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Tendinopathy Rehabilitation


Tendinopathy is classified as impaired function (reduced force transmission from muscle to bone) and pain in the affected tendon. [1][2] Despite recent advances in research into tendinopathy rehabilitation, it is still somewhat in its infancy. We manage this situation very differently now than we did 10 years ago A different treatment might be seen again in 10 years. There seems to be plenty of theoretical research but little in terms of high quality clinical trials. I mean we’ve built a lot of theories about tendon pathology function and rehabilitation, but we have Surprisingly, there are few high-quality studies demonstrating clinically significant improvements in treatment.

Peter Malliaras et al [3] recently reviewed the literature on loading plans for Achilles tendon and patellar tendinopathy (the 2 most common types) and found some methodological flaws. Only 2 studies were considered ‘high quality’, only 2 studies described adequate blinding, and most did not Measured with proven results. They also found that about 45 percent of patients showed no significant improvement after the exercise program. So while we can make some recommendations, there is still some way to go before we have conclusive evidence on tendinopathy recovery.

Developing a rehabilitation plan for patients with confirmed symptomatic tendinopathy requires complex clinical reasoning with reference to pathoanatomical diagnoses. Tendon pathology and subsequent rehabilitation can vary widely depending on the site of pathology; Tendinopathy stage; functional assessment; activity status of the person; contribution issues throughout the kinetic chain; comorbidities; concurrent speech [4].

There are many treatment options for tendinopathy and many factors to consider, it may be helpful to think about what our main treatment goals are and keep this in mind. Our main goal in tendinopathy rehabilitation is to improve the ability of the tendons and muscles to manage load. it is important to introduce Patient education and counseling are key parts of our interventions. For patients with nonacute Achilles tendinopathy, clinicians should advise that they do not require complete rest and that they recovery. Clinicians may recommend it to patients with Achilles tendinopathy. Key elements of patient counseling may include [5];

  • Theories supporting the use of physical therapy and mechanical loading
  • Modifiable risk factors, including body mass index and shoe wear
  • Typical time course of recovery from symptoms.

Tendons and muscles function together as a musculotendinous unit – we need to consider this in rehabilitation, not just tendons. [6]. Each component of the rehabilitation program, especially the loading, must be based on the Muscle/tendon/skeletal units in order to achieve the goals of specific management phases without causing pathological conditions or exacerbation of pain [4].

Rehabilitation Progression

The goal of any rehabilitation strategy is from pain to performance. Goom[6][7] recommends considering it in stages:

The 6 stages suggested by Goom [6][7] were merged into 4 stages by Malliaris et al. [8]

Protocol as described by Malliaris et al. (2015) (level of evidence: 2a) [8]StageIndicationDosage1. Isometric loadingPain above minimum pain during isometric exercise5 repeated for 45 seconds 2 to 3 times per day; progress to 70% maximal voluntary contraction as pain permits2. Isotonic in the body loadingMinimum pain during isotonic exercise3 to 4 sets at a 15RM load progressing to a 6RM load every second day; fatigue load3. Strength storage loadAdequate strength and with the other side is resistance loading and the first strength storage exercise (meaning less pain during exercise and pain in load tests returning to baseline in 24 hours)Continue to gain volume and then intensity through strength-storage exercises to simulate the demands of sport4. Return to sportLoad tolerance to energy-storage exercise development which is also required on trainingAdd training drills gradually then competition when they can cope with full training

Phase 1 – Reduce Pain

The first goal in the management of tendinopathy is often pain relief. It is often a patient’s most troublesome complaint and pain in the muscles can lead to decreased function in the associated muscles. Henriksen et al[9] tested the effect of experimentally induced achilles tendon pain. They found that neuropathic pain caused “broadened and reduced motor responses with functional effects on ground action potential“.

