Transcription
Whether you're experiencing symptoms related to your shoulder, elbow, hip, knee, or ankle, I'm going to teach you everything you need to know about how to rehab tendon injuries and pain. For warning, this is a long video with a lot of detail, so feel free to use the timestamps.
Tendons are a type of connective tissue that transmit forces from muscles to bones to produce movement. Their ability to store and release energy, especially as it relates to the patellar and Achilles tendons, improves power and movement efficiency and helps to protect muscles from injury.
The classification of tendon injuries has changed over time, and there is still debate and uncertainty about the exact cause of symptoms. For decades, gradual, non-traumatic tendon pain was labeled as tendonitis because it was believed to be an overuse type injury that resulted in acute inflammation of the tendon. Based on our knowledge at the time, recommendations would often include rest, ice, and anti-inflammatory medication.
However, research as far back as 1976 started to question whether this was truly the case. As these tissues began to be studied under a microscope in the 80s and 90s, scientists actually discovered an absence of inflammatory cells. In 2002, the British Medical Journal published an article titled "Time to Abandon the Tendonitis Myth."
For a period of time, tendonosis became the preferred diagnosis for many medical doctors and physical therapists because various studies consistently found a degenerative process associated with painful tendons rather than acute inflammation. Therefore, tendinosis was considered a chronic overuse injury.
But as of 2012, tendinosis is not the preferred diagnostic label because the only way to truly determine the extent of degenerative changes in a clinical setting is with imaging. However, imaging usually isn't recommended because these changes are quite common in the asymptomatic population, and imaging doesn't typically influence the diagnosis or treatment. Plus, there are a variety of studies showing that individuals can have an improvement in symptoms and function despite no changes in tendon structure on imaging.
What should we call it then? In 2019, an international group of tendon experts suggested that tendonopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading. Mechanical loading just refers to anything that loads the tendon. In the case of the patellar tendon, that would mean squatting, jumping, decelerating, etc. For the elbow, it would be related to things like gripping, lifting, and twisting.
As it relates to symptoms, there's a dose-dependent relationship with the magnitude and rate of loading. Sticking with the patellar tendon example, I'd expect a single-leg squat to hurt more than a double-leg squat. I'd also expect a double-leg jump to hurt more than a double-leg squat. Tendons are affected more by the speed of the movement or the rate of loading, and this will be an important consideration for exercise selection and programming. The range of motion can also play a role, which I'll talk about later.
So, instead of focusing on inflammation or what the tendon looks like on imaging, the goal of rehab is twofold: one, improve your tolerance to various forms of loading, and two, restore the function of the affected tendon and muscle, the rest of the involved limb, and you, the person in general.
A fundamental component of rehab is understanding and monitoring pain. Do you have to avoid pain during exercise, or is it safe to push into a little pain? Well, the majority of researched exercise programs use pain-based criteria for progressing exercises. In fact, some papers actually increase the difficulty of an exercise if participants have a decrease in pain.
Silber, Nagle, et al. in 2007 helped popularize the model that's most often used today, which involves exercising to a tolerable level of pain. This is unique to you. One person watching this video might only be comfortable exercising with slight pain, while someone else might be comfortable exercising with moderate pain. There's not necessarily a right or wrong way to go about it, but there are some strategies that you can use to help find what works best for you.
You're not only going to monitor symptoms during exercise but immediately after and the following day. Ask yourself three questions:
1. Is my pain tolerable during exercise? If it's helpful for you, you can rate your pain on a scale from 0 to 10 and determine the highest acceptable number for you. Some physical therapists might recommend staying at a 3 out of 10 pain or less, while others might suggest a 5 out of 10 pain or less. You get to decide.
2. Is my pain better, worse, or the same after exercise? Tendinopathy may exhibit a warm-up phenomenon, in which symptoms actually improve with physical activity, so it's possible that you feel better after exercising for a short period.
3. Is my pain better, worse, or the same the day after exercise? This is the most important question because it gives us an understanding of how you're responding to the current dosage of exercise. If you feel fine during and immediately after exercise, but you have a significant worsening of symptoms the next day, that's an indication that you're doing too much and need to back off a bit.
You can assess your next-day symptoms with your normal functional activities or use a specific assessment, such as a single-leg squat variation. In the case of patellar tendonopathy, for example, you rate your pain on day one with a single-leg squat variation as a 3 out of 10. You then perform your exercise routine with intolerance, go about your day, and go to bed without any major issues. The next morning, you perform the movement again, but this time you rate your pain as a 6 out of 10. This means that even though your symptoms were tolerable during exercise, you might have done more than what you can currently recover from. You didn't do any harm, but decreasing the volume or intensity would be recommended.
