Chronic Tendinosis and Eccentric Exercise

Are you frustrated by a chronic case of Achilles or Patellar tendonitis? In a recent Sports Medicine Corner article, I focused on acute injury and things that you can be doing during that phase to help get you back to running. Today, the focus will be on the chronic stage of injury.

Chronic injuries can be very frustrating. There is actually not much “inflammation” present, which makes the term tendonitis (inflammation of the tendon) a bit of a misnomer. There is not much to see; no swelling, redness, or discoloration. Nothing to suggest that there is really anything wrong at all, other than the fact that you are having pain in your tendon that is affecting your ability to run or walk (if it’s really bad).  A more accurate term for this chronic case of tendon degeneration is tendinosis. Tendinosis is thought to be caused by a breakdown of the collagen fibers within the tendon without the presence of inflammatory cells. Inflammation is necessary for full healing of the microtears to occur. Without it, the body gets caught in a stage where it is breaking down collagen (cellular level of tendon), starting to repair it with scar tissue, but before full healing occurs, there is another microtear. Repeat this process over and over again, and you are left with chronic tendinosis.

If you are suffering from this condition, most commonly occurring in the Achilles or patella tendon with runners, you have probably tried everything at this point. New shoes, ice, heat, ibuprofen, injections, stretching, heel cups, avoiding hills, maybe even avoiding running altogether; nothing seems to really make it better. A key missing component of your routine could be eccentric exercise.

An eccentric muscle contraction is generated when the fibers of a muscle lengthen as they lower a load. It is often referred to as the “down phase” of an exercise. For example, when you curl a weight with your bicep and then lower it back to the starting position, the eccentric phase occurs when you are lowering the weight back to the starting position. This type of muscle contraction causes a stretch to take place within the muscle and tendon. It also causes mictrotears within the fibers which are repaired with scar tissue. The major benefit of an eccentric contraction is that the scar tissue that is laid down is aligned in a uniformed fashion along the angle of pull of the tendon.

Concentric contractions, or the “up phase”, are more demanding on the body and can cause more damage to an injured tendon. This is why it is important to eliminate the concentric contraction while you are performing exercises to remedy chronic tendinosis.

For Achilles tendinosis, try this:

Standing, use your non-injured leg to raise your injured ankle into a pointed position, so you are standing on your toes. Now, shift all of your weight to your injured leg. Slowly, lower your heel to the ground. Shift your weight back to your good leg and get back into the toe standing position. Repeat the process 15 times for one set. So it’s up with the good leg, down with the bad leg.  It should take you about twice as long to complete the down phase, or eccentric part of the exercise as it takes you to complete the concentric phase.

For patella tendinosis, try this:

With the injured leg, stand on something that has roughly a 25 degree decline. With all weight on the injured leg, slowly bend the knee to about 60 degrees of flexion (stop before you hit 90, as that is the point in the range of motion where the most stress is on the patella tendon). Shift your weight onto your good leg and lift your body back up into a standing position. Repeat 15 times for one set.

For both of these exercises, don’t worry if you experience soreness while performing them, this is normal. In successful cases, with regular performance (daily) of eccentric contractions, pain should dissipate and a return to normal, pain free activity is possible after roughly 12 weeks.

No running for 12 weeks?? Don’t worry, that’s not necessarily the case. It depends on the extent of the tendinosis. If running causes mild discomfort, it’s ok to keep doing it. If running causes the pain to become debilitating during your daily activities, lay off of it for a while.

Don’t forget about those muscles that attach to the injured tendons. Self- massage through the use of a foam roller, Stick, Tigger Point Ball, or Orb can help to loosen muscles, therefore, reducing the strain they create on tendons.  In the case of Achilles tendinosis, focus on the calf and shin muscles. For patella tendinosis, pay attention to the IT Band and the quadriceps.

Eccentric exercise in conjunction with massage can help get you over the frustrating condition of chronic tendinosis. Start adding these things into your routine, but be patient. Remember, it took a while for the tendon to get into its current state, it will take a while for it to get back to its original self!