Tendonitis is one of the most pesky injuries that can plague an athletes career, which can derail both practice and performance. This article seeks to explore the mechanisms of tendonitis and how to successfully implement a rehabilitation plan to overcome tendonitis.
Table of Contents
- How Tendonitis develops
- Common misconceptions about tendinopathy rehabilitation
- General summary of studies on tendinopathy
- Corrective measures
- Planning rehabilitative sessions
- Regarding the supplements that may help
This article is updated Dec 2016. On the Overcoming Gravity reddit, I’ve had a few threads on Tendonitis protocol that I’ve shared with users reporting success. This is the most recent link. If you want to discuss this article, go there. This is a very complicated topic, since the research is very conflicting in a lot of places.
How Tendonitis develops
Tendonitis is an outdated term due to the fact that the condition may not contain inflammation. The term used by most professionals now is Tendinopathy, which covers the broad spectrum of the degeneration of the tendon.
Here is a pictorial example of the process:
Image source. Sourced from the 2009 Cook and Purdam study.
In general, tendinopathy is an overuse injury. This condition arises when the volume of the workouts exceed your body’s ability to recover. Since our muscles have better blood supplies than our connective tissue (tendons, ligaments, cartilage) and bones, they often are able to adapt to the stressors of exercise placed on them faster. This leaves our connective tissues and bones vulnerable to overuse since they cannot heal as fast. If excessive stress is placed on them, they start to react negatively to the stress.
Appropriately modified stress is able to be recovered from fully. The further you go into dysfunction, the less chance there is for a full recovery.
Since this article was written, there has been a lot more research into modeling the various ‘stages’ of tendinopathy and how they react to increased exercise and dysfunction. Here is the 2016 model from Cook.
Image from the most up-to-date Cook model study (Sept 2016).
Here are the stages explained:
- Tendinopathy starts out with stress being placed on the tendon. If the stress overloads the ability of the tendon to adapt then the tendon enters a state of reactive tendinopathy.
- Reactive tendinopathy tends to exhibit signs and symptoms of tendonitis such as pain, soreness, achiness, and so on localized around the affected area. Symptoms generally go away with ceasing the aggravating exercise(s). If the load(s) on the tendon are appropriately modified, the tendon will be able to repair itself and move back into normal tendon stage. In this state, it is only possible to see degenerative changes under a microscope. There may be inflammation present in the reactive tendinpathy stage.
- If excessive stress is continually placed on a tendon in reactive tendinopathy, it may start to devolve into a tendon dysrepair state. Tendon disrepair occurs when excessive loads are applied to a tendon in the state of reactive tendinopathy. During this process, the normal repair mechanisms of the tendon in reactive tendinopathy are disrupted by continually applying overloading forces to the tendon, which results in a state of disrepair (and hence degeneration). An appropriate analogy for this would be continually pulling off scabs: it leads to the repair process being disrupted and more scabs continually being developed until there is obvious signs of scar tissue.
- Reactive on degenerative tendinopathy is the transition of the reactive tendinopathy to the tendon dysrepair classification and hence the start of a degenerative state. In this state, it is possible to see small scale disruptions in the tendon in imaging techniques such as MRI. There is typically dysfunctional or no inflammation present in the tendon dysrepair stage.
- Degenerative tendinopathy is the state of the tendon which has transitioned past reactive on degenerative tendinopathy. In this state, it is possible to see large scale disruptions in the tendon in imaging techniques such as MRI. There is typically dysfunctional or no inflammation present in the degenerative tendinopathy stage. There is limited reversibility of the degeneration. Large scale forces placed on a tendon in tendon disrepair, especially the degenerative tendinopathy stage, can lead to large scale tearing of the tendon resulting in grade II (partial) and grade III (full) tears.
As you can see, this current “process” of tendinopathy involves a reactive and then degeneration response of the tendon through various stages leading to larger and larger disruptions in the tendon. Signs and symptoms of disruption such as pain, soreness, achiness, and so on especially with increases in symptoms. Once the “degenerative” process starts the tendon is in a stage of “tendon dysrepair” of which the two stages are reactive on degenerative and degenerative tendinopathy.
The “repair process” arrow going up is progressively less filled in. From current research we know that a tendon in a state of reactive tendinopathy can repair well back to normal tendon structure. However, as you move into tendon disrepair classification, the ability to repair such tissue decreases as you get more severe. What ends up happening instead is that scar tissue develops which is much less strong than normal tendon tissue because of the type of collagen (type III collagen instead of type I) and orientation of the collagen structure (scar tissue is haphazard collagen deposition instead of parallel alignment which is stronger).
