Based on recent research, in the most acute phases of significant tendon injuries, immobilization should only be utilized for the first 3 days.
It has been found that having an increased intensity in a controlled environment through sport specific moves or low level plyometrics can help prepare the body for quicker healing AND reduce the rate of re-injury as opposed to just strengthening the muscles and stretching.
For lower extremity injuries, such as hamstring, patella, Achilles, or foot/ankle strains, an introduction to plyometrics would constitute the ability to take a small hop forward on both legs and stick a soft landing.
A great example would be a pogo hop or marching based drills shown below
This is very light and allows the nervous system to fire up and rewire the connections in the body by creating blueprints for movement patterns that will be utilized in activity with faster rates of speed and force.
The nervous system is what supplies the power to working muscles and controls the output of them as well, along with taking information in based on where the body is in space and making subconscious corrections to keep you in the best position possible for a task.
As these activities work in the background and in conjunction with or recovery process, we will want to start to move towards some isometric based activities that progress to eccentric activities as well.
Remember when we talked about the pre-stretch muscles create on tendons.
Well the isometrics will be a good start to recover the pre-stretch component to allow the muscle to be placed in an optimal length for effective joint positions, along with placing lower grade stresses on the tendon to begin to adapt/prepare for increasing activity.
In the case of a hamstring strain, a box bridge isometric (shown below) is a great start as the body is more supported and the hamstrings are not to be exerted at 100% potential in this position. (We want to keep our loads at about 50% when performing these).
Isometrics in this case should be held to 5-10s of time, followed by a 30s rest. The goal is to build towards 3-5min of total working time. This can take a course of a few weeks to months depending on your ability, and should ONLY be progressed by 10-20% per week.
An example would be 8 sets of 5s holds = 40s total work. The next week you would do 10 sets at 5s = 50s total work. Perform these activities in your training for 2-3x/week. (At the end stages, you may perform some holds for 10-20s at a time).
Mind you, you don’t have to completely check this box off to perform other strength work. This should be implemented based on the injury you have in conjunction with other activities such as squats, deadlifts, step-ups, etc. Also keep in mind that if running is still not feasible, some form of aerobic activity as an Airdyne bike would be very useful in this scenario.
After you begin to progress with the isometric’s, we want to increase the tension by having isometrics in an eccentric form, meaning the muscle is placed at a greater length in order to handle end range positions so it does not give out and place unneeded stress on tendons.
Again, keeping the loads at 50%, below is an example of a continuation of the box bridge by using an RDL hold for 5-10s. (Keep the same principles of increasing total work time weekly).
For Achilles/ankle strains, a seated calf raise will be more beneficial than a standing as the load is too high in standing. Pec strains can be in push-up holds, and patella tendon issues could utilize a wall squat hold with body weight.
As things progress with strength in the isometrics, you want to be simultaneously be progressing our plyometric work to faster rates of loading and absorbing.
This would entail a depth drop landing from a small box on 2 feet, progressed to 1 foot, all while controlling the landing down.
A false drop from the toes is another great example to speed up the loading.
A personal favorite of mine is an Oscillatory Isometric, as it provides a quick drop to landing, forcing you to control the position in a more stable manner.
And lastly, a squat clean is good for catching the weight as you come down, forcing you to absorb the load quickly and redistribute the forces within surrounding connective tissues.
As all of these progress, jumping and faster running paces should be introduced as you need to recreate the spring actions on the other side of the equation.
The programming and specific implementations are beyond the scope of this blog as it would need to be addressed on an individual basis and depends upon the level of activity needed to return to. The purpose of this post is to gain more insight and have a starting point to addressing the acute phases of a tendon injury. The process can be as creative as you want it to be, but the principles remain the same.
To recap, tendons perform optimally when they are pre-stretched by muscles prior to landing. This allows them to absorb force and redistribute it quicker for a release of energy to propel you forward.
With poor joint positioning and inefficient muscle activity, the tendon may not be optimally loaded, causing repetitive stress and eventual strains.
By changing position and recapturing optimal muscle tension first, the tendon can learn to adapt to the pre-stretch states to prepare for faster rates of force.
Isometrics under lower loads for a total time accumulation of 3-5min helps to improve the tolerance of the muscle and connective tissues for increased activity. Then it is progressed to loading at longer lengths so the muscles do not give way on the tendon as much.
Plyometrics at low loads work in the background to assist in refining movement patterns (via the nervous system) so the body can position itself and make corrections for movements at full speed.
The strength work and plyometrics progress to teach faster rates of absorption, along with improving the turnaround rate of propulsion to maximize movement efficiency and tissue health.
Perhaps you have a tendon strain that is giving you some struggles and you still don’t know how to figure this thing out.
That’s what we are here for. To be your local expert and guide so you don’t have to be overwhelmed and worry that you won’t be 100%.
We can take the steps necessary to get you back on your feet with little to no down times, all while not losing other fitness qualities while you recover.
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Dr. Peter Dionisopoulos is the owner and founder of Dynamic Performance & Rehab. He has a Doctorate in Physical Therapy and enjoys to help active adults maintain their lifestyle and provide natural solutions to their pain.
All information on this website is intended for instruction and informational purposes only. The authors are not responsible for any harm or injury that may result. Significant injury risk is possible if you do not follow due diligence and seek suitable professional advice about your injury. No guarantees of specific results are expressly made or implied on this website.