If you are experiencing pain at a joint that started over time, typically is worse with more activity, and did not have a particular event that led to its onset, you may be experiencing tendinopathy. This is commonly seen in the following areas:
- Heel — Achilles (heel cord)
- Knee — Directly above or below the kneecap
- Hip — Gluteal, groin, or hamstrings, often near where the muscles originate on the pelvis
- Shoulder — Biceps or rotator cuff (small collection of muscles and tendons around the shoulder blade that connect to the upper arm)
- Elbow — Epicondyles (bony prominences on either side of the elbow) commonly referred to as golfers or tennis elbow
This guide will describe what tendinopathy is and provide strategies to decrease pain and get you back to the activities you love. We will discuss three common cases and offer exercise program modifications for each.
What Are Tendons?
Tendons are a type of tissue that connect muscles and bones. Ligaments, which are similar tissues, connect bones to other bones. When athletes squat, run, jump, or decelerate, tendons take the force generated by muscles and distribute it across joints in order to move our bones.
Tendons are primarily composed of a protein called collagen, which forms a rope-like structure of linearly arranged, tightly wrapped protein molecules. Healthy tendons contain relatively few cells and a limited blood supply. In the past, people thought this relative lack of cells and blood flow meant that tendons did not adapt much after adolescence. We now understand that tendons do respond to mechanical load and adapt, just slowly. If tendons did not adapt, the muscle growth from strength training would become problematic. This is because bigger, stronger muscles would pull on unadapted tendons, increasing the risk of tendon tears among gym goers. Fortunately this is not the case.
When tendons endure loads that exceed their capacity, they experience microtrauma, which is damage at the cellular scale. This happens in muscle tissue as part of the training process as well. Microtrauma causes changes to tendons, and whether those are positive or negative depends upon several factors.
In general, beneficial tendon adaptation occurs with higher loads, performed at a slower pace. [1, 2] Beneficial adaptations here include strengthening of the tendon and increased tolerance and resiliency to the forces imposed during physical activity. However, tendons also need to be exposed to different types of forces, ranging from heavy and slow to lighter and more explosive. It is ultimately the dose, volume, intensity, and duration of stress that determines whether the tendon responds positively or negatively.
What is Tendinopathy?
Tendinopathy is a negative or pathological development of the tendon; the “-pathy” suffix comes from the Greek “pathos,” which denotes disease or suffering. You may be more familiar with the term “tendonitis”, which implies the presence of inflammation, but the evidence for inflammation in tendon pain is not clear. [3] The main symptom of tendinopathy is pain over the tendon with physical activity and from pressing on it (palpation). During tendinopathy, the normally linear, organized collagen structure becomes less linear and organized; new blood vessels grow into the tendon, and tendons thicken in more chronic instances.
As mentioned above, beneficial tendon adaptation occurs with higher loads, performed at a slower pace. This describes most strength training activities, so are people who lift weights at lower velocities (like you, powerlifters) less likely to experience tendon pain? Unfortunately not. In fact, tendinopathy is a common complaint among people who train for strength. This can be for a few reasons, including:
- Not enough variation in an exercise program, also called over-specificity. Too much of the same stresses applied too frequently.
- Longer term (chronic) increases in loading, volume, or intensity beyond what tendons are capable of handling. We can call this overuse.
- Sudden changes in exercise programming with novel distributions of load. This would be a more short-term effect, which we will refer to as acute overload.
Note that we did not mention a lack of flexibility, nor a lack of “perfect” technique on various exercises as likely causes for tendinopathy. That was not an oversight on our part. They are not the probable causes of this condition. Your quadriceps tendinopathy was not the result of insufficiently stretchy quadriceps. It also did not occur because your knee was slightly out of position from a supposedly “ideal” location while squatting. While the causes of tendinopathy are complex and not fully understood, overall loading appears to be the primary culprit in most scenarios. Flexibility and technique should be relegated to minor, if not irrelevant, status in these discussions.