For the Achilles tendon, it could be heel raises. For the hip, it could be walking or standing on one leg. For the elbow, it could be gripping. For the shoulder, it could be a lateral raise. Anything works as an assessment as long as it loads the affected tendon, it brings about some level of discomfort, and you're consistent with your choice. But if you're going to test it, test it once, not 30 times per day, and accidentally flare up your symptoms.
So, to summarize: Do you have to avoid pain during exercise? Not necessarily. Is it safe to push into a little pain? Yes. However, you're going to have to find what works best for you.
Two other fundamental components of rehab are load management and activity modifications. This is a simplified explanation, but most tendinopathies are thought to occur when the intensity, frequency, and volume of tendon loading exceeds your capacity to recover and adapt appropriately. It often comes down to doing too much, too soon, although that will look slightly different for more active individuals versus less active individuals.
Let's tie the goals of rehab, pain monitoring, and load management together by reviewing the boom-bust cycle. Tell me in the comments if it sounds familiar. You have a spike in activity over the course of a day, week, or month that contributes to an increase in symptoms. You decide to rest completely, and your symptoms go away. Excellent. You recognize that you overdid it last time, so you don't do quite as much this time around. However, you have a flare-up despite doing less of the same activity. You rest again until your pain goes away and repeat this process until your activity level is severely diminished.
This is not an uncommon cycle. It's often driven by the belief that pain is bad and rest is good, while also using a reaction in pain as the primary metric for success. But that's not the way to approach tendonopathy because rehab can take 3 months, 6 months, or even a year or longer. Symptoms will fluctuate on a day-to-day and week-to-week basis, which is why your focus should be on function while monitoring pain to guide the appropriate amount of physical activity.
An increase in function will not always correlate with a linear decrease in pain. If you go from running one mile with a 3 out of 10 pain to running three miles with a 3 out of 10 pain over the course of three months, that's actually significant progress. The pain may seem like it's staying the same, but technically it's getting better because it requires more activity to reach the same level of pain that you initially experienced.
Remember, one of the primary goals of rehab is to restore function. You'll monitor your symptoms during and after exercise to ensure that you're not exceeding your current capacity while keeping track of your progress with the various exercises at the same time. You'll reduce the frequency, intensity, or volume of activities that are aggravating your symptoms and limiting your functional progress, such as running, going to the gym, or playing a sport. If needed, you can replace the reduction in that specific activity with a different activity that doesn't exacerbate symptoms to maintain your fitness.
Before outlining the exercises, I want to revisit the concept of inflammation. As more studies were done on tendons, researchers discovered that inflammation does exist in tendinopathies. I want to bring this up because I think some individuals may have misinterpreted what I've said in previous videos. I normally say something along the lines of this: although inflammatory markers are present, inflammation is not believed to be the primary driver of the condition, and some inflammation just reflects the normal response to regular tendon loading and adaptation.
There are different types of inflammation. Inflammation can be more acute or chronic. It's complex. For tendinopathies, the inflammatory markers present aren't changing the plan for rehab. The previous model of complete rest and ice often leads to the boom-bust cycle I described. Plus, loading is healthy for tendons when the appropriate dosage and recovery is provided.
What may be more important is knowing that chronic low-grade inflammation can influence tendinopathies, particularly as it relates to lifestyle and metabolic factors. Sleep, stress, stress, nutrition, alcohol intake, smoking, exercise habits, and anything else that affects your overall well-being can also affect the onset and persistence of symptoms. How much this matters will vary case to case, and I'll give an example toward the end of the video. But even if you're dealing with rotator cuff tendonopathy and you've been wanting to improve your general health, I wouldn't underestimate the power of small changes, such as simply increasing your daily step count.
Let me break down the typical framework of rehab for Achilles and patellar tendonopathy, and then I'll describe how this process relates to other body regions. Rehab is often divided into four stages: isometrics, heavy slow resistance, energy storage and release, and return to sport. In reality, these aren't distinct stages. There's going to be overlap, and in many cases, you'll be performing all of these categories simultaneously. The idea is that you are gradually increasing the demand and complexity of movements over the course of weeks and months, specifically ramping up the amount of load and, more importantly, the speed of loading throughout the stages.
Plyometrics and sports-specific movements are crucial for getting you back to your previous level of function and performance. But we've learned that quicker movements don't actually cause the positive adaptations we're looking for in tendons, particularly increasing their stiffness, as theorized by Merman and colleagues, some of the leading researchers in the field. A loading-induced increase of tendon stiffness would reduce tendon strain at a given force, which could prevent the development of structural impairments and pain in tendons. To be clear, tendon stiffness is different from the sensation of stiffness. This has more to do with the strength of the tendon.