These “stages” are not exactly discrete and able to be diagnosed accurately except with medical imaging techniques. These stages progressively move into one another, so there’s no time where you may only be in one stage and then immediately go to another stage. It’s most likely that you will be between stages of normal and reactive tendinpathy or between stages of reactive tendinopathy and tendon dysrepair. A trained medical professional may be able to give a diagnostic analysis of where you likely are according to the presentation of signs and symptoms and reaction to training.
General signs and symptoms of moving from reactive tendinopathy to tendon dysrepair and more degenerative changes:
- Total rest does not work
- The tendon is stiff, achy, or sore after periods of inactivity such as after waking up
- You have chronically worked through signs and symptoms such as pain, achiness, soreness, stiffness, and so on for longer then 3-4+ weeks you may be at higher risk
Hence, it is important to remove offending exercises from any form of tendinpathy and apply rehabilitation as soon as possible to stimulate the ailing tendon toward as much normalization of healthy tendon as possible.
Common places where tendonitis is easily developed are located at:
- Medial epicondylitis (inner elbow – Golfer’s elbow) which arises from excessive pulling exercises.
- Lateral epicondylitis (outer elbow – Tennis elbow) which arise excessive hyperextension of the wrist.
- Triceps tendonitis (elbow) which arise from excessive pushing exercises.
- Biceps tendonitis (elbow) which arise from excessive pulling exercises.
- Wrist tendonitis (wrist) which arise from overuse at the computer or in excess flexion/extension of the wrist.
- Patellar tendontis (patella/knee) which arise from overuse in running, plyometrics, or weightlifting.
- Hamstring tendonitis (knee) from overuse in running, plyometrics, or weightlifting.
- Achilles tendonitis (ankle) which arise from overuse in running, plyometrics, or weightlifting.
If you have sore joints or tendons that are starting to become sore, this is your body letting you know that you should back off from exercise. This indicates that those body parts are under excessive volume or repetitive strain that you cannot recover from.
Common misconceptions about tendinopathy rehabilitation
- Rest — You may encounter “rest” for tendinopathy as a common form of treatment from doctors, physical therapists, advice from others, and so on. Rest typically only works in the range of normal tendon to reactive tendinopathy. It typically does not work for tendinopathy moving toward tendon dysrepair and degenerative tendinopathy stages.
- Ice — not particularly useful. Analgesics are more useful for pain. Compression is more useful for swelling. Blood flow does not need to be depressed below normal levels.
- Pain — You may have heard that you shouldn’t push through painful exercises as pain is bad. This is false. The reality is that you shouldn’t push through aggravating exercises. The difference between painful and aggravating is simple. Some exercises during the rehabilitation process may be painful, but they yield a positive result over the course of the next few sessions. These painful exercises are positive to the rehabilitation process. On the other hand, non-painful exercises may aggravate the tendon and lead toward more degeneration. Hence, it is best to remove aggravating exercises that lead to decreased performance, increased pain, and signs and symptoms of progressive tendinopathy. Pain is generally correlative in an acute injury to an aggravating exercise, but not in a chronic injury (3-6+ months). Hence, why I tend to suggest painful rehabilitative exercises be only performed under qualified medical professional treatment. Do so at your own risk.
- Blood flow — another common misnomer of tendonitis is that increasing blood flow helps repair. I believed this previously, but research has show that tendinpathy typically increases blood flow to the tendon (which makes sense given that injuries typically will have increased blood flow). Thus, injured tendons actually slightly swell up as seen in the above ultrasound image. Rehabilitation actually decreases blood flow to normalize it.
General summary of studies on tendinopathy
The only thing in the scientific literature that has high quality evidence to support rehab in tendonitis currently is eccentrics. Everything else seems to be approximately no evidence to low evidence with a few things such as ECST (extracorporeal shockwave therapy) or PRP (platlet rich plasma) maybe being tentatively moderate evidence in lower body tendinopathies (although it varies).
- High quality evidence = multiple random controlled trials support it
- Moderate quality evidence = at least 1 random controlled trial supports use of it, with underlying scientific reasoning, case studies, and other non-RCTs.
- Low quality evidence = scientific reasoning, case studies, non-RCT studies support the use of it
- No evidence = Doesn’t work
- Conflicting evidence = studies don’t agree.