There are also other established contributors to tendinopathy. For example, having high blood cholesterol and diabetes both increase the risk of tendinopathy. Inflammatory diseases like rheumatoid arthritis, gout, and ankylosing spondylitis can cause various forms of tendinopathy. Additionally, certain drugs can cause tendinopathy. The most common of these are Fluoroquinolone antibiotics, including Ciprofloxacin, Levofloxacin, and Moxifloxacin.
General Management Principles for Tendinopathy
Absolute Rest Is Not Recommended
Tendons adapt to exercise, and removing all load does not lead to positive adaptations. This is one of the ironies of tendinopathy. Achy connective tissues discourage people from exercising, but rest results in detraining. This makes the tendons less resilient over time. This loss of tendon capacity increases the chances of symptom recurrence upon return to activity. Ceasing to exercise can result in short term reduction of pain, but unfortunately does not solve the problem.
Find an Entry Point
Instead of thinking of training versus rest as absolutes, it is better to approach rehab plans as a spectrum. We want to find an entry point with different exercises, positioning, tempo, or absolute load that allows the athlete to stay active, but does not dramatically increase symptoms. In some instances, loads will need to be significantly scaled back. Training with tendinopathy is not about testing our tolerance as much as finding tolerance and building from there.
Should vs. Could
When selecting weights for strength training, we are fans of autoregulation, where the load is adjusted based on how someone is performing on a given day. We often use a tool called Rating of Perceived Exertion (RPE), which is closely tied to the idea of Repetitions in Reserve (RIR). A typical rating of perceived exertion is estimated by “Could you do ‘x’ number of reps if you were to exert at or near your maximal effort?” This approach to autoregulation will not be helpful with tendinopathy.
In the rehab context, pain, rather than the ability of your muscles to produce force in isolation, should serve as the brake on exertion. An RPE 8 effort might normally imply that you could do two more repetitions. Instead, asking, “should you do two more repetitions?” leaves a wider margin of error for mitigating pain symptoms. This principle can also apply to exercise selection. As we will explore later, an excellent way to make workouts more tolerable is by using different exercises. If an exercise aggravates your tendinopathy, it may be useful to temporarily switch to another movement while symptoms are resolving.
Heavy Slow Resistance Training
The cornerstone of any tendinopathy rehabilitation protocol is going to be heavy slow resistance training. We mean “slow” here to describe a controlled tempo, not that the weight is so heavy that it can only be lifted slowly. This typically starts with a “3-0-3 tempo”:
- three seconds through the eccentric (muscle elongating under a load),
- no pause while changing direction, and
- three seconds through the concentric (muscle shortening under a load) phases of a repetition.
For the remainder of the article, if you see “heavy slow resistance training,” we mean “tempo work done for the purposes of rehabilitation,” not grindy, near-maximal efforts. Most research has been conducted on patellar and Achilles tendons, but we will extrapolate those principles to other areas of the body. The goal is to have a plan in place that directly addresses the aggravated area using sufficient load to drive adaptation, while not overshooting someone’s tolerance.
In the beginning phases of rehab, we recommend using heavy slow resistance training two to three times a week and to place it at the beginning of a workout. This serves two major purposes: it allows us to focus on the area of concern while the athlete is fresh, and it can serve as a warmup to increase tolerance for activities later in the workout. As symptoms subside, the heavy slow resistance training can move to the end of the session alongside other general accessory training. Because tendons adapt slowly, we commonly keep these exercises in a program for 12 to 16 weeks.