The pain will typically worsen as reactive tendinopathy progresses. Normally the muscles swell due to increased load. This is discussed in detail in our previous article linked above. In short, part 1 is primarily concerned with reducing pain in functional muscles (whether this is indeed the case). reactive or active response above the underlying tissue damage).

The key to reducing pain is managing the load on the muscles:

  1. Avoid activities that place a tensile load on the muscle generally this is any activity that will require stretching or direct contraction of the affected muscle.
  2. Interrupt the activities of the Stretch-Shortening-Cycle (SSC) that occurs when the muscle must behave like a spring that expands then contracts to store and then release energy.
  3. Isometric exercises can help reduce the pain.[10][11][12][13] This exercise should be done where the muscles are not normally centered on the muscles. Can be repeated several times daily using 40-60 s holds 4-5 times to reduce pain and maintain a muscle force and tendon loading. In more irritable muscles, bilateral exercises may be indicated for shorter holding periods and fewer daily repetitions[14].
  4. Anti-inflammatory drugs such as ibuprofen can be used to help reduce the reaction.

Phase 2 – Improve Strength

Once the pain resolves you can move on to phase 2 and work on strength. Strength is the ability to energize and in this context we aim to improve the ability of muscles and tendons to energize and manage loads. Muscles and tendons respond to load but are thought to be repetitive loads such as walking or running are unlikely to trigger significant changes in flexibility. Instead, heavy loads are needed to induce muscle and tendon changes that improve their load-bearing capacity. Strength is an important building block for muscle function without adequate energy for muscles poor power and endurance.

There are a number of options in terms of apple cider vinegar do not have a recipe for this. Choosing an appropriate load requires clinical judgment and consideration of patient values.[15] Exercises prescribed will depend on pain levels and areas of weakness patient goals and requirements of their sport. The question is how much energy is needed? In general we aim for equal strength left and right and this can be measured with a 10 rep max (10RM – maximum weight you can lift 10 times).

Research has focused on tendinopathy loading regimens that are generally appropriate in 3 categories eccentric combined or heavy slow resistance training.[16] Goom[6] summarizes the evidence for lower limb energy systems:

In this phase of rehab you are trying to achieve strength changes by exercising with sufficient load in a a muscle’s mid-range position. Avoid exercising with heavy weights in areas where muscles are likely to compress. Following the study by Alfredson et al[17]. which is remarkable exercise has been considered the gold standard for years. More recent research has shown the importance of repeating concentric phase exercises combined with heavy slow resistance training[18].

Heavy slow resistance training (HSR) has recently become another exercise option. Gaida and Cook [18] briefly discuss HSR and eccentric motion in their 2011 paper on patellar tendinopathy. They note that each approach has pros and cons. Odd jobs are usually prescribed as high Frequency of Workouts – Alfredson’s work recommends doing 2 workouts of 3 x 15 repetitions twice a day. In contrast, HSR is typically performed 2-3 times per week, but in many cases requires the use of exercise equipment.

HSR involves using high loads – approx. 70-85% of your 1RM (1RM – 1 Rep Max – refers to the maximum weight you can lift one time with good technique). Determining the 1RM is difficult, especially in patients with pain, so it can be approximated. 80% of 1RM is roughly equal to 8RM which is With good technique you can lift a maximum of 8 reps.

Choosing a load depends on the stage and severity of your condition, as well as your level of confidence in resistance training. Those who have less pain and respond well to heavy loads may start closer to the 8RM. Others may need to be built up gradually. Although the ultimate goal is to achieve these higher load Creates optimal tendon adaptation and muscle strength changes. The ACSM guidelines [19] recommend training between 8 and 12RM when starting strength training, although there is some debate over the exact parameters and this is based on studies in healthy people rather than those with tendinopathy. they suggest Repeat 2-3 times a week, 3 sets of 8-12 times each, with 2-3 minutes in between. Kongsgaard et al. [20][21] used a progressive approach, starting with a lower load of 15RM and increasing to 6RM over 9–12 weeks, provided there was no significant increase in pain. They use squat leg press and “Hack squats” and recommend doing 4 sets of each exercise with 2-3 minutes rest between sets, repeated 3 times a week.