General summary of various things that work and don’t work:
- High quality evidence = eccentrics. This is likely the best study explaining why eccentrics work.
- Moderate quality evidence = ECST knee and achilles (moderate to weak), PRP for knee (moderate to weak but need to be in conjunction with eccentrics, overall mixed results). ECST for calcific tendonitis. Surgery (variable from low to moderate, and depends which surgery. Some have high satisfaction)
- Weak evidence / No evidence / Conflicting evidence = PRP (platelet rich plasma), LLLT (low level laser therapy — weak helpful, mainly for pain), ECST (covered above), prolotherapy and other sclerosing injections (probably helps, but still limited evidence), stretching and balance training (no evidence or make it worse — hence why I only use stretching for range of motion deficits), massage/manual therapy (case studies weak evidence in support, systematic reviews none), acupuncture (might help lower body), dry needling (little to no evidence), ergonomics (useful for pain management, but doesn’t solve the problem), supplements like fish oil, gelatin, vitamin C, L-lysine, glucosamine and chondroitin, (See bottom of this article for supplements section), etc.
- No evidence = Ultrasound (doesn’t work), NSAIDs (no evidence as tendinopathy is generally not inflammatory)
- Makes it worse = corticosteroids/cortisone (short term better pain and function, long term worse)
Therefore, the primary exercise(s) are based off of only eccentrics. The peripheral work that may help is simply other comprehensive things you can do that won’t hurt but may help due to the range of no evidence to low quality evidence that is the rest of the treatments. There may be some placebo effect involved, but who cares if you’re getting better. The reason why I grouped weak evidence to no evidence is that even if there was a potential beneficial effect, the effect is usually very low at most or it may work for pain but not actually the tendonitis. It’s hard to distinguish when there’s a lot of conflicting results.
Eccentrics — The only high quality evidence for rehabilitation
Research note: Heavy slow resistance (HSR) is a protocol that has gained a bunch of popularity in the past 5 or so years which seems to be effective for lower body tendonitis (achilles and patellar specifically). In this, you aim to do 3 sets of 10-15 reps with heavier weights and a slow eccentric phase. This has been proven to work for around 60-80ish% of the population with those tendinopathies as well, so if you want to use a scientifically proven method for lower body tendinopathies you can try this. If that doesn’t work, the higher reps protocol has had some success with non-responders of HSR. Likewise, the opposite: if you’ve tried higher reps and not tried HSR then HSR might work for you.
This is my take on eccentrics with a higher repetition phase and lighter weights which I have found to work in my athletes (primarily gymnasts and climbers) at about the same ratios. Choose HSR to start if you want to go by the research, but you can use higher repetitions effectively too.
- Do an exercise that works the muscles and tendon in question. So medial epicondylitis you do wrist curls, biceps you do biceps curls, Achilles you do calf raises, etc.
- 30-50 reps for 3 sets. Start at 30 and work your way up to 50 slowly. If higher reps make it worse after a few sessions then drop back down. Working through pain is fine, according to the scientific literature as long as function is improving.
- Not to failure on the reps. This is super duper important as going to failure when most people re-injure themselves!!
- 3-5s uniformly slow controlled eccentric and 1-2 seconds concentric. For example, 5121 or 3111 and eventually down to 3010 or 2010. Basically, controlled is the name of the game.
- 3x a week frequency. Can go up to 4x a week if it helps. If it doesn’t help drop back down.
If one does not work, then try the other. I’ve seen multiple cases where high repetitions didn’t work but HSR did, but if HSR didn’t work the higher repetitions do. I suspect this might be due to the stage of tendinopathy: the tendon dysrepair stage might benefit from a lighter stimulus of high repetitions whereas if the tendinopathy is particularly bad such as the degenerative tendinopathy stage it may benefit from heavier repetitions to stimulate healing. This is only my hypothesis.
The majority of the achilles and patellar studies showed that working through pain was fine during eccentrics rehabilitation. However, be smart about it: if working through pain ends up aggravating it — the tendinpathy is getting worse over sessions instead of better — then don’t keep doing it.
Note for medial epicondylitis / golfer’s elbow: Since overuse tendonitis can affect the medial epicondyle area from two different factors you want to do eccentrics from wrist flexion and supination slowly to wrist extension and pronation to hit the pronator teres, and slow wrist eccentric curls for two eccentric exercises total. Split the 3 sets of 30-50 reps into two for the exercise: 3 sets of 15-25 for each exercise.
