Eccentric Training and its Importance in Recovery from Tendinopathy

Our bodies are amazing pieces of art, made up of organs, bones, muscles, joints, and tendons, all working together to keep us alive and on-the-go. When we’re healthy, we feel on top of the world, able to engage in serious competitions, grueling races, and intense workouts. But all it takes is one injury to set us back, so much so that even simple housework tasks seem painful to complete.

If you’ve ever suffered from tendinopathy, then you know the pain I’m referring to. Some people with tendinopathy may only have mild symptoms while others suffer from debilitating pain. So what exactly IS tendinopathy, and what can be done to help recover from it? That’s what I plan to address below. Let’s dive in!

FIRST THINGS FIRST…WHAT IS TENDINOPATHY?

The human body is made up of approximately 4,000 tendons, which are the rope-like tissues that attach muscle to bone. Any pain or discomfort occurring in and around the body’s tendons is broadly known as tendinopathy. There are many ailments that fall under the tendinopathy umbrella, including tendinitis, tendinosis, as well as partial or complete tear of the tendon.

Tendinopathy can occur at almost any site of the body where a tendon connects a bone to a muscle. I’m sure you or someone you know has suffered from one of the following problems:

Golfer’s elbow (inner part of the elbow)

Swimmer’s shoulder (top of the shoulder)

Jumper’s knee (front of the knee)

Tennis elbow (outer part of the elbow)

Achilles tendonitis (back of the heel)

De Quervain’s disease (back of the wrist)

How does tendinopathy even happen? Well, the basic function of a tendon is to transmit force from a muscle to its corresponding bone to control movement. When the demand is greater than the tendon’s load capacity, that’s when injury can occur. Repetitive stress beyond the tendons load capacity can cause small micro trauma leading to changes within the tissue including disorganized collagen bundles, increased ground substance (inflammation), cellular death, and formation of new blood vessels and nerve endings.

The symptoms of tendinopathy can run anywhere from pain and swelling to stiffness and restricted mobility at the affected joint. Because these symptoms are similar to other conditions (e.g., arthritis) some people don’t take the needed and immediate steps to correct. They may think, “Well, my parents had this so it’s just hereditary” or “I’m getting old, it’s just a part of the aging process, right?” NOT TRUE!!!!!

I’m here to tell you that tendinopathy can be treated. Clients of mine who have been suffering from some type of tendinopathy for months on end, have found relief from the agony. “How???” you might be asking yourself. The first step is seeking the correct medical advice from a Doctor of Physical Therapy if the initial pain does not go away after 3-4 weeks.

MISCONCEPTIONS ABOUT TENDINOPATHY

Rest is Best

Rest is often recommended as the first form of treatment. However, evidence suggests that prolonged rest is actually the least effective form of treatment for tendinopathy. Complete rest may help relieve pain. However, it is not an appropriate solution. When tendinopathy occurs, the cells in the tendon itself are disrupted; they are not appropriately aligned in the normal direction where they should attenuate force as they’re pulled and stretched. When they do begin to heal, the fibers will not align appropriately as the condition continues to permeate without appropriate intervention. If these fibers are mismatched, they won’t have the appropriate strength when you start to apply force during movement and activity. No amount of rest will fix this issue.

Anti-inflammatory Medicine Will Help

Anti-inflammatory medications like Advil and Ibuprofen are supposed to reduce the inflammation, thereby lowering the level of pain. And that’s exactly what they do. However, the problem with anti-inflammatories is that they will neither reduce tendinopathy itself, nor keep it from getting worse, nor make it completely better. In fact, when tendinopathy occurs for an extended period of time, there is no longer a presence of inflammation and therefore anti-inflammatories will have no purpose to reduce inflammation. So while anti-inflammatory drugs may be fine to get you through the day, in no way, shape, or form, are they a 'fix' for tendinopathy.

Surgery is the Answer

Surgery is often considered a last option in the treatment of tendinopathy if it persists after exhausting all non-operative options. The most commonly performed procedure is open surgical removal of scar tissue of the involved tendon. Although good results can be achieved, these procedures cannot guarantee optimum results. Failure rates can be as high as 20% to 30% with some of these procedures, and it’s often difficult to predict who will have continued problems after surgery.

SO WHAT DOES HELP?

Painful tendon disorders are a major problem for endurance athletes and active adults alike. Heck, I’ve even helped several patients who have suffered with tendonitis simply because of gardening, painting, or any activity that produces a lot of repetitive movement from a particular tendon.

Difficult to manage, options like the ones discussed above have shown limited and often unpredictable success on tendon injuries. Even when diagnosed early and appropriate and intensive management is used, rehabilitation of tendinopathy can take several months.