Here is a common way to structure these exercises, but realize this will vary significantly based on the person and their symptoms:
- Weeks 1 – 4: 4 sets of 10 at RPE 8 at a 3-0-3 tempo
- Weeks 4 – 8: 3 sets of 10 at RPE 8 at a 3-0-0 tempo
- Weeks 8 – 16: 3 sets of 10 at RPE 8 at a consistent tempo
We want to target the area where an athlete is experiencing symptoms, while also maintaining fitness in the rest of the body. For heavy slow resistance training in particular, it is unlikely that exercise will be completely pain free in the beginning, and it does not need to be. We suggest keeping the intensity of symptoms to less than a subjective 3 to 4 out of 10. If this makes it difficult to hit the prescribed exertion, that is okay. Symptom management is much more important than absolute effort at the beginning. Below is an non-exhaustive list of exercise options for this component of rehabilitation. The exercises selected can and should vary based on the equipment available and what the person tolerates best.
Table 1: A listing of some common exercises used for rehabilitative heavy slow resistance training, arranged by various areas of the body.
Addition By Subtraction
There is a tendency in the rehabilitation world to add an exercise or treatment modality for every symptom an athlete experiences. This can lead to bloated programs and warm-ups with too many unnecessary exercises. In the performance-oriented world, a common assumption is that more is better. That is not entirely wrong. Increases in volume and intensity over time help an athlete build fitness and capacity. But they can also lead to overuse and pain. When things start to hurt, new exercises are added to help, and the problem sometimes gets worse.
Because treating tendinopathy focuses on desensitizing the area and building tissue tolerance, we should audit an athlete’s entire program. Reducing the total number of exercises, mileage, or total number of working sets is often the best choice in the earliest stages of rehab.
“Addition by subtraction” does not just apply to what goes on during training. If an athlete is experiencing increased stress or demands at work or school, or is not sleeping well, finding ways to manage stress or improve sleep can be as beneficial as any set of tempo training ever will. Athletes are not just their tendons when going through rehab; it helps to step back and consider the entire picture when it comes to stress management.
Working Around and Working Through
With some injuries, pain and reduced function simply need some time to improve. Athletes can sometimes work through their symptoms, training mostly normally as their symptoms resolve. However, athletes typically need to work around symptoms instead. They can still train, but more significant modifications to exercises and loading are needed. Remember, rest generally is not much help, but doing the same stuff over and over does not improve matters either. That can be a source of resistance at first if someone is very narrowly focused in their athletic pursuits. Embracing different training methods and meaningfully lowering exertion allows people to get better more quickly.
Variation is important for all athletes and should be more widely applied. Even among those without pain, endurance athletes benefit from the variety that strength training provides. Lifters should participate in aerobic training as well to meet current physical activity guidelines. Building a broader foundation of athleticism distributes training stresses in helpful ways and reduces the risk of overuse-related pain.
Increase Capacity and Tolerance
As symptoms subside during the rehabilitation process, an athlete should be able to tolerate more work. However, this needs to be approached thoughtfully. Two of the biggest mistakes athletes make with tendinopathy rehabilitation are not choosing a sufficiently conservative starting point with load (weight, mileage, etc.) and trying to return to prior levels of performance too quickly. It is perfectly acceptable — and is frequently necessary — to take a large amount of weight off the barbell. This is a great time to remember that fractional plates exist and that increasing weight by less than five pounds at a time is just fine to see progress.
The process will likely take longer than the athlete wants, and there may be fluctuations and setbacks along the way. These are not reasons to change course, but they do require patience and being honest about current symptom tolerance and overall stresses from training and life.
Passive Modalities Do Not Expedite Healing
Athletes are often attracted to the use of passive modalities such as cupping, dry needling, kinesiology tape, electrical muscle stimulation (e-stim), massage, and many others. Passive modalities in physical therapy are generally defined as things that are done to someone with the aim of reducing pain or increasing function, without any active participation on their part. Most treatments besides surgery and exercise fall under this umbrella. Unfortunately, the scientific evidence supporting any of these types of passive treatments for tendinopathy is not good. [4] There is simply no physiological justification for why any of these modalities would expedite healing, nor have they been shown to do so.
