| | | Tendinopathy: Dose Dependent Destruction

Author / Matthew Zanis

When we are sick, we see a physician who prescribes us medicine. When we need to dial in our diet, we see a nutritionist who prescribes us an eating plan. When Christopher Walken has a fever, he needs a prescription for more cowbell.  When athletes need to empower their performance, they come see us, strength and conditioning coaches, for a training prescription. And just like other professions, getting the dosage wrong in training can have substantial consequences on the health, well-being, and performance of our athletes.

Unlike the cowbell, more is not always better; even too much water can kill you (8). When it comes to strength training, too much of a good thing often results in damage to connective tissue.  More specifically, the highest prevalence of these injuries occur in tendons (6). The aim of this article is to describe how too much or too little stress in tendons during training disrupts the balance of the body’s natural adaptation system, and how understanding this “goldilocks effect” will help you correctly dose your athletes to ensure high performance and unwavering durability.

So, You’ve Caught the Tendonitis?

We hear it all the time from these athletes: “Coach, I’ve got a killer case of tendonitis in my knee.” What do you typically do with this information? Recommend they stop training? Send them to see a physio? Or, do you critically think about why this particular athlete is experiencing pain in their knee? With an -itis , we typically think of inflammation and how to counteract it with rest, ice, and anti-inflammatories.

However, most of these symptoms go on for weeks or months before they are brought to our attention; by then the inflammatory process has passed, so we’d be more accurate using a term like tendinopathy, meaning some sort of change to the tendon has occurred (9). It should also be noted that tendons don’t heal through the inflammatory process like a muscle. Tendons are stubborn; rather than trying to build new, strong Type 1 Collagen (a very costly process) (7), the body instead makes that tendon thicker with Type 3 Collagen that is only typically found in your skin and blood vessels (9).

This adaptation process is a response that allows that tendon to handle more load via a larger cross-sectional area. By the time the tendon has grown thicker, the previously injured tissue is now “healed.” But why does it still hurt? Pain is multifactorial, but it does have a lot to do with the capacity of the tendon to handle stress. Our job as coaches is to rehabilitate the whole athlete through appropriately dosed strength training in order to ease their pain while achieving set goals.

We do this with smart programming via progressive overload with good posture and position. On a physiological level, progressive overload allows us to increase the strength and capacity of tissues. Neurologically, we improve movement patterns and efficiency. And psychologically, progressive overload increases confidence, decreases fear of movement, and lowers sensitivity to pain (2).

When this principle is broken, like having a novice athlete test a 1RM back squat, athletes may develop improper movement patterns and subject their tendons to excessive stress, which can increase their risk of  injury. We need to stress to progress, but understanding where our athlete falls on their athletic continuum is critical. What does their training history look like? What type of loads are they accustomed to? Failure to acknowledge these key points will disrupt the overcompensation process described by Dr. Fred Hatfield (5).

The Tissue Homeostasis Model

All tissues of the body, including tendons, are designed to accept, transfers and create forces. This concept is typically referred to as the rate of force acceptance and rate of force development, respectively. Our athletes, and their tissues, fall somewhere on a continuum of function, described as the tissue homeostasis model (4). This demarcates the boundaries for safe and effective load acceptance and transference within a given training stimulus. Were the athletes previously sedentary? Have they established a base level of strength by completely exhausting a linear progression program like Bedrock? Where they are on the spectrum will determine our dosing strategy.

At the upper end of the spectrum, we find dosages of higher volume and intensity, which will create the stimulus needed to produce a positive adaptation; pushing an athlete beyond their upper threshold will cause damage at a rate greater than the body’s ability to adapt and recover. This is typically what happens to tendons when asked to handle too much load, speed, or volume, like  when a basketball player is told that more jumps will increase his or her vertical. The key here is finding a balance in the tissues between stress and recovery.

On the lower side of the continuum,we find doses that actually weaken or atrophy the tissues. This is the principle of reversibility at work, AKA  “use it or lose it.” The most common example is an athlete coming back from a knee injury. They are essentially in a detrained state, having only done body weight squats and banded knee extensions for the past 16 weeks. This was not enough load to stimulate growth and development. Asking them to squat their previous 5RM on Bedrock would be a mistake because they haven’t progressively built up their tissue durability.

The middle of the spectrum is where everyone likes to stay because it’s comfortable. But, comfort breeds complacency and mediocrity. Here, people are accustomed to the loads, they have adapted to the volume, and they are at ease with the relative intensity. This is where the average gym-goer is, and more often than not, where they will stay. The stresses applied eventually stop driving a strength adaptation in the system and shift to increasing muscular endurance, which then interferes with making further strength gains (5). This defies the science of getting stronger and is often the source of why endurance athletes who begin strength training develop so many overuse tendon injuries (1).