I understand for some of my readers, this all may sound depressing. “So what DOES work Dr. Rob?” you may be wondering. Thankfully, several studies, as well as my own personal experience with clients, has shown the use of eccentric exercise to be an effective intervention for tendinopathies. Not only that, but eccentric exercises can improve the capacity of the tendon, which leads to an improved ability to adapt to load. Improving the capacity of the tendon will actually help decrease the chance of tendinopathy injuries occurring in the first place.

Rather than treating the symptoms, eccentric training goes deeper than that and gets right into treating the actual problem, allowing the opportunity to not only heal, but strengthen the tendon to help prevent future problems.

WHAT EXACLTY IS ECCENTRIC TRAINING?

I might be putting the cart before horse here, by delving into the importance of eccentric training without even explaining what that is. If you partake in resistance training (weight lifting), you’re already familiar with this action, just not the term.

Resistance training involves three types of movements: eccentric, concentric and isometric contractions. Eccentric training is focused on the elongating, lengthening phase of a movement in an exercise where tension is acting on the muscle using resistance. For example, in a bicep curl, it’s the action of lowering the weight back down from the lift away from your body (as long as the weight is lowered slowly rather than letting it drop!).

This is the opposite of the concentric phase, where the muscle shortens while producing force (e.g., basically contracting the muscle). In the same bicep curl example, this would happen when you are raising the weight towards your body during curl. I've provided quick footage (see right) of yours truly demonstrating eccentric versus concentric to better explain the difference.

The third phase is known as isometric exercises, which are contractions of a particular muscle for an extended period. Also known as static strength training, isometric exercise is one that involves muscle engagement without movement. Instead of movement, you pick one position and hold it.

AND HOW WILL ECCENTRIC TRAININGTHIS HELP ME WITH TENDINOPATHY?

If you wish to treat tendinopathy with eccentric training, you basically need to remove or minimize the concentric element out of the movement and concentrating more on the eccentric portion. The general idea is simple: you can strengthen the tendon with lengthening movements resulting in a speed up of the healing process. The benefits of performing eccentric training involved improved protein deposition and collagen formation for strength of the tendon, realignment of healing tendon fibers along the lines of tension applied during activity, and helps to build strength and size of the muscle greater as it causes a restart to the inflammatory process allowing healing to occur again in those who have experienced tendinopathy symptoms greater than 3 weeks.

For example, eccentric exercises that can help with Achilles tendonitis are:

• Standing on the edge of a step, with the opposite foot off the ground, gradually lower or drop the heel you wish to work on, until you can’t stretch any further

• Put the opposite foot on the step to take the weight off the foot you just lowered, without using any strength to get it back in position

• Repeat these steps for approximately 15 or 20 reps for 2-3 sets

With elbow tendonitis, you can use the following exercises:

• Place a weight in your hand that is manageable and have a seat at a table in good posture with your hand and wrist off of the edge of the table while having elbow bent to 90* • Use your opposite hand to raise your wrist and hand towards the ceiling while your forearm remains on the table. • Under your own power and in a very slow and controlled manner, slowly allow gravity to lower your hand and wrist towards the floor until it is at rest at the bottom of the motion • Repeat this for approximately 15 reps for 3 sets

Essentially, you can turn all and any exercise into an eccentric exercise into something that can treat tendinopathy. All you have to do is follow the principles. Understanding that all of the strenuous work of the exercise needs to be completed during the lowering or lengthening phase of the movement. If there is a concentric or shortening phase then it needs to be much quicker than the eccentric portion. Tendons like to be loaded and provided with tension. They just needed to be treated with the right load, at the right time, doing the right movement. There is no specific way to heal one specific form of tendinopathy but some trial and error is involved to see which activity or exercise will provide the least amount of irritation to the tendon while causing an appropriate load that result in healing. If you are out there dealing with this condition and are frustrated with the lack of results with the things you have tried already, don't fret. The right person and intervention is out there. you are just one step closer. Up to this point you found all of the things that have not worked for you so THE thing that WILL work is right around the corner. Do what you can to avoid surgery as much as possible because you will still need to see a Doctor of Physical Therapy afterward in the end. Don't wait. Get the right intervention sooner rather than later so you can get back to the things you love today instead of sometime tomorrow.

I hope this was helpful to you and gave some insight on eccentric training and its positive effects on tendinopathy. If you have any questions about how to incorporate these exercises correctly into your workout, please reach out by calling 516-387-0053 or visit www.ascentptny.com. We are always here to help you. You can also fill out a patient inquiry form here to help get you set up with a Doctor of Physical Therapy.