Tendinopathy Strength Training: The Key to Permanent Recovery

If you are struggling with long-term tendinopathy, strength training is an absolute must to recover fully. A progressive and targeted strength training programme is essential as it restores structural integrity and cellular properties of the injured tendon, rebuilding its ability to tolerate load and allowing for long-term recurrence prevention. 

You may have found that rest, shockwave therapy or massages are helpful at first, but the pain always seems to return eventually. You might also find yourself struggling to progress workouts without flaring the pain up. This is likely because you have addressed initial symptoms but haven’t targeted the root cause of tendinopathy with a gradual, targeted strength training programme.

The Science behind Tendon Healing 

When tendons are exposed to physical stimulus, they adapt by becoming stronger to accommodate and support function (like muscles or skin callouses!). Adaptation occurs by way of a process called collagen turnover, where collagen fibres in tendons break down and are replaced by stronger new fibres. Fibres that have become disorganised and randomly oriented during structural breakdown are also realigned to enhance stiffness and structural durability. In most tissues in the body containing collagen, this process is relatively quick, but in tendons it is slower due to the high fibre density (think a tight bundle of cable fibres) and relatively poor blood supply compared to tissues like muscles. Healing can therefore take anywhere from a few weeks to a few years, depending on tendon thickness and the stage/chronicity of the injury. 

Targeted Strength Training

Exercises are essential to improve blood flow, relieve pain and induce tendon adaptation. They should be specific to the injured tendon to directly strengthen it, as well as address underlying factors causing overload of tendons. Such underlying factors can include faulty biomechanical movement patterns, poor technique or weak stabilising muscles, and can be identified by a trained physiotherapist. Training should also be specific and personalised to the patient, meaning that exercises should be prescribed according to what is feasible and achievable for the individual performing them. 

Timing and Progression – When and How?

Strengthening exercises should begin as early as possible in the timeline of injury, as long as pain is tolerable and feasible. In the initial stage of tendinopathy, isometric exercises can help relieve pain and gently restore muscle activation. Exercise can then gradually progress towards low resistance, concentric, then eccentric and eventually heavy slow resistance and sport-specific training. Studies show that high-intensity strength training (>75% maximal strength, low volume) can increase tendon stiffening and thickness, muscle strength and improve pain and function (Radovanović et al., 2022). This means that simply doing high-repetition (more than 10 reps), bodyweight (for lower limb injuries) or lightweight exercises may not provide sufficient stimulus to induce tendon healing. Exercises should also be specific to the injured tendon and be executed frequently enough to trigger tendon adaptations, without worsening tendon irritation. Lastly, exercise progression should also be adjusted according to the individual’s tolerance and pain response, as opposed to an incremental increase in intensity over time in standard training programmes. 

Seeking Physiotherapy Help 

Resting and managing symptoms can be a great way to kickstart tendinopathy rehab, but they do not address root causes of pain or help to rebuild tendon strength. Our physiotherapists at Core Concepts are trained in administering pain-relieving treatments and guidance on rest, and subsequently prescribing specific and safe exercise programmes. They are experienced in identifying common underlying mechanisms of injury and fixing them to get patients back to being able to do the things they love, be it fitness regime, competitive sports or simply activities of daily living. If you’re struggling with stubborn recurring pain from tendinopathy, do not hesitate to reach out to our team to start your healing journey. 

References: 

Radovanović G, Bohm S, Peper KK, Arampatzis A, Legerlotz K. Evidence-Based High-Loading Tendon Exercise for 12 Weeks Leads to Increased Tendon Stiffness and Cross-Sectional Area in Achilles Tendinopathy: A Controlled Clinical Trial. Sports Med Open. 2022 Dec 20;8(1):149. doi: 10.1186/s40798-022-00545-5. PMID: 36538166; PMCID: PMC9768072.