For medial and lateral epicondylitis (golfer’s and tennis elbow) the “Tyler Twist” flexbar can also work effectively.
Peripheral work that may help:
- Remove the aggravating and offending exercise(s) by going down a progression or substituting them. Do not stop working out.
- If things are too painful isometrics can be useful at 70% to 80% (Note: 80% of 8 RM so probably around 50-60% 1 RM) of MVIC (maximum voluntary isometric contraction). In other words, put the joint(s) in neutral position and load it and hold for 5-10 seconds or until pain is reduced without moving the joint(s). This should be done before the rehab work to reduce any pain that may occur.
- Light stretching for the agonists and antagonists (light strength = slightly into discomfort). If this does not help, remove it.
- Heavy stretching, ONLY IF there is a range of motion deficit that needs to be corrected. For example, very inflexible forearms for a climber. Otherwise, stretching may aggravate a tendon, especially in the dysrepair or degenerative stage.
- Soft tissue work or massage to the affected muscle — a bit to the tendon itself is OK but it can aggravate it in some cases. Aim to loosen any knots or tight spots in the muscle which may be putting tension on the tendon at rest.
- Strengthening to the antagonists (so if it’s biceps tendon, strengthen the triceps. Forearm flexors then do forearm extenstor work, achilles then do some anterior tibialis strengthening). Eliminating imbalances that can be a potential risk factor and maybe cause are a good idea.
- Mobility work throughout the day non-painfully
- Heat can be useful. Don’t use ice (or RICE protocol). Analgesia is better for pain than ice, and compression is better than ice for swelling. No reason to use ice. MEAT — movement, exercise, analgesia, treatment — is better.
Achilles — Achilles tendonitis is the most studied in the literature, and here are the 3 most popular regimens in order of new to old.
- Silbernagel — http://www.raynersmale.com/blog/2015/10/22/treatment-of-achilles-tendinopathy-with-combined-loading-programs
- Alfredson — http://www.runnersworld.com/sweat-science/eccentric-calf-strengthening-for-achilles-tendinopathy-five-years-lat
- Curwin and Stanish — http://www.mincep.com/prod/groups/ump/@pub/@ump/documents/content/ump_content_421642.pdf
Planning rehabilitative sessions
Integration with regular workouts is the same. Do your workouts, then the structure suggested above. If the workouts require use of the injured limb and does not aggravate it, then make sure the tissue is sufficiently warmed up before doing anything.
Proper structuring of the modalities listed above is important. Here’s the combination of things that I’ve found work the best.
Ordering of rehab/prehab:
- Heat and/or mobility to warm up
- Soft tissue work, if wanted
- Light stretching
- Strengthening with agonists and antagonists including the sets of 30-50+ not-to-failure exercises with the 3-5s eccentric.
- If you need more range of motion then flexibility work if needed
- Follow up with mobility work, especially if there is new range of motion from the flexibility work
Eccentrics (agonist work) is performed 3-4x per week. The rest such as mobility, soft tissue massage, heat, and so on can be performed 5-7 times per week. If the rest of the peripheral work makes it feel and perform better with higher frequency, feel free to do so.
Remember, having an injury or something you need to add in prehabilitative work doesn’t mean that you should rest everything and neglect other training. If you have medial epicondylitis (elbow tendonitis) for example you can still do legs and core work as well as do other skill work for your sport and corrective nature things such as flexibility/mobility.
One of the big things with tendonitis at “stability” joints such as the elbows is that there tends to be a loss of mobility in the wrists and shoulders thus putting more stress on the elbows. The same thing occurs with tendonitis at the knees and losses of mobility at the ankles and hips. Thus, if you have tendonitis at the elbows or knees you should work on improving the strength, flexibility, and mobility of the two joints surrounding it.
Getting back to exercise
I generally recommend start with 40% intensity or so and ramping back up about 20% every 1-2 weeks. So it may take about 3-6 weeks to get back into your regular workouts, depending on how bad the tendonitis was before. Longer if it was more severe.
Generally speaking, whether you use heavy slow resistance or higher repetitions, I always recommend working back into various weighted exercises and progressions with high repetitions. Start out within the 15-20 range before ramping down into the 5-12 range for strength and hypertrophy. Slowly go down about 2-3 repetitions per week.
