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Isometrics vs Eccentrics: Rethinking Tendinopathy Rehab

Isometric Exercise in the Early Management of Tendinopathy: A Potentially Superior Approach

Tendinopathy represents a significant challenge in musculoskeletal health, characterized by pain and functional limitations arising from tendons affected by overuse or injury.1 This condition impacts a diverse population, from elite athletes striving for peak performance to individuals engaging in everyday activities.1 Historically, the understanding and terminology associated with tendon pain have evolved. The term "tendinitis," which implies an inflammatory process, has largely been replaced by "tendinopathy," a broader term acknowledging the predominantly degenerative nature of these conditions in many cases.1 Exercise-based interventions form a cornerstone of tendinopathy management, with eccentric and isometric exercises being commonly employed strategies.7 While eccentric exercises have traditionally been favored, this report aims to argue, based on current research and theoretical advantages, for the potential superiority of isometric exercises, particularly in the early stages of tendinopathy rehabilitation.


Tendinopathy is best defined as a clinical syndrome involving pain and dysfunction associated with overuse or mechanical loading of a tendon, reflecting a complex, often failed, healing response at the tissue level.1 This condition is not simply an inflammatory disorder but involves a spectrum of pathological changes within the tendon's structure.1 At a cellular and matrix level, tendinopathy is characterized by a disorganization of collagen fibers, an increase in the non-collagenous matrix including proteoglycans and glycosaminoglycans, neovascularization (the growth of new blood vessels), hypercellularity of tenocytes (tendon cells), intracellular abnormalities within these cells, and potentially cellular apoptosis (programmed cell death).2 These structural alterations indicate a degenerative process that compromises the tendon's mechanical integrity.2 Common symptoms of tendinopathy include pain that is typically exacerbated by movement and loading of the affected tendon.2 Individuals may also experience local tenderness upon palpation, stiffness in the affected joint, and weakness in the associated muscles.2 Swelling or the presence of palpable nodules around the tendon may also occur.3 Interestingly, in the very early stages of tendinopathy, pain might decrease during activity only to worsen afterward or the following day, a pattern indicative of the tendon's response to mechanical stress.2 The underlying mechanisms contributing to tendinopathy are multifaceted. Repetitive overload that exceeds the tendon's capacity to adapt is a primary factor, leading to micro-damage and initiating a cascade of events that result in a failed healing response.1 This process involves an increased rate of matrix remodeling and an altered tendon environment that can further impair healing.2 Neovascularization, along with the ingrowth of small nerves into the tendon tissue, is theorized to contribute to the pain experienced in tendinopathy, a phenomenon termed neurogenic inflammation.1 Furthermore, tendinopathic tendons often exhibit an increased ratio of collagen type III to type I, along with a disorganized arrangement of collagen fibers, which contributes to the tendon's reduced tensile strength.3 Tendinopathy can affect various tendons throughout the body, with common locations including the shoulder (rotator cuff, biceps), elbow (lateral and medial epicondyles), wrist, hip (gluteal, hamstring), knee (patellar, quadriceps), ankle (Achilles, peroneal, posterior tibial), and foot (plantar fascia).2


Isometric exercises are characterized by muscle contraction that occurs without a noticeable change in the length of the muscle or the angle of the joint.11 During these exercises, the muscle generates force to either maintain a specific position or to resist an immovable external force.27 Examples of isometric exercises include holding a plank position, performing a wall sit, or pushing against a fixed object like a wall.12 Isometric exercises load tendons specifically through the sustained muscle contraction. Even though there is no significant joint movement, the contracting muscle exerts tension on its attached tendon.11 This sustained tension creates a tensile load on the tendon, the magnitude of which can