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 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?
- has been present for 2-4 weeks
- exquisitely tender to palpation
- highly irritable
- exceptionally sensitive and painful to everyday, non-strenuous activities
- holding empty pots, walking, going down stairs
- 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
Research supports active treatment over surgery for tendinosis. First, are eccentrics, which is the lengthening of the muscle as load is applied to it. If this sounds like gibberish, let’s take a bicep curl with 5lbs 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. As you slowly lower the weight back down, this is the eccentric part of the exercise. Generally, research suggests that slow eccentrics bring a higher load to the tendon and therefore a higher remodeling stimulus that breaks the cycle of tendon break down 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. Patellar Tendinosis will involve a squat variation where the knee comes over the toe or perhaps using a decline board. Achilles Tendinosis will involve 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 protocols 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.
My opinion on this is…don’t think too hard about it. Just load it—everyday, multiple times per day… and to low levels of irritation/pain that resolves within 12-24 hours. You can also add weight every week to keep increasing the load! The amount of weight will depend on your symptoms, but if you’re not flaring up, 3-5lbs/week would not be too much.
2. Heavy Slow Resistance Training
Literature equates Heavy Slow Resistance Training (HSRT) with eccentric exercises. They both get similar, improved results in studies by the American Journal of Sports Medicine. I give my patients variations of both, but the HSRT only needs to occur 2-3x/week versus the multiple times per day slow eccentric training. The actual resistance training exercise will vary depending on the body part, but we’ll use Achilles Tendinosis as an example:
- Heel raises with bended knee in the seated calf raise machine
- Heel raises with straight knee standing on a disc weight with the forefoot with the barbell on shoulders
- Heel raises with straight knee in the leg press machine.
Specifics of this protocol include that all exercises are performed bilateral with equal weight on both legs with full range of motion in all joints. Slow, controlled movements are imperative. One successful research study used 6 seconds per repetition. The number of repetitions should decrease while load gradually increases every week as the tendon gets stronger. This may vary based on a variety of factors including your specific injury status, current exercise regime, and pain.
Example Rep/Load Scheme:
(RM= Maximum amount of weight that a person can possibly lift for a certain amount of repetitions)
3. Stay Active
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!!!
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, stay active and if there’s low levels of tendon pain that is okay, I promise. If anything, you’re giving your body and brain the message it shouldn’t be worried about it…and they really shouldn’t.
In conclusion, in the name of playing your beloved, chosen sport without pain, this is a do-able program. Consistency is key when it comes to these exercises…you have to be committed. You might want to even maintain the HSRT even after your back on the field/court/track/road as a way to prevent this pesky problem from returning!
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.