If you’re in the reactive tendinopathy stage and just rest lets it normalize then you’ll want to work back into it over 2-3ish weeks. Tendon dyrepair will take 3-6ish weeks. The degenerative tendinopathy stage will tend to take anywhere from 5-6+ weeks most likely. Usually the latter two stages will need to be played by feel depending on how your tendon is responding to the intensity, volume, and load of exercises. Don’t be afraid to back off if it’s being aggravated.
For my patients and clients, I like to keep very high repetition isolation work in someone’s routine for another 1-2 months after they have fulled recovered and are back to normal activity. For example, if you had biceps tendonitis, you should continue to keep doing high-repetition, not-to-failure sets of biceps curls such as 3 sets of 30 repetitions.
Remember, pure rest doesn’t work unless you are in the reactive stage. Don’t do pure rest. Always do some sort of prehabilitation or rehabilitation work.
This is simply a general guideline and your case may vary. Talk to a qualified medical professional before using any of this information because it is not tailored to your specific case.
Overcoming Tendonitis is difficult but it can be done successfully.
Braces and equipment
Braces do NOT fix the problem, but they can be an effective tool for pain management while you rehabilitate an injury (under the proper supervision of a medical professional). Here are some pictures of braces that are effective for pain management of various conditions.
Clicking the image will take you to it.
Lateral and medial epicondylitis
The smaller area-specific braces help with pain management. There are sleeve-type braces that may also be effective, but from what I’ve seen in real life the smaller ones you can compress around the area tend to be the most effective for pain alleviation. Two examples are above.
Research for medical epicondylitis is virtually non-existent. Research on lateral epicondylitis is depressing, as some treatments work short term for pain and function but are long term ineffective. It goes away on it’s own in some people.
Generally, wrist braces suck because it’s hard to find one that fits really well. If you have tendonitis and need to limit mobility and add some stability, ACE wraps or any type of elastic wrap works fine.
Triceps tendonitis — Compression bracing may help. Something like this may work, but sizing is a big issue.
Shoulder tendonitis — No bracing really helps. Be aware of posture/alignment and scapular mechanics.
Like the elbow, the knee straps that are more effective for pain management are the smaller ones. You can try sleeves if you want, but I don’t think they work as well.
Compression bracing may be more effective for achilles than other areas, probably because there’s a lot of interaction between the muscles of the foot and how the ankle functions. This is why calf stretching is integral to improving plantar fasciitis, because the superficial posterior (back) line of fascial goes all the way from the back down the leg and into the foot. Remember that this doesn’t solve the issue, contrary to popular belief of easy fixes.
Soft tissue devices where you can compress the muscles and massage them can be effective in some cases if you need myofascial release and/or trigger points that cause a lot of tension on the affected tendon. Loosening these tight muscles can provide instant relief in some cases.
Regarding the supplements that may help
- Fish oil — Maybe. Essential fatty acids and anti-oxidants helped and didn’t help. The latter is hard to say because almost nothing works for lateral epicondylitis in the long run.
Carlson’s fish oil is one I have used before. High DHA/EPA content. Doesn’t taste nasty.
- Gelatin — Most likely helps. Gelatin has collagen in it, and hence can potentially be used for tendon repair. Cartilage too. This is especially true since the body cannot make all of the needs of collagen production itself. Take pre- and post-exercise.
Knox unflavored gelatin is solid. Add it to your food/drinks. Jello works as well.
- Vitamin C, L-Lysine, hyaluronic acid — also components of tendons like gelatin. Only hyaluronic acid has research from what I am aware. Seems more effective in tendon surgery than tendinopathies, but may help.
- Glucosamine/Chondroitin/MSM — unknown. Athlete hearsay at this point.
Here’s a solid one if you want to try it.
This article was originally published August 19, 2009 on Eat Move Improve. Updated Dec 2016.
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Author: Steven Low
Steven Low, author of Overcoming Gravity: A Systematic Approach to Gymnastics and Bodyweight Strength (Second Edition), is a former gymnast who has performed with and coached the exhibitional gymnastics troupe, Gymkana. Steven has a Bachelor of Science in Biochemistry from the University of Maryland College Park, and his Doctorate of Physical Therapy from the University of Maryland Baltimore. Steven is a Senior trainer for Dragon Door’s Progressive Calisthenics Certification (PCC). He has also spent thousands of hours independently researching the scientific foundations of health, fitness and nutrition and is able to provide many insights into practical care for injuries. His training is varied and intense with a focus on gymnastics, parkour, rock climbing, and sprinting.