A third option for strength training is the combined approach of Silbernagel et al. [22]. They use recovery stages and progression patients based on the patient’s symptoms. They also encourage a return to sport under monitoring. Silbernagel et al. Do not use % to describe specific payload Instead, they start with a 1RM of resistance (for calf raises) and progress in a similar fashion to Alfredson’s – using packs or weight machines to increase the load. However, there are several key differences. Silbernagel et al. including concentric and eccentric The exercise and progression components include strength exercises and plyometric exercises. Therefore, Silbernagel’s findings apply to most stages of rehabilitation, not just strength.

Malliaras et al. [3] reviewed the literature on Achilles and patellar tendinopathy. They found that HSR training was more likely to result in tendon adaptation, but further research is needed. They found no evidence for isolating the eccentric component (like Alfredson), although they found Acknowledging that multiple underlying mechanisms, such as neural adaptation, have not been studied. Overall, Malliaras et al. [3] found that combined and eccentric loading and HSR loading had the highest level of evidence for improving neuromuscular function.

There are several modifications that can be adapted to the strength work to suit the needs of an individual and have a specific effect on the muscles. These include time under pressure velocity of pull position of limbs during exercise range of movement covered rest between sets and planning exercises. For example an increased time under tension when applying a slower load may increase the stress on the muscle and cause greater flexibility but the increased speed will improve capacity and settlement for activities related to Stretch Shortening Cycle. Changing limb position during an exercise (e.g. Leg squat position) will change the direction of the load and is useful to consider as people go in many different directions so they will encounter different loads . . . .

On a practical note it is worth remembering that the muscle response to loading takes time considering the short-term and long-term response to loading. In the short term, collagen production will be lost around 24-36 hours post-workout – so give adequate rest days for strengthening intervals food choices.

In the long term consider that significant changes in muscle strength take 6-8 weeks and muscles change slowly so it may take 3-4 months to respond to a loading program. All of the assessments mentioned above include a minimum 12-week recovery period – there’s no quick fix!

Phase 2 summary – tendinopathy is likely to lead to decreased muscle strength and function. Restoring this is important for long-term root health. There are many strength techniques but they all have the same goal – gradually increase the load on the muscles and tendons as pain management. Strength work should be done in intermediate positions to avoid muscle compression. Ideally the optimal strength variation should be enough load that your patient can only handle about 8-12 reps (i.e. 8-12RM) and you may need to build for this as pain permits.

Phase 3 – Functional Rehabilitation

For many people, pain relief and added strength building and a gradual return to normal activities will be enough to rehabilitate an arthritis. If this is combined with ongoing strength work to maintain muscle loading capacity and a reasonable training program, then the risk of recurrence will be very low. However, for some with severe or persistent tendinopathy or those whose sports require higher loads, progression through the modalities to include functional rehabilitation is recommended.

Before starting functional rehab pain should be adequately controlled and there should be adequate baseline recovery. As a rough guide 10 rep max should be equal left and right for the involved muscles.

For every athlete, there will be a certain amount of load and load that the muscles have to cope with. When building efficiency we need to consider what activities our patients are working on and adapt the efficiency and environment accordingly. It can help to think about what works rehab in 3 broad categories:

  1. exercises specific to the functional requirements of the affected muscles and tendons
  2. improving the load capacity of the whole ‘kinetic chain’.
  3. and addressing the movement dysfunction associated with the tendinopathy.
Functional rehab for muscle and tendon

For this we need to think more in terms of muscle activity and transition position reps sets. This involves working on how the muscles are working and what positions they are in through the program then adapting exercises to perform in these situations. Consider also the strength-endurance requirements on the muscles and consider adjusting loads and reps accordingly.

