Last week’s blog delved into what tendons are, what tendons do, and the different diagnoses people may receive regarding their tendon pain. Regardless of the diagnosis, we can be sure of one thing: tendons need the optimal amount of load in order to adapt and recover.
Why do tendons like load?
Whether it is a change in mechanical properties, collagen synthesis and organization, or blood flow, it is unclear the exact reason why tendons respond and adapt favorably to load (Docking et. al 2019).
A recent article comparing eccentric and concentric exercises for tendon pain notes, “it is well known that tendon cells (fibroblasts) respond to mechanical stimuli in the form of strain” with their being an “optimal strain” for each tendon and each individual body (Couppe et al. 2015). The authors noted, “the tendon is responsive to loading and will respond more strongly to greater loads” (Couppe et al. 2015), which emphasizes our point: tendons NEED load to adapt!
What you tell your Made 2 Move PT regarding your pain can help us lead you down the path to healing as we uncover the optimal load for your body.
What is the “best” way to load a tendon?
Concentrically? Eccentrically? Isometrically? The reality? All of these ways can be valuable depending on the individual variances, pain levels, and overall goals. Passive treatments like ice, heat, and rest may feel good in the moment and can be useful in minimizing pain but we must progress beyond these. Dr. Cook notes, “Addressing pain is critical; however, interventions directed solely at pain have a minimal effect on the associated kinetic chain deficits or tissue capacity and may result in the recurrence of pain” (Cook et. al 2016). Thus, what can we do to both minimize pain and improve tendon function?
There has been tons of debate over the “best” way to load a tendon. Even though instagram claims otherwise, there is not a “best exercise” or “one movement that will change your life” when it comes to loading tendons.
It has been noted that “targeting the specific musculotendinous unit with isolated, single-joint tasks provides the greatest opportunity to induce adaptive changes to the tendon” (Docking et. al 2019). Incorporating and progressing these single joint exercises, say a leg extension for patellar tendon pain, into compound movements, like a back squat, can help progress back to more functional “life-like” activities.
There are multiple ways the research has outlined that we can utilize to build tendons back up: “magnitude and type of adaptation likely depend on the exercise regime, including the magnitude of the load, range of motion performed, contraction mode (eccentric lengthening/concentric shortening), movement speed, number of repetitions, and rest periods between the exercise sessions” (Docking et. al 2019).
This demonstrates the plethora of ways in which we can load a tendon! In deciding the right way to load a tendon for an individual, one of the most critical variables is balancing the loading: if it’s overuse, we need to let the tendon calm down then build its capacity back up. If it’s underuse, we need to skip the rest and start rebuilding up the tendon’s capacity for load.
A thorough evaluation with a PT can help you begin to differentiate and understand what it is your tendon is asking for. Being in tune with the signals your body sends you is another way to start to understand what your tendons are saying when they talk to you via pain, soreness, or any other sensations.
Loading Tendons Progressively
The best way to load a tendon? Similar to the proposed tendon continuum in describing tendon pathology, there is a tendon continuum in deciding the “best way” to load a tendon.
The entry point: ISOMETRICS
A simple way to kill 2 birds with one stone: isometrics (holding a muscle in a contracted position at the same length). A 2015 article on patellar tendinopathy found that isometric quadriceps contractions led to a decrease in pain that lasted 45 minutes after the exercise.
Additionally, muscle inhibition is common in those with tendionpathies and this study found that “heavy isometric exercise reduced cortical muscle inhibition and may be a factor in the mechanism of pain reduction” (Rio et. al 2015). Thus, isometrics are a great way to decrease pain while also beginning to load and subsequently strengthen the surrounding muscle and tendons. Eventually, we will need to move beyond isometrics in order to prepare the tendon for the demands of sport, but isometrics can be an incredible entry point in PT with people in which pain is a limiting factor. This could look like a body weight wall squat in the case of patellar or quad tendon pain.
Beyond isometrics…SLOW, HEAVY LOADING
Stopping at isometrics is where many rehab programs fall short in addressing tendon pain and dysfunction. They load patients isometrically which helps alleviate their pain. But how often are tendons staying at a static length in their absorption and transmission of load during our daily lives or sports? Very rarely. Thus, it is critical that tendon rehab be progressed and advanced beyond isometrics. Once isometrics become tolerable, your Made 2 Move therapist will progress to moderate-heavy loading through full ranges of motion. This could look like doing a slow, heavy, and controlled barbell back squat.
Progressing to PLYOS
After your tendon is able to tolerate heavy loads slowly, it is time to start incorporating some plyometric, or jumping type movements to work the rubber band, elastic qualities of the tendon. This may look like bunny hops, skater jumps, plyo push ups, or ball throws. In progressing beyond our back squat for patellar tendinopathy, we could now move to weighted jumps.
Moving at SPORT SPECIFIC SPEED
Lastly, we will progress to jumping and moving weight at faster speeds and in patterns that mimic the sprinting, jumping, kipping, throwing, or snatching that you are trying to return to. Progressing past our weighted jumps, we could now help the athlete in the above example sprint, decelerate, and change direction in order to return to the field.
The Tendon Treatment Takeaway:
Similar to most rehab here at Made 2 Move, we believe that there is no “one way” and there is no “best way” to load a tendon. Rehabbing a tendon is dependent on the individual. Basically, the research is telling us there are many ways to skin a cat. This is good news! Whether we load the tendon heavy and slow for a few reps, or lighter and faster for a ton of reps, the most important thing is this: we are loading the tendon, which means adaptations will occur.
The literature may say that heavy loading a tendon is best, but what if someone mentally doesn’t handle high loads well? This literature is irrelevant to them. The most important thing is knowing how to progress and regress exercises depending on the messages YOUR tendon is sending you.
Some soreness the following day? We probably stressed the tendon an appropriate amount and can build on this next session. An increase in pain 24 hours later? We may have overloaded the tendon (or not recovered well) and now we know for next time. Does this pain mean we damaged or degenerated your tendon beyond repair? No! It is simply is a message your body is sending that our Made 2 Move PTs are here to help you decipher.
Have you been dealing with some nagging tendon pain and are interested in working with a PT that will individualize your care to your goals and needs? Reach out to email@example.com today to set up an evaluation with one of our PTs. We can’t wait to see you!