In order to do this, tendons require heavy loading for a duration of at least 3 seconds at a time. Isometrics and heavy slow resistance serve the same purpose of trying to create the positive tendon adaptations, which is partly why they're at the start of this rehab framework. Now, you have no idea if your tendon stiffness is actually improving because it requires specialized equipment to measure. So focus on the process I'm going to lay out and the goal of improving your function. I say this because research is messy, and there are many studies in which people get better despite not having the predicted tendon adaptations.
Stage Zero: Isometrics. Most tendonopathy protocols have isometrics listed as stage one, but they're listed here as stage zero because I don't think there's an isometric milestone that you need to pass before performing the next group of exercises. And although isometrics can temporarily reduce pain for some individuals, they are not a magic bullet like previously believed. The benefit of isometrics lies in your ability to easily control the range of motion, intensity, and rate of loading for whichever exercise you perform.
Here are five examples for patellar tendonopathy:
1. Double-leg wall sit.
2. Single-leg wall sit.
3. Heel-elevated wall sit. The single-leg and heel-elevated variations are both progressions of the double-leg wall sit.
4. Spanner squat with a strap or band anchored around your legs and a squat rack. You'll sit back until your hips and knees are roughly at 90° angles.
5. Single-leg seated knee extension. You can perform this exercise with a machine, band, or some other setup with your knee between 90 and 60° of flexion.
You're going to choose what works best for you based on your preference, equipment availability, tolerance, function, etc. Here's an example of how the seated leg extension is applied in research: Bend your knee to roughly 60°. If you're using a machine, make sure it's too heavy for you to move. Push at your maximum tolerable effort for 3 seconds, relax for 3 seconds, and repeat for four total repetitions. Rest 1 to 2 minutes. Repeat four more times for five sets total. Perform this three times per week.
A few things to note:
1. Try it on your unaffected side first so you know what it feels like.
2. Ramp up and ramp down your effort the first few times you try it so you don't accidentally get a spike in symptoms.
3. And I recommend pushing at your maximum tolerable effort because it should feel hard.
This is one protocol that's been used in research to improve tendon stiffness that's easy to implement and doesn't take much time. For some people, this might be all they do. For others, they might just add this to their pre-existing programs. Keep in mind that if your knee is bent to 75°, that's okay. If you hold each contraction for 3.5 seconds, that's also okay. Unfortunately, this is not a perfect science. You're just aiming for a high load in a fairly neutral or stretched position, at least a few times per week.
For the Achilles tendon, you can do a seated or standing heel raise. For the elbow tendons, you can do isometric wrist flexion or extension. For the rotator cuff, you can do external rotation or abduction. For gluteus, you can do hip abduction.
What about other protocols? They're fine too, although it's possible they're contributing more to muscular adaptations. A previous example I've given is to pick one exercise option to complete for three to five sets of 30 to 45-second holds with a 2-minute rest between sets. This can be done as a warm-up prior to your workouts or as an independent stimulus one to two times per day. A greater volume and frequency of loading doesn't seem to lead to better adaptations of the tendon, but that doesn't mean these exercises can't be performed four to seven times per week instead of three if that's what you prefer.
As I said, the tendon adaptations don't always perfectly align with an improvement in symptoms and function, and a variety of protocols over the years have been shown to work. You just want to take these overarching principles and apply them to your specific situation.
For the next stage, you can pick any exercise as long as it is tolerable and sufficiently loads the tendon. Here are four options for the knee:
1. Squat progressions can be made by increasing the resistance over time or choosing a variation that emphasizes the extensors more, such as a heel-elevated squat.
2. Split squat. Similarly, progress the resistance, range of motion, or amount of forward knee travel over time.
3. Step down. Progress by elevating the height of the step or your heel, or increase the amount of forward knee travel.
4. Single-leg seated knee extension.
You can perform one to two exercises for two to four sets of six to 12 repetitions, two to three days per week. I'd recommend picking at least one single-leg variation. The speed of each repetition should be slow. For example, if you're performing a squat, descend over the course of 3 seconds, pause for 1 second at the bottom, and ascend for 3 seconds. That's a 7-second repetition. If you want to ensure consistency with your tempo, you can download a metronome app on your phone. Remember to manipulate the range of motion, intensity, etc., as needed, and focus on consistency, gradual progressions, and strategies that align with your goals.