Strengthening the entire kinetic chain

By ‘kinetic chain’, we mean the rest of the body involved in a task. If we strengthen the other muscles that affect this process we should theoretically be able to reduce some of the load on the muscles and tendons involved. In doing so we can also improve economies of scale and efficiency. For for example in a trail runner with achilles tendinopathy we will also look at how the gluts and hamstrings are working to optimize uphill running.

Addressing movement dysfunction

Movement dysfunction is complex. It includes a number of factors including strength joint range of movement tissue flexibility movement control and biomechanics. There is a lot of variety in what is ‘normal’ and some debate which aspects of movement we should change or even if we can actually change some of these aspects. Load is such an important area in the development of tendinopathy it may be more likely that it is extrinsic factors such as training volume and intensity that are more relevant than intrinsic factors such as biomechanics. Like many aspects of patient care it comes down to analyzing the person and considering how each element is related and constitutive. For movement dysfunction investigate the difference between the symptomatic and asymptomatic side and see if it is associated with pathology. Also aim to give back enough range and control of movement exercise.

If we want to make the event realistic why not just do our usual sports?

Silbernagel and colleagues[22] demonstrated that there are specific benefits associated with maintaining sports as part of your rehab as long as pain is adequately managed. For example running is obviously beneficial on cardiovascular fitness but not very effective at building strength or improving muscle loading capacity. In addition running activates the muscle’s Stretch-Shortening-Cycle which requires adequate muscle strength to avoid overloading the muscle. The difference between functional rehab and just doing your sport comes down to the type of loading and how. muscles and tendons react. A graded return to sports is a valuable component of tendon rehab but it is not a substitute for proper strength work.

In summary

Functional rehab can be a complex area and requires individualized assessment of the individual. Exercises should be designed to improve the load capacity of the affected muscles and tendons during function as well as the rest of the chain. Identifying appropriate dysfunctional movement can do it challenging but should involve the investigation of joint movement and soft tissue movement and biomechanics. These areas should be addressed with respect to the comorbidity and control for pain during load-bearing. Exercises should be in positions performed by the compressed muscles use with caution.

Return to sport [8][6][7]

To move from stage 3 to return to sport, the following steps should be taken:

  • Increased Strength: Build strength by reducing repetitions but increasing muscle contraction speed
  • Developing Stretch-Shortening-Cycles (SSC): Returning to Running by Introducing Plyometrics and Grading
  • Replicate the demands of training on the tendons by increasing load tolerance to energy storage exercises
  • Add training for this sport
  • Competition when patients can tolerate full training
Tendon neuroplastic training

Rio et al. [23] found that current rehabilitation uses self-paced strength training (eg, patients perform 3×10 contraction weightlifting – without any external cues/timing recommendations). This type of training may lead to tendinopathy recurrence because it does not adequately address motor control issues Corticospinal drive to muscles is thus not altered.

External rhythm training involves the patient concentrically and eccentrically contracting muscles in response to auditory (eg, using a metronome) or visual cues. Externally rhythmic strength training has been shown to alter tendon pain and corticospinal control of muscles.

Tendon neuroplasticity training uses strength-based training and external cues as a strategy to optimize neuroplasticity. This has been shown to be effective for patellar tendinopathy and further research is needed for other tendinopathy.