If such treatments make someone feel better and they are taking care of the things that truly help with symptom resolution, then they can take advantage of them. However, we must avoid using passive treatments as permission to continue to make poor training decisions. They do not help people recover faster so that they can train harder. The most important components in rehab will always be adequate sleep, nutrition, managing stress outside of the gym, and making good training decisions.
Now, let’s examine a few case examples to illustrate how we manage tendinopathy in practice.
Tendinopathy Rehabilitation Program Case Studies
Case 1: Over-specificity
A powerlifter has been running the same program for the last six months that consists of four days of training per week. They use rate of perceived exertion (RPE) for selecting their weights, but admittedly have a tendency to train beyond their target exertion and put too much weight on the barbell. They are currently squatting three times per week, benching four times per week, and deadlifting twice per week. Over the last two months, they experienced increasing shoulder and knee pain that necessitated taking weight off the bar as the weeks went on. They consistently work to a weight where they feel symptoms and use that to determine the upper threshold of load. Their current program is as follows:
Table 2: The original program used by our hypothetical trainee illustrating an overly specific training approach that resulted in tendinopathy.
While heavy slow resistance training is warranted to address symptoms and build capacity, this athlete also would benefit from more significant alterations to their current program.
Temporarily taking a break from heavy singles at RPE 8, at least on squat and bench press would be a good start. Strength can be largely maintained at lower RPE targets, and the current priority should be controlling symptoms. However, changes may not be required across the entire program. If the deadlift is not problematic, the athlete may be able to continue with the current exertion, set, and repetition scheme for that movement.
On day one, the athlete is low bar squatting followed immediately by competition-style bench pressing. This is a lot of stress for the painful shoulder in one session; the athlete may benefit in the short term by distributing that across different days. They are also low bar squatting twice per week. This is likely overly specific training for a rehab phase, repeatedly loading the same tissue in the same pattern. There are many ways to squat or do similar movements, and we would explore other options in the short term.
Because the focus was on powerlifting, almost all the lifter’s previous exercises were conventional versions of a squat, bench press, or deadlift. While specificity is necessary to address the currently painful areas, using different exercises and patterns helps build a broader base of athleticism and physical capacity. Variations in exercises that include single-leg versions, different types of bars, machines, dumbbells, and moving in different directions can distribute load through different parts of the body. Tendinopathy represents a maladaptive response of a particular tissue. Therefore, loading the same tissue in the same manner repeatedly is part of the problem and should be avoided. Additionally, we will use the ideas of working around and working through their current limitations. There are multiple ways of programming for this athlete, but one hypothetical template could look like this:
Table 3: A potential rehabilitative program for the overly specific case. Note the variation in exercises and inclusion of heavy slow resistance exercises that begin each session, along with their recommended tempos.
At the start of each session, we use heavy slow resistance exercises for either the shoulder or the knee. Low bar back squat has been temporarily replaced with safety bar squats and dumbbell split squats to allow shoulder symptoms to subside. If the athlete is still feeling knee symptoms here, we may incorporate a controlled tempo or other technical modifications to move in a more tolerable way. Competition bench is now done for sets of six at lower weights. For the supplemental bench press, a controlled tempo variant has replaced the faster, “overload” slingshot movement. We want to emphasize the slow part of the movement.
We introduced a few machines to the program, and there are two exercises that involve a single leg movement and moving in a different direction. The athlete does not need to entirely reset what they are doing but instead expand their program and make modifications.
The big changes we recommend for an overly specific program are:
- Add in different, more tolerable movement variations
- Use tempo work for the specific area, scaled to tolerance
- Reduce the weight on problematic lifts
Case 2: Dramatic Increase In Exertion
A lifter with just over a year of experience decides to focus on increasing their total for squat, bench press, and deadlift. They were on a self-guided program for their training, typically lifting two to three days per week. The program consisted of a variety of free weight and machine-based movements, four to five exercises per day, and the athlete increased weight until the exercise was “hard enough.” They recently found a more tightly prescribed program that involves lifting three days per week, consists of only low bar back squat, bench press, overhead press, and conventional deadlift, and advocates adding weight to each session until the athlete plateaus. The athlete completed the program for three months but developed elbow and gluteal pain, and their lifts have gone down after an initial increase. They trained consistently but are increasingly frustrated with their decreases in strength and increases in pain. They are now experiencing symptoms with daily activities such as walking, going up and down stairs, and sitting at their computer.
