All About Tendons
Tendons transfer force, produced by muscles, to our skeleton, allowing us to move.
Injuries to tendons (tendinopathies) are caused by overuse, resulting in degeneration of the tendon’s collagen (which is the main structural component of the tendon).
Overuse injuries to tendons occur when the micro trauma or damage that occurs to tendons with loading (frequently through exercise) exceeds the repair ability of the body.
Too much stress (or the inability to adapt positively to stress) on the tendon combined with inadequate recovery time leads to this type of injury (which we commonly see in most sports).
Tendon rehab research is relatively in its infancy. And it’s changing all the time – management of tendon is very different now than a few years ago.
Theories exist on tendon pathology, function, and rehab but there are few high-quality studies with clinically significant evidence for treatment methods.
Current research does however support use of progressive rehabilitation programming based around mechanical loading.
Research has focused on tendinopathy loading programmes that generally fit within 3categories eccentric, combined or heavy slow resistance training.
Tendon and muscle function together (= musculotendinous unit).
Consider this for rehab, not just the tendon itself.
What’s our main treatment goal? It does depend on the individual to some extent, but the key in tendon rehab is to improve the capacity of the tendon and muscle to manage load.
Phases of Rehab
Phase 1 – Pain Management and Isometrics
Initial painful phase - the tendon swells in response to an increase in load. So here we focus on reducing pain in a reactive tendon (whether this is truly reactive or a reactive response on top of an underlying degenerate tendon).
The key to pain reduction is managing load on the tendon:
Avoid activities that place a compressive load on the tendon, usually this is anyactivity that would involve stretching the muscle or tendon.
Isometric exercises can help to reduce pain.
Start with isometric holds in a mid-range position for each musculotendinous unit (as there is no tendon compression in this position).
Can be performed multiple times a day, said to have a pain-relieving/analgesic effect.
They can be repeated several times a day, to reduce pain and maintain some muscle capacity and tendon load.
Phase 2 - Strength Gains
Strength= the ability to produce force.
Our aim is to improve the muscle and tendon’s ability to produce force and manage load.
Muscles and tendons respond to load, more specifically heavy load.
This load is needed to promote changes in muscle and tendon, to improve their load capacity.
Strength is therefore an essential building block for muscle function, without adequate strength muscle will have poor power and endurance.
These have been considered the gold standard of tendon rehab for many years.
Here we are aiming to achieve strength changes by exercising with sufficient load in a muscle’s mid-range position.
Initially, we want to avoid exercising with heavy loads in positions where there is likely to be tendon compression.
Recent research shows the benefit of concentric exercises as a progression fromeccentrics during this strength phase with heavy slow resistance exercises.
Exercise prescription here will depend on pain levels, strength deficits, individual goals and activity specificity but generally the aim should be achieving equal strength.
Research shows that it takes 6-8 weeks for muscle strength gains and 12-16 weeks for significant tendon changes.
Eccentric exercises, building to concentric strength work
Should be no more than 3-4/10 pain while performing exercise
Perform every other day
Use 24h pain scale as a guideline for exercise progression (or regression)
3 sets of 8-10RM as a guideline to progress to next phase of rehab.
Phase 3 – Plyometrics and Re-Injury Prevention
Alongside this phase, continue with strength work to maintain tendon load capacity and a gradual return to training activities.
For sports, we require high levels of loading.
Progress to dynamic exercises (energy storage and release)
Increase speed to improve the ability of tendon to store and release energy
Exercise will depend on tendon being rehabilitated, and goal activity
Perform twice a week
For every athlete, there will be a specific amount and type of load the tissues will have to cope with, which is why feedback is important.
When building functionality and specific strength, we need to consider what activities we are working towards.
Research suggests three categories:
1. Exercises specific to the functional requirements of the effected muscle and tendon
- for each injury site, consider muscle function in different exercises, positions, reps, sets; strength-endurance demands on the muscle; and modification of loads and reps.
2. Improve the load capacity of the entire 'kinetic chain'
- we produce full body movements much more often than isolated exercises, our rehab needs to be reflective of this by focusing on strengthening the effected tendon in conjunction with other muscles.
3. Address movement dysfunction that links to the tendinopathy
- for performance increases and re-injury prevention.
More on Addressing Movement Dysfunction
Why has this injury happened? The more we know the more we can prevent it from happening again.
Consider underlying causes e.g. muscle weaknesses/dysfunctions, mobility restrictions, training load or daily activities.
Explore strength deficits, joint range of movement, tissue flexibility, movement control and biomechanics.
Given that load is a key factor in development of tendinopathy it is likely that external factors (e.g. training volume and intensity) are the cause (in most cases). Always assess individual factors.
Phase 4 - Return to Sport and the Green Light
For Return to Sport:
- Increase in power/plyo focus - increasing the speed of the muscle contraction to build power (return to run programme alongside here if lower body injury)
- Load tolerance - by adding progressions that replicate the demand placed on the tendon for individual sports/activities
- Add full-body sports specific training drills
- Return to competition when athlete can tolerate full training without flare-ups
- Maintenance program performed with adequate recovery time to allow sporting performance.
Achilles pain, stiffness and muscle power deficits (Martin et al, 2018).
Tendon neuroplastic training – changing the way we think (Rio et al, 2015).
Tendinopathy– rehab progression (Goom, 2016).
Sport and exercise-related tendinopathies (Scott et al, 2012).