide you through your recovery journey.
At AgilePT, we're here to support you every step of the way, so you can return to your sport or everyday life with confidence and strength.
Nick graduated from The Ohio State University in 2010 with a degree in English. His focus at that time was to continue rowing competitively, which brought him to the Boston area. There he completed his Doctorate of Physical Therapy from Massachusetts General Hospital Institute of Health Professions in 2018.
In Boston Nick worked at a clinic well known for treating professional runners and other endurance athletes. He enjoyed working with high schoolers and their parents the most. It was here he developed a passion for treating tendinopathy. Having had his own experience with a high hamstring tendinopathy he found it helpful to be able to empathize with others going through this uniquely frustrating condition. It also was here that Nick first started to learn about bike fitting and he has since gone on to obtain his Level 1 International Bike Fit Institute certification.
Nick has enjoyed being a competitive endurance athlete for 17 years. He has gone from world championship trials as a rower, running 5ks to half marathons to ultra trail runs in the White Mountains, to racing UCI cyclocross as a category 2 cyclist. Nick no longer races competitively due to a heart condition but you can now find him olympic weightlifting, mountain biking or gravel riding, taking photos of bike races, or hiking with his wife and 2 dogs.
Nick enjoys taking an active treatment approach with an emphasis on play and variability, he believes movement is the best medicine, and often complex problems have simple solutions.