It is imperative that we find a “sweet spot” where the total imposed stress is enough to disrupt tissue homeostasis and propagate change without reducing structural integrity of the tendon.

Let’s Take Another Look at That Tendonitis…

Now that we know how tendons respond to stress, and that we have to balance our athletes between too much and not enough of it to ensure they continue to make progress, let’s walk through how we might work with that athlete who comes in to the gym with a self-diagnosed case of knee tendonitis from Dr. Google.

First we need to find out how long they’ve had the nagging pain, what movements make them feel it the most, and what they’ve tried to do to fix the symptoms.  If you’re working with novice athletes, there’s a good chance they started feeling the pain yesterday. It hurts when they do the movements they are the least familiar with, and they’ve done absolutely nothing to fix it other than watching YouTube videos on their phone.

Next, check their posture and position in the exercise they are struggling with.  Often, you can get rid of painful symptoms an athlete thought was “the itis” just by helping them move better.  However, if they are moving correctly, it may be time to consider the volume and progression of load they are going through in their workout program (which we’ll address in the next article)..

Finally, figure out what exercises they can do so that you continue to provide a healthy dose of stress. You want to  them to their boiling point where they are capable of recovering, not their breaking point.

Master Your Movement: Get the Dose Right

To improve performance, coaches must determine the optimal dose that will adequately and optimally load the athlete without breaking them down. Coaches must recognize where the athlete falls on the athletic continuum and consider what forms of stress, other than the barbell, that affect their athletes. With so many variables at play, knowing how to  appropriately load them can get tricky; simplifying the equation with a program like Bedrock will allow you to systematically control their training, ensuring they obtain the appropriate dosage of stress without tipping the scale.

We are the “Masters of Movement.” We owe it to our athletes to think critically and purposefully about how we dose their training in order to load them in a way that elicits positive changes to empower performance.

Are you or your athletes having trouble with nagging injuries and can’t seem to get them under control? You may have crossed the threshold of tissue tolerance with the way you move. Hit up our Remote Coaching for an individualized assessment with Dr. Matt Zanis and a personalized training plan to get you back on track.


  1. Bartolomei S, Hoffman JR, Stout JR, Merni F. Effect of Lower-Body Resistance Training on Upper-Body Strength Adaptation in Trained Men. J Strength Cond Res. 2018;32(1):13-18.
  2. Booth J, Moseley GL, Schiltenwolf M, Cashin A, Davies M, Hübscher M. Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care. 2017;
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  4. Dye SF. The pathophysiology of patellofemoral pain: a tissue homeostasis perspective. Clin Orthop Relat Res. 2005;(436):100-10.
  5. Hatfield FC. Power, A Scientific Approach. McGraw-Hill Companies; 1989.
  6. Järvinen M. Epidemiology of tendon injuries in sports. Clin Sports Med. 1992;11(3):493-504.
  7. Maffulli N, Moller HD, Evans CH Tendon healing: can it be optimised? British Journal of Sports Medicine 2002;36:315-316.
  8. Sutton MA, Oenema O, Erisman JW, Leip A, Van grinsven H, Winiwarter W. Too much of a good thing. Nature. 2011;472(7342):159-61.
  9. Xu, Yinghua, and George A. C. Murrell. “The Basic Science of Tendinopathy.” Clinical Orthopaedics and Related Research 466.7 (2008): 1528–1538. PMC. Web. 25 Apr. 2018.
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Matthew Zanis

PT, DPT, FAAOMPT, OCS, ATC, CSCS Former baseball catcher and an avid outdoorsman. Worked with Division 1 basketball, football, and track and field at the University of Pittsburgh, along with the Pittsburgh Pirates and Arizona Cardinals organizations. Received a Bachelors in Athletic Training from the University of Pittsburgh in 2011 and a Doctorate in Physical Therapy from Duke University in 2014. Is board certified in Orthopedics and a Fellow through the American Academy of Orthopedic Manual Physical Therapists. Is a PT with the United States Olympic Committee and USA Shooting. Currently operates his performance therapy practice in Scottsdale, AZ with Dr. Tom Incledon of Causenta Wellness, and became a Power Athlete Block One Coach in September of 2017.

Dr. Zanis utilizes the Power Athlete Methodology to optimize performance, reduce injury risk, and rehab his clients and athletes through movement assessment, coaching, and individualized program design.

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