The lifter went from a broad program where they varied their exertion to an overly specific routine where progress is dictated by forcing weight increases every session. Progress in all forms of training does not continue linearly. There will be fluctuations in performance (and weight on the bar) from session to session. We need to get symptoms under control and find an entry point. We can do that by reintroducing autoregulation and incorporating more variation in their program.
For the elbow pain, wrist curls might be useful, but we are in danger of piling on stress and bloating the program as mentioned earlier. While there are times that such an approach could be helpful, we are going to avoid it here. A better idea would be temporarily limiting how much low bar back squatting and bench pressing they do. Switching to a high bar position, using a safety squat bar, or a belt squat would allow for lower body training while applying less stress to a sensitive elbow. They may also benefit from using a multi-grip bench bar, chest press, or dumbbells to place their hands in different positions and distribute load for upper body training. In all of these instances, it is not about removing alI stress but working around areas that hurt. If the elbow symptoms don’t resolve through the removal of the low bar position stresses and inclusion of bench press variations, we might consider some more directed work, like wrist curls.
For the gluteal pain, using controlled tempo movements on a hip abduction machine (if they have access to one) could help. We would also introduce single leg work via a single-leg romanian deadlift, split squats, box step-ups, or other variations. While a belt squat might relieve stress on the elbow, it might also aggravate the glutes. Certain exercise variations might not be appropriate when rehabbing more than one area. Isolation-style movements can be of great use in these cases. As symptoms improve, some of those variations might be appropriate and can be tolerated again. A beginning program may look as follows:
Table 4: Initial rehabilitative program for lifter struggling with elbow and gluteal pain.
In addition to incorporating autoregulation, moving to a heavier top set followed by lighter back off sets for the compound lifts would allow strength to be built while lowering overall demands on the sensitive tendons. For example, working up to a top set of 3 repetitions at RPE 7, followed by sets of 4 to 6 reps at a 10–15% lighter load would accomplish this. The program can be supplemented with variations where the goal is not to set personal bests on every lift but to distribute the load and allow the athlete to adapt. As symptoms improve, and the athlete is tolerating movements better, the program could progress to the following:
Table 5: As symptoms improve and the athlete with elbow and gluteal pain can tolerate more work, the program might evolve this way.
Dramatically increasing the exposure to powerlifting-specific movements at heavier weights with less variation in exercises and load selection were the likely causes of the problems here. Performance fluctuates according to stress at work, sleep, and many other variables; approaching training with the expectation of constant progress is a recipe for overuse syndromes. In this scenario, adding in tempo training without altering other aspects of the athlete’s program would add extra stress and likely only aggravate their tendinopathy. The biggest changes that need to happen here are:
- Decreasing the overall intensity of the program
- Reintroducing autoregulation (for example, using RPE)
- Adding in variation to distribute load
Case 3: Too Much, Too Fast Coupled with a Change in Training Modality
An athlete has been participating in a three day per week lifting program and completing an hour of aerobic training a week on various devices. They recently decided they are going to train for a half marathon and found a 12 week program. Their lifting program is an upper body/lower body split that is mostly machine based. They typically follow a 3-sets-of-8-to-12 repetition scheme, aiming for each set to be three to four repetitions away from failure. Their aerobic training has been low intensity steady-state work on a rower, stationary bike, or assault bike, keeping their heart rate under 150 beats per minute. In preparation for their race, they reduced their lifting to two days per week and started running four days per week with two longer and two shorter runs. In the first four weeks, they increased their mileage from 8 miles the first week to 24 miles per week. During this time, they also developed Achilles tendon pain in both heels. It is not interfering with daily activities, but any run longer than 3 miles causes pain that is becoming increasingly distracting.
