Today I will discuss a stage-based approach to the rehabilitation of tendon pain. We will break down the process into four stages, which reflect the framework discussed by Jill Cook in her research. Let’s remember that first, we must identify and remove the triggering load in order to reduce pain in the acute phase.  


Stage One 

The goal is to reduce the patient’s pain level, which will allow them to start engaging in the rehab process. Then, we start focusing on strength gains to increase their load-bearing capacity. In stage one, isometric exercise is a good beginning but we must assess the patient’s response. If the pain does not decrease over the first few days or weeks, we need to double-check our differential diagnosis. At this stage, we should always try to stay away from compressive loads in order to reduce pain quickly. We will start with heavy loads (weight) and slow movements, if any.  Remember, heavy weights and isometrics or slow movement do NOT represent “Heavy Tendon Loads” but they are “Heavy Muscular Loads”. The starting load will be determined by the patient’s capacity (desk job vs. athlete). A simple prescription target is to get our patient to complete five reps of an exercise for a 45s hold. We will adjust the load as needed if it is too easy or too hard for the patient as well as assess their 24-hour response. If the response is positive, we will progress the load slowly as we grow through stage 1. If the response is negative, we should repeat the process with a lesser load. 


Note: Research is showing us that reducing the time under tension is not the best way to achieve the goals of stage one. Therefore, adjusting the load or weight the patient is sustaining is a  better option than reducing the time of the hold.  

Stage Two

In stage two, the goal is to continue building load-bearing capacity while slowly introducing compressive loads. We should be intentional about isolating our work to the muscles and tendons involved. This will allow for greater adaptations compared to a multi-joint movement approach.  At this stage, we start to introduce isotonic exercises with slow and controlled movements through concentric and eccentric contractions. All of these are safe for the tendon as speed is not yet part of the equation. In turn, we will start adding compressive loads as we put the patient through greater ranges of motion. At this stage, utilizing a metronome to guide the tempo may be a way to help the athlete focus on each rep while triggering the motor cortex. Always check your 24-hour response! 


Stage Three 

The main goal in this stage is to start introducing speed of movement in order to raise the demand on the tendon. As we start to add tensile load (spring-like tendon action), it is important to make sure we do so very progressively to avoid overloading and going back to stage one. The session should only start two days per week and progress to three days per week with one to two days between sessions in order to give us time to assess the 24-hour response, which will be measured through increased pain, soreness or stiffness. We will start on two legs while progressing forces and rep count, then move to a single leg while progressing forces and rep count. Start with absorbing force, then move to producing force. In other words, start with the eccentric load capacity, then move to the concentric load capacity. For example, a beginner exercise to bias absorbing forces can be to be up our toes and drop into a squat position. On the other hand, biasing force production would be the other way around; start in a squat position, then push into an up-tall position on the toes. It is important to remember that in between these loading days, the patient should continue with a  thorough strength maintenance program as we keep on progressing.  


Stage Four

As we enter stage four, we will start to individualize the prescribed activities as they relate to our patient’s goals. For an athlete, we may start to implement running, jumping and cutting in a  multi-plane fashion. As they progress through that, we may start introducing them back to their sport while managing their training loads as they build a tolerance to the team training environment. This return-to-training process should be a staged approach as well. Similarly to stage three, start with two to three days per week with at least 1 day between sessions to assess the 24-hour response. The patient will also continue with a maintenance strengthening program through this progressive return to play.  


Be sure to continue reading in part four, in which I discuss Achilles and patella tendon programming. 


* Information from this blog series was drawn from the Barça Innovation Hub Course – Lower Limb Tendinopathy merged with my personal experience on tendinopathy Return To Play.