  1.  Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM et al. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther. 2018 May;48(5):A1-A38.
  1. ↑ Jump up to:6.0 6.1 6.2 6.3 6.4 Goom T. Tendinopathy – rehab progression – part 1. Accessed online at Tendinopathy – rehab progression – part 1 30 Jan 2016
  2. ↑ Jump up to:7.0 7.1 7.2 Goom T. Tendinopathy – functional rehab. Accessed online at Tendinopathy – rehab progression – part 1 30 Jan 2016
  3. ↑ Jump up to:8.0 8.1 8.2 Malliaras P, Cook J, Purdam C, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. The Journal of orthopaedic and sports physical therapy. 2015 Sep:1-33. (level of evidence: 2a)
  4.  Henriksen M, Aaboe J, Graven-Nielsen T, Bliddal H, Langberg H. Motor responses to experimental Achilles tendon pain. Br J Sports Med. 2011 Apr;45(5):393-8.
  5.  Ebonie Rio, Dawson Kidgell, Craig Purdam, Jamie Gaida, G Lorimer Moseley, Alan J Pearce, Jill Cook. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med 2015;49:1277–1283.
  6.  Mathijs van Arka, Jill L. Cookb, Sean I. Dockingb, Johannes Zwervera, James E. Gaidab, Inge van den Akker-Scheeka, Ebonie Riob. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. Journal of Science and Medicine in Sport, available online 7 December 2015
  7.  Goom TS, Malliaras P, Reiman MP, Purdam CR. Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. J Orthop Sports Phys Ther. 2016;46(6):483-93.
  8.  Rio E, Purdam C, Girdwood M, Cook J. Isometric Exercise to Reduce Pain in Patellar Tendinopathy In-Season: Is It Effective “on the Road”? Clin J Sport Med. 2019;29(3):188-192.
  9.  J L Cook, C R Purdam. The challenge of managing tendinopathy in competing athletes. Cook JL and Purdam CR. Br J Sports Med 2014;48:506-509
  10.  Jayaseelan DJ, Mischke JJ, Strazzulla RL. Eccentric Exercise for Achilles Tendinopathy: A Narrative Review and Clinical Decision-Making Considerations. J Funct Morphol Kinesiol. 2019;4(2):34.
  11.  Silbernagel KG, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. J Athl Train. 2020;55(5):438-47.
  12.  Håkan Alfredson, Tom Pietilä, Per Jonsson and Ronny Lorentzon. Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis. Am J Sports Med 1998 26: 360
  13. ↑ Jump up to:18.0 18.1 Gaida JE1, Cook J. Treatment options for patellar tendinopathy: critical review. Curr Sports Med Rep. 2011 Sep-Oct;10(5):255-70.
  14.  Nicholas A. Ratamess, Brent A. Alvar, Tammy K. Evetoch, Terry J. Housh, W. Ben Kibler, William J. Kraemer and N. Travis Triplett. Progression Models in Resistance Training for Healthy Adults. Med. Sci. Sports Exerc. 2002;34(2):364–80.
  15.  Kongsgaard M, Qvortrup K, Larsen J, Aagaard P, Doessing S, Hansen P, Kjaer M, Magnusson SP. Fibril morphology and tendon mechanical properties in patellar tendinopathy: effects of heavy slow resistance training. Am J Sports Med. 2010 Apr;38(4):749-56.
  16.  Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, Magnusson SP. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009 Dec;19(6):790-802.
  17. ↑ Jump up to:22.0 22.1 Karin Grävare Silbernagel, Roland Thomeé, Bengt I. Eriksson and Jon Karlsson. Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy: A Randomized Controlled Study. Am. J. Sports Med. 2007; 35; 897
  18.  Rio E, Kidgell D, Moseley GL, Gaida J, Docking S, Purdam C, Cook J. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med. 2015 Sep 25:bjsports-2015. Available from: http://bjsm.bmj.com/content/50/4/209 [Accessed 25 Feb 2017]
  19.  Fix Physio. Achilles tendinopathy Stage 1: Isometric calf raise exercises Available from: https://youtu.be/MYehmaMlKSs [last accessed 01/03/2018]
  20.  Fix Physio. Achilles Tendinopathy Stage 2: Isotonic calf raise exercises. Available from: https://youtu.be/JM9yxhxrqus [last accessed 01/03/2018]
  21.  Bourassa Rehab. Isometric Calf strengthening Available from: https://youtu.be/ijJ4bzFPDMM [last accessed 01/03/2018]

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