While already quite active, the problem is the sudden change in training modality and volume. Not only did they overload the tendons, they did so through a single, repetitive, higher-impact activity. Over the course of four weeks, the athlete tripled their running volume, clearly exceeding their tolerance.
They should perform heavy slow resistance training for their calves, but they also need to temporarily reduce their running mileage. If pain consistently starts around the 3 mile mark, then they need to run for distances less than that at the beginning. The athlete could add calf-centric tempo work two times per week into their lifting program and still participate in four days per week of cardiovascular training. In the initial phase, two of those days would be runs less than 3 miles and two other days of either rowing or biking. More running can be introduced as symptoms improve. Longer runs can be scheduled to confirm that they are increasing their capacity and tolerance.
The lifting in this scenario serves to complement their running goals. Because the affected areas are the heels, we have a lot of options available to us with their strength training. We left things open ended to cater to the athlete’s preferences. The one constant would be the heavy slow resistance training for their calves, with the goal of increasing the tendon’s capacity for load. Given that the athlete has experienced these symptoms with running, we would recommend this exercise remain in their program through their training cycle for the race. The program might look as follows:
Table 6: Sample rehabilitative program for an athlete that recently significantly upped their running training and developed Achilles tendinopathy.
The program is not complex, nor does it need to be. It is more important that the athlete has exposure to resistance training, has some variation in intensity, and performs tempo work for the involved area. The athlete could continue this program for the entirety of their half-marathon preparation, and this would provide the needed exposure to external load. In this scenario, we recommend:
- Temporarily reducing running distance and frequency
- Using heavy slow resistance training for the involved area
- Finding a tolerable starting running distance to maintain running exposure
- Using different, more tolerable aerobic training modalities to allow the athlete to continue to build a base while symptoms decrease
Summary
Tendinopathy is frequently experienced by athletes across many sports, and addressing it requires a multifactorial approach that involves assessing the overall training program, managing training stimuli, working around problematic movement, and implementing changes that allow for pain symptoms to decrease. There is no one size fits all approach to structuring a program. While heavy slow resistance training is a mainstay of the evidence based approach to rehabilitation, if performed in a vacuum, it can add additional stress to someone who is already displaying an inability to tolerate their current workload. The goals are to find an acceptable entry point, reduce volume and intensity where needed, and build the athlete back to prior levels of participation and beyond.
Designing an individualized program is based on the athlete’s symptoms, their current and past training programs, and the available equipment. This article presents three common scenarios with guidance for how to manage symptoms, but if you require additional assistance, our rehab team is willing and available to help.
Special thanks to Tom Campitelli for his help in writing, editing, and creating graphics for this article.
Derek Miles is a residency trained physical therapist currently working at Stanford Children’s Hospital as the Advanced Clinical Specialist in the rehabilitation department. He worked at the University of Florida prior for 10 years in sports medicine treating a variety of athletic injuries from overuse to post-operative. He is involved in the peer review process for academic journals and has spoken at national level conferences within the physical therapy profession. If not treating patients or in the gym Derek is likely either cooking some form of meat or reading books related to various random topics. He occasionally brews a pretty good American Pale Ale as well.
Thomas Campitelli began his barbell coaching career in 2009 and his clients have included the elderly and infirm as well as national and international competitors in powerlifting. Based out of sunny Oakland, CA, he travels extensively throughout the US and the world to coach and lecture at barbell seminars. Tom works with lifters of all levels of ability both in-person and remotely, and has many years of experience assisting his trainees at competitions where he provides a calm demeanor and an excellent eye for attempt selection. He brings an expansive understanding of human movement and strength programming as well as a compassionate approach to his coaching that enables his clients to succeed at their varied pursuits.
