Treating the Painful Tendon
Tendon-related pain is a very common condition seen in Physical Therapy clinics and gyms across the globe. There are also several different types of tendon pathologies, including tendinitis, tendinosis, and tenosynovitis (irritation to the sheath surrounding the tendon). Dealing with these issues can be frustrating as they limit what you can do at home, at work, and for recreation.
When you typically think of rehabbing a painful tendon, most people envision soft tissue work, mobilizations, massage, ultrasound etc. However, those types of treatments only provide temporary relief, and do nothing to treat the underlying reason WHY the tendon hurts in the first place!
There are many different things that need to be considered when treating tendon issues, however the most important is LOAD. Tendon issues arise when the load placed on the tendons is more than they are capable of dealing with at that point in time, which is why these are generally described as overuse injuries. The stronger a tendon is, the more capable of dealing with load it is. When it comes to load, the devil is in the dosage. Not enough load and the tendons can’t adapt and get stronger, but too much load and they become irritated and painful.
When rehabbing a painful tendon, the most important thing is how you begin to load and strengthen that tendon. Careful attention should be placed on HOW MUCH load is applied to the tendon, and the manner in which it is applied. This is because different types of activities stress tendon to different degrees. In general, stress on tendons increases as you go from isometric (i.e. non-moving) activity, to slow speed activity, to fast speed activity, and finally to plyometric activity. When rehabbing a painful tendon, I typically progress corrective exercises in this same manner.
Long duration isometrics have been shown in the literature to significantly and immediately relieve tendon related pain (albeit for a temporary period of time), and are a great way to start re-introducing load to a painful tendon. I typically have patients perform an isometric exercise for 5 reps of 45 second holds, with 1-2 minutes rest in between. Examples of isometric exercises would be wall sit variations for patellar/quad tendon pain, calf raise variations for Achilles tendon pain, and hip abduction variations for glute tendon pain. When a patient can tolerate isometric exercises with extra weight (whether that is a kettlebell, barbell, dumbbell etc.), I progress them to slow speed exercises.
Slow speed exercises are my next line of attack for working through tendon pain, as they are slightly more stressful than isometrics, but are tolerated very well and allow you to further strengthen the tendon. The usual protocol I utilize is called Heavy Slow Resistance (HSR) training, and involves a three second lifting and three second lowering phase for an exercise, but with no pauses. For patellar or quad tendon pain I will typically start with partial range HSR box squats and gradually progress range of motion and load as the tendon adapts. For Achilles tendon pain I will prescribe HSR calf raises, starting from the floor and progressing to toes elevated and with extra weight as it becomes less painful. For glute tendon pain I usually start with HSR side-lying clamshell or hip abduction exercises and progress to standing exercises.
The final step in rehabbing and strengthening tendons is the introduction of fast speed and/or plyometric activities, but this is based on each patient’s unique needs. If I am treating an athlete, I will certainly have them performing plyometrics as the last phase of rehab. However, if I am treating someone who does not participate in sports, I usually just end with faster speed exercises, as they do not have to regularly perform plyometric activities in their daily lives. For fast speed training I utilize similar exercises as the ones used during slow speed training, just with a much faster lifting and lowering speed. For plyometrics, I like to program various hopping/skipping drills first, then work to double and single leg jumping and bounding.
If you have any questions about how I can help you treat your tendon pain, or you are currently dealing with a tendon related injury, email me at Drryan@proletept.com to schedule an evaluation with me to start relieving your pain and getting you back to the activities you want to do!
- Dr. Ryan VanNieuwenhuyze PT