Let me answer a few questions I anticipate receiving:
What about eccentrics? Eccentrics can work, but they're not necessary, and I find them less desirable because they typically require more volume and time. Tendons respond to load regardless if the contraction is concentric, eccentric, or isometric.
Does it have to be heavy? Not necessarily, as research has demonstrated clinical improvements with moderate loads, but your aim should be to progress the load or difficulty over time.
When can you progress from isometrics to these exercises? Whenever it's a bit of trial and error, and when you start doing these exercises, you might still continue performing isometrics two to three times per week.
What else should you be doing? Training the rest of your body as needed. If you're a basketball player with patellar tendonopathy, you should be including hip and ankle exercises, conditioning, etc. If you're a tennis player with elbow tendonopathy, you probably want to include some shoulder exercises. The focus is the affected tendon, but you still want to take a holistic approach to rehab.
Along with the isometrics and heavy slow resistance training, stage two includes jumping, landing, plyometrics, and exercises that prioritize a faster rate of loading. These exercises should be performed two to three times per week with an emphasis on execution. There's an infinite number of possibilities and loading schemes here, so I'm just going to provide two options for the knee. You don't have to follow the exact order of either.
1. Countermovement jump, to box countermovement jump, bilateral depth drop, bilateral depth jump, single-leg depth drop, and single-leg depth jump.
2. Forward lunge, forward lunge with step back, step and land, step and land with a step back, and running with a step back.
As you can see by my lack of explosiveness, my tendons probably aren't very stiff. For the Achilles tendon, you'd want to work through a progression that eventually gives you the confidence in hopping multi-directionally on a single leg. The energy storage and release aspect of this stage applies more to the patellar and Achilles tendons, but the idea of integrating faster functional movements applies to the other tendons as well.
Stage three: Return to sport. There are no distinct exercises that need to be performed in this stage. Instead, this stage is about gradually returning to your preferred sport or activity. For example, if you're a marathon runner, you train for that marathon over the course of several months as you build up your volume. If you're a recreational basketball player, the same thought process applies. You can't expect to just jump back into hours of full-court games after doing 3 months of exercises in the gym. You have to build back up to it.
Please understand that these are guidelines, not hard and fast rules. My hope is that you take this information and individualize it to your specific goals and needs. Let me give four examples:
* If you're a basketball player in the playoffs, you might have limited flexibility as it relates to your training and games. For that reason, you would probably just do the isometric protocol three times per week.
* If you're a recreational gym-goer with biceps or rotator cuff tendonopathy, you might incorporate isometrics three times per week while also modifying your exercise selection, intensity, and tempo. Some of your normal training can be heavy slow resistance.
* If you have gluteus tendonopathy but you're also dealing with other comorbidities, you might choose to prioritize your overall health as a means to improving your symptoms and function over time. You could place a greater emphasis on direct loading of the gluteus tendons.
* If you're a runner, do you have to stop running completely? Not necessarily. You can incorporate runs into this rehab framework, but you probably have to change something. You might have to do less weekly miles or fewer runs per week, but you can make up that difference with the exercises in this video or through other forms of training. If you continue to run but can't stop yourself from consistently overdoing it and falling into that boom-bust cycle, then it might be worth considering taking a break from running.
You don't want to be your own worst enemy here. Don't turn a six-month process into a two-year process by being impatient. Initially, if nothing else, remember the goals of rehab:
1. Improve your tolerance to various forms of loading.
2. Restore the function of the affected tendon and muscle, the rest of the involved limb, and you, the person in general.
What about foam rolling, massage, icing, or whatever else you can think of? If it's low cost and low risk, you can pretty much try out anything. However, these things aren't the focus of rehab because they don't have an additive benefit to exercise alone. Don't let them take away from the goal of progressively improving your function.
With regards to injections, the research isn't promising. For example, a randomized control trial by Kernie et al. in 2021 found that a PRP injection is no better than a sham or fake injection for Achilles tendinopathy. Here are similar findings for the knee and elbow. Corticosteroid injections often have positive short-term effects on pain but lead to worse long-term outcomes. A paper by Deodal states, "This review supports the emerging clinical evidence that show significant long-term harms to tendon tissue and cells associated with glucocorticoid injections."
Unfortunately, there's not a quick fix. Rehab takes time, consistency, effort, and dedication to a structured plan.
Thank you so much for watching. If you enjoyed the video, please hit that like button, subscribe, turn on notifications, and leave any comments down below. If you're looking for a rehab or performance program, or you're interested in working with us one-on-one, visit our website at E3rehab.com. Peace.