Research Update: Isometric strengthening exercises for tendon pain

Over the past number of years isometric strength training has been in vogue for physiotherapists, movement coaches and strength & conditioning coaches to implement with their patients or athletes to help manage various tendinopathies. A tendinopathy is a type of injury to a tendon that usually occurs over long periods as a result of some form of overuse of a tendon and a failure for the tendon to adapt to this for any number of reasons.

Isometric strength training involves the forceful contraction of a muscle or group of muscles where there is no change in the angle of the joint or length of the muscles. A good example of isometric training often implemented is a wall squat hold where the quads and glutes are contracting with no change in their length or the joint angles. The theory behind the increased use of isometric training in recent times has been that it may be beneficial as an early treatment tool in the management of tendinopathy and also for midseason pain management for athletes with tendinopathy.

However, the scientific evidence behind recommending isometrics in these scenarios may not in fact be as straightforward as is thought and this was recently neatly highlighted in an editorial in the large British Journal of Sports Medicine journal. This week’s blog will briefly summarise the main points of the editorial:

  • Firstly, the evidence for the use of isometric training as an early treatment tool in the management of tendinopathy and as a mid-season pain management tool for athletes with tendinopathy has largely stemmed from 2 small studies involving only 26 participants in total. These studies reported greater improvements in pain in patients with patellar tendinopathy just after isometric contractions compared to isotonic contractions involving changes in muscle length.
  • However, a study that included a separate group of 20 individuals with patellar tendinopathy and implemented the same methods as the above studies did not replicate these results and other similar studies involving Achilles tendinopathy, plantar-fasciopathy and lateral elbow tendinopathy did not identify isometric training as being more beneficial than walking or training involving isotonic contractions where the muscle length is not static and in some cases increases in pain were experienced.
  • The overriding argument for the use of isometric exercise is that they produce short term pain relief and that the patient should continue using isometrics until pain has settled and they can easily perform them. However, this is not in line with other previous studies that supports using isotonic contractions in the early stage of tendinopathy management and further, small levels of tendon pain during exercise may in fact be beneficial to recovery of tendinopathies.
  • Promoting isometrics as a quick fix to reduce pain for tendinopathy could be harmful to its overall management and a focus on the long term recovery over periods of months and promoting and improving the resilience of the joint and the patient may be of more benefit.
  • An interesting point made in the editorial regarding the use of isometric exercise for the in season management of tendinopathy is that the effects of using a previously painful tendon during sporting activity after the pain relieving effects of the isometrics is unknown and may potentially in fact lead to further pain or injury.
  • On top of this, the editorial noted that studies have reported no differences in the pain relieving effects of isometric exercises compared to that of isotonic exercise for patellar tendinopathy during a sports season. Larger studies have observed that maintaining pre and in-season strength and conditioning training using isometric and isotonic contractions reduces the number of injuries for several tissues in the body by about 30-40%.
  • Some evidence suggests that pain monitoring and providing sufficient time to adapt to the training, rehabilitation and sporting stimulus allows for continued participation without affecting the overall recovovey of the tendinopathy


So then, what does all this mean?

Firstly, physiotherapists, movement scientists and strength & conditioning coaches should be wary of the latest trends and should be fully informed of all the treatment and exercise modalities they implement before the use them.

Secondly, the main take home message from the editorial is that we should not ignore isometric exercise, but we need to gain a better understanding of its effects on tendinopathies. Until then, physiotherapists, movement scientists and strength & conditioning coaches should continue to prescribe progressive strengthening that is most appropriate for each individual athlete and progress them using an evidenced based approach.


Mark speaking on the For Fit Sake Podcast with Ciaran Ruddock and Rory McInerny from FFS

Deskbound? What preparation are you doing?

The average American spends 13-hours a day in a seated position. Most people reading this won’t be from America but there are close similarities in how our days are set-up. Take a minute to calculate all the time that you are spending sitting? It might help to picture this day;

You wake up in the morning, hop into the shower and then head down to sit at the breakfast table, you spend 40mins catching up on your social media platforms and sleepily spooning some porridge and coffee into you. It’s time to head to work so you hop into the car / bus / luas / dart for between a 30-60min journey and you manage to find yourself sitting again. You arrive at your desk plonk yourself down onto the ergonomic chair, switch the monitor on, sign in and get to work. You take a coffee break for 30mins at 11am then it’s back to the desk for a couple of hours before lunch. Lunch rolls around just as your stomach begins to grumble, you make your way to the cafeteria sit with the crew and munch away. 60mins later you are back at your desk. 17:30 rolls around and it’s time to hop back into the car / bus / luas / dart to head to the gym. You lash out a 60min workout then head home for dinner. Once again you find yourself sitting at the kitchen table. Next you migrate to the couch with the laptop to watch the latest addictive Netflix series, catch-up on emails, browse through Asos or read a few news articles. 23:30 rolls around and it’s time for bed!

The above day is what a normal day looks like for most people. Give or take a few minutes here or there walking to and from meetings, maybe getting to cycle or walk in and out of work. But if you calculate the amount of time you spend sitting it can be an interesting exercise to do.

Now lets take it for granted that you are going have to spend a large portion of your day sitting. What are you going to do to counteract this? We know that every single joint in the body gets it’s nutrients through movement, take articular cartilage (found at the end of bones between joints). This gets its nutrients from synovial fluid. It doesn’t have a blood supply. Synovial fluid is secreted when a joint is moved. Thus, in the absence of movement – the cartilage cannot stay healthy. Unhealthy joints lead to pain, now just consider the joints in your body that don’t get to move throughout the day. Neck, Shoulders, Scapula, Wrist Spine (multiple joints stacked on top of each other) Hips, Knees and Ankles. If you are going to have to sit for 8+ hours a day how are you going to keep your joints healthy? If healthy joints require movement and the environment that you are in does not offer them the requisite movement then what will you do?

We recommend that you take each of your joints through their full range of movement on a daily basis. If the environment you are in is not offering your joints the movement then you are going to have to supplement them with something extra. Try this, it takes 10mins but requires consistency, you will never regret moving your joints through their full range of motion.

Lettuce know how you get on!