Chronic Tendon Injury Blog 2 – Eccentrics Versus Slow Heavy ResistancePete Kissel
Part 1 of this tendon rehabilitation post looked at some new research supporting the role for isometric exercises. Although isometrics can be helpful to manage tendon pain in the short term, full range dynamic loading strategies give a better stimulus for muscle and tendon adaptations for long term rehabilitation.
For chronic tendon issues (tendinopathy) we have historically recommended eccentric exercises. Eccentric exercises were shown to be an effective treatment strategy over a decade ago by a Swedish research group. But recently a heavy slow resistance protocol has shown similar clinical results, with better patient satisfaction and program compliance. Check out this quick video to see the basic differences between an eccentric only program and a heavy slow resistance program for achilles tendinopathy.
The most significant advantage of the heavy slow resistance program is only 3 rehabilitation sessions are required in a week versus 7 days a week for the eccentric protocol (14 sessions total). Both programs are 12 week while avoiding aggravating work or sport demands. Some cases of mild tendinopathy, where pain during sport or competition is less than 3/10, may be able to incorporate one of these rehabilitation approaches while competing or working. See the eccentric only or heavy slow 12 week program design details below.
A Heavy Slow Resistance program encourages a 3 second concentric and 3 second eccentric tempo. There is early evidence to support the use of external pacing cues, such as a metronome, to maintain the tempo which may have some additional (motor control) benefits over a self-paced tempo. More to come on this.
In our clinic a typical rehabilitation session for an Achilles tendinopathy using the heavy slow resistance protocol might look as follows: whole body general warm-up (side shuffles, Carioca’s, forward/backward light jogging etc), 3 sets of 30 second isometric hold off a step (load and angle of ankle dependent on symptoms) followed by loaded slow step-ups/walking lunges/heel drops. Stay tuned for a collaborative effort with SST Burlington’s Dave Scott-McDowell demonstrating heavy slow resistance training for the most common tendinopathy cases we see in our clinic.
**Please note that no 2 rehabilitation plans are the same. Although we may use the program design below as a guide, there is always significant variation in load intensity, exercise selection and progression/regressions based on individual circumstances.
Eccentric movement only program
Usually the same exercise every session. 3 sets of 15 repetitions, 2 times daily, 7 days a week for 12 weeks. Each repetition is 2 seconds duration.
Use unaffected side to reset for each successive repetition (see video above as an example).
Work through non-disabling pain 3-4/10. Progressively add load/weight as tolerated. Load can be increased with bodyweight, dumbbell/barbell or adding weight to a back pack etc.
Heavy Slow resistance Program
Pain during exercises is acceptable, but pain and discomfort are not to increase after cessation of training. 1 exercise per day, 3 different exercises per week. For example for patellar tendinopathy options for exercises might be front squat, back squat and walking lunges.
Week Session Number Tempo Rep range
1 1-3 3:3 15 x4
2 4-6 3:3 12x 4
3 7-9 3:3 12x 4
4 10-12 3:3 10 x 4
5 13-15 3:3 10 x 4
6 16-18 3:3 8 x 4
7 19-21 3:3 8 x 4
8 22-24 3:3 8 x 4
9 25-27 3:3 6 x 4
10 28-30 3:3 6 x 4
11 31-33 3:3 6 x 4
12 34-36 3:3 6 x 4
2-3 minutes rest between each set.