Earlier this year in London, I saw the Queen, Prince Charles, and Dr. Peter Malliaras.
Only one of them came prepared with new insights about tendonitis.
Dr. Malliaras, PhD, is one of the world’s leading tendinopathy clinicians and if you get the chance to take one of his courses, I highly recommend you do so.
The two biggest aha-moments I had in his seminar fit the old “good news, bad news”-cliché.
Let’s start with the bad news.
Here’s the Bad News
As part of his work, Dr. Malliaras regularly performs ultrasound imaging. For him, it’s an important tool to reassure patients by saying “look, you’ve got 80% normal tendon” and to aid in differential diagnosis.
Clinicians can see tendon pathology on ultrasound, but much like a shoulder with a torn rotator cuff can be pain-free, a pathological tendon is not necessarily painful. This confirms my patellar tendonitis treatment advice: “Just because you’re pain-free, doesn’t mean your tendon is healthy”, but here’s the bad news.
Once a tendon has become pathological (i.e., the collagen alignment inside the tendon has degraded and other negative changes occurred), the pathological changes will not go away again.
You read that right.
Once a tendon has become degenerated, it will stay degenerated, as shown by ultrasounds of recovered tendinopathy patients. These folks are pain-free and able to enjoy their sports without a problem, but the inside of the tendon has not returned to the pre-injury state.
Here are my key takeaways from this.
1) Ignoring the pain is officially the worst way to deal with tendonitis, because of the high risk of doing irreversible damage to the tendon.
2) To prevent pain from coming back once you’ve recovered, keep doing strengthening exercises for your tendon. That brings us to the good news.
You CAN Get Rid of Pain (In Many Different Ways)
The most popular exercise for patellar tendonitis is eccentric squats on a slanted board. It’s been around for decades and looks like this.
A newer treatment approach relies on heavy slow resistance training (HSR), which you can do on the leg press machine, the leg extension machine, the smith machine, hack squats, and even with barbell back squats.
Of course your next question is, “which one is better?”
If you look at the landmark study by Koonsgard from 2009, you’ll find that while HSR has a slightly better outcome in terms of pain scores at the 6-month follow-up compared to eccentric training, the difference is not statistically significant.
In this study, some people did better on HSR exercises and others on eccentric training.
The key insights in terms of outcome difference were that both, eccentric training and HSR, are superior to corticosteroid injections over the long-term, and that patient satisfaction was higher in the HSR group, because of the lower training frequency.
At the seminar, Dr. Malliaras said, “It doesn’t matter what exercise you do, people will get better.” That is, as long as you’re using an exercise that can be progressed and are not progressing too fast.
Here’s my take on the advantages of heavy slow resistance training compared to eccentric squats.
Pros and Cons of HSR for Tendonitis
+ Lower training frequency (in the first months only – I advise against daily training with eccentrics as soon as you do single-leg variations)
+ Potentially better than eccentrics if exercise irritates your tendon easily (HSR allows for adding resistance in small increments, so you’re progressing more gently)
+ Allows for isolating the quadriceps muscle group (in the squat, quad weakness may be masked by more engagement of other muscles)
– Requires gym membership (and you will need to drive there)
– Requires technique instruction (for smith machine squat, back squat, and leg press) to reduce risk of back injury
If you already have a gym membership and are experienced with the required exercises, HSR is a good option. If you’d rather train at home, eccentric exercises are the more attractive option.
Regardless of which exercise you pick, be sure to move slowly and without momentum. You need to avoid flare-ups.
How to Make Your Knees Strong Again
The research is clear on one thing. Your knees won’t get better with resting. You need progressive loading.
Let me show you a simple way to get rid of pain and make your knees strong again.