| | | Tendinopathy: Isotonics Rehab Part 2

Author / Matthew Zanis

Now that you’ve learned some background information on tendons, their function, and how they heal covered in Isotonics Rehab Part 1, we can get to the important part: using this information to establish a sound start, which will provide the ‘launch pad’ for an effective and time sensitive rehabilitation program.

We’ve learned that load is the primary stressor our tendons perceive, and is the stimulus that drives rehabilitation. Now, we must find and implement a training volume that YOU can benefit from. This will fall within the envelope of function discussed in my last article, lying somewhere between the minimum effective dose for your body and the maximal stimulus you can recover from. Don’t be that guy or girl that goes full “throttle”; I know it’s tempting to jump right to the maximal load you can handle, but this will do more harm than good, and mess up the rehabilitation process in the long term.

What’s The Goal?

Our main objective is to improve the load bearing capacity of the viable structures remaining in the injured tendon. We want a net synthesis of collagen, versus a net degradation. In other words, we want to shore up what we got, and not keeping knocking holes in the wall.  Unfortunately, it’s not as simple as it may seem.

Cells are sensitive to forces such as shear (unaligned forces pushing in opposite directions), tension (pulling force), and compression (aligned forces pushing in the same direction), and will respond accordingly through cellular proliferation, migration, tissue repair, altered metabolism, and even stem cell differentiation and maturation. This stem cell thing is really cool, because that means those cells can develop into anything the body needs!  This includes bone, muscle, tendon, ligament, and even nervous tissue! Following resistance training, we get an increase in collagen turnover. However, this includes both synthesis AND degradation.

Technically, you are breaking yourself down each time you train, and actually experience a LOSS in protein. We don’t see an upswing until roughly 36 hours after your clang n’ bang session is over.. This is why rest is so critical! Without appropriate recovery, tendons become vulnerable to re-injury with excessive loading.

Taking this into consideration, you need to remember that stress to the body is not limited to the confines of your gym. The demands of daily living also come into play, especially if you have an active job and lifestyle. When tendons become pathological due to injury, those same life stressors play a significantly greater role because the tolerance for load in that tendon is already diminished.

Remember, the point of training is to stimulate a growth adaptation in the tendon. You can’t do that if you blow your Johnnie WOD every training session. This is why it makes more sense to underestimate yourself at first, ensure you are tolerating and recovering from the current load well, and progressively build volume over the time frame laid out below.

The following strategy will allow you to progress through your tendon rehab safely, as long as your total stress impact doesn’t exceed your capacity and ability to recover. Finding the right balance will take some trial and error.

Tell Me The Plan Already!

  1. 3 Sessions per Week (36-48 hour rest between sessions)
  2. 4 Sets with a 2 minute rest between sets
  3. Choose an exercise that is most functionally applicable to your desired goals of training
    1. ex. Squat, Split Lunge, or Step Up for Patellar Tendinopathy
    2. ex. Barbell Calf Raise, Seated Calf Raise for Achilles Tendinopathy
    3. ex. Loaded Wrist Flexion and Extension for Elbow Tendinopathy
  4. The repetitions/loads change each week, with you doing the most weight you can to complete the number of repetitions noted for the week (repetition max- RM)
  5. Range of motion kept to mid-range to prevent excessive compressive loads at end-range
    Example: Achilles tendon against calcaneus at end range of dorsiflexion during a calf stretch

TEMPO Protocol

  • 3 seconds eccentric (slow lowering)
  • 3 seconds concentric
  • 6 second total time under tension per rep
  • You do the math – this can get pretty spicy!
  • Pain during exercises is acceptable (about a 4 out of 10) but pain and discomfort should NOT increase after stopping the exercises.

Progressive Overload

Week 1: 15 RM (usually 60% of 1 rep max)

Weeks 2-3: 12RM (usually 65% of 1 rep max)

Weeks 4-5: 10RM (usually 70% of 1 rep max)

Weeks 6-8: 8RM (usually 75% of 1 rep max)

Weeks 9-12: 6RM (usually 85% of 1 rep max)

The best I can offer is education on these several factors, validated by the literature to be important. I will leave the nuts and bolts of programming up to you on an individual basis.

Master Your Movement: Slow Down to Speed Up

Once tendon strength is improved, you can then resume regular training sessions and eventually return to sport. Hold your horses though! We still need to train the tendon to perform its primary task – acting like a spring! This is the crucial last stage. The tendon needs to relearn how to store and release energy.

Gone are the days of relying on passive treatment. It’s time to sack up and take responsibility over your injury rehab. Successful outcomes are dependent upon the simple principle of load management. If you need some help in how to get started addressing your specific injury, set up a Remote Coaching program with Physical Therapist and Power Athlete Block One Coach, Dr. Matt Zanis to get you on the right track with an individualized program designed to get you off the bench and back on the starting line.

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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.


  1. Martha on July 24, 2018 at 5:22 am

    This is awesome and relieving – thank you!

    • Matthew Zanis on July 25, 2018 at 9:15 pm

      Martha, you’re welcome! I am glad you found this helpful! 🙂

  2. Daniel C. on July 24, 2018 at 11:23 am

    Definitely appreciate this. Could you clarify one thing? Is the RM just for weight or is it also the prescribed amount of reps? Example, W1 are we doing 4×15?

    • Matthew Zanis on July 25, 2018 at 9:43 pm

      Daniel. Good question. The RM is the prescribed amount of reps. You are correct that week one would look like 4 x 15. That being said, I urge you to err on the side of caution. We want to build upon each week with progressive overload. For example, I do not want you to try and find a new 15RM the first week. These sets should be challenging, yet manageable.

  3. Mike Smith on July 26, 2018 at 9:47 am

    Amazing series, supremely helpful information. Quick question however: You stated that you should pick an exercise that is most functionally applicable to your goals, but which movement(s) should I be using on this protocol to rehab a hip flexor tendinopathy? Perhaps a combination of compound and isolation? Any feedback or knowledge would be helpful! Thank you again for writing this series of articles

    • Matthew Zanis on July 27, 2018 at 9:54 pm

      Mike, thank you for your question. I would first start with some dead bug isometric holds. If you are doing them correctly, you will likely make your hip flexor feel like it is starting to cramp. From here, I would move on to loaded lunge holds that focus on hip extension on the leg with the symptoms. If you need further assistance or would like to discuss individualized programming for your issue, follow this link https://powerathletehq.com/training/remote-coaching/

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