Tendinopathies are some of the most frequent and most persistent injuries in sports. We are going to show you how to effectively treat tendinopathies most common in running with Heavy Slow Resistance (HSR) Training. It is the latest evidence-based treatment for tendinopathy. Research has shown it to be effective and we have seen incredible results using it in our clinic.
The most important thing for you to understand is that tendinopathy comes about due to an over-load of the tendon. So, in conjunction with this treatment approach, you need to manage your training load. If you are experiencing pain that is greater than a 3/10 (10 being the worst pain ever, 0 being no pain at all) during or after your training sessions, or 24 hours after a training session (e.g. upon waking in the morning), you are over-loading your tendon and you need to cut back.
The HSR Training protocol works by increasing your tendon’s ability to handle the relevant load (e.g. running 10km at 5min/km). During running your tendons have to handle multiple-times your body weight with each stride. Through correct application of HSR we will effectively increase the tensile strength of your tendon so that it will be able to handle running-specific loads and you will get to the point that you can run pain free again.
Unfortunately, the process requires a bit of patience and perseverance. Tendon tissue takes three months to fully adapt, so if you have a chronic tendinopathy, you are in for a good three months of rehabilitation. You will, however, slowly be able to increase your training load (as tolerated) through the rehabilitation period. Rush it and you will suffer the consequences. We need to optimally load the tendon in order to achieve the desired adaptation. If you load it too much (or too little!), it will remain aggravated and painful.
During your rehabilitation, make sure not to irritate the tendon by performing excessive stretching. Rather use a foam roller or go for physiotherapy treatment to help to reduce tension in the relevant muscle group/s. Once your pain has settled, you will be able to re-introduce stretching.
Research also shows that rest (too little load), corticosteroid injections, and anti-inflammatory medications can actually weaken the tendon and do more harm than good ! Make sure that whoever is treating you is up to date with the latest research on tendinopathy management and has identified whether your tendinopathy is acute or chronic (treatment may vary).
Most importantly, make sure that you have a clear diagnosis of tendinopathy before beginning HSR Training.
How to perform Heavy Slow Resistance Training
|Week||Reps||Sets||RPE*||Rest Between Sets|
|* RPE: Rate of Perceived Exertion. See more on this below.|
You will perform three tendon specific exercises (we have given two examples, double up on one of them), three times per week with one days rest between each session. If you are still able to run (if you experience more than 3/10 pain while running, stop!), do not run on the day that you do the HSR exercises. You may need 36-48 hours rest between activities that usually aggravate your tendon. You will begin with 4 sets of 15 repetitions in your first week and progress your reps as shown in the table above.
The movement is slow and controlled, three counts up, three counts down. This is important. Performing the movement faster will reduce the effectiveness of the exercise. Give yourself 2-3 minutes to recover between exercises. A nice way to do that is to perform another strength exercise in between your HSR exercise sets.
Of great importance is your Rate of Perceived Exertion (10 being the most you’ve ever exerted yourself, 0 being no exertion at all). If your RPE is too low, you are loading the tendon below the necessary threshold and risk aggravating it. Make sure that RPE is always above a 6/10 (rather too high than too low). Tendons need to be loaded sufficiently to adapt optimally.
If you feel that you can only tolerate two of the three exercises for the first few weeks (the muscles often protest before the tendon does!), listen to your body, start there and slowly build up. It is obviously ideal to follow the protocol as closely as you can, however, we have had success in treating tendinopathies with only two exercises per session. We have found that for some people, four sets of three different exercises (twelve sets in total!) is a bit too much, so we adjust accordingly.
The key is to keep a record of how your tendon responds. Make a note of your pain levels (score out of ten) upon rising in the morning, running (if able), and during and after your HSR sessions. When you experience an increase in pain, particularly 24 hours after activity, you know that you are over-loading the tendon. If you are loading your tendon correctly, your pain should not get worse during the HSR session.
If your pain increases or if you are in any doubt, get the advice and assistance of a health professional who specializes in musculo-skeletal injury rehabilitation.
HSR Training is hard core - but so worth the effort. A bit of sweat is better than persistent and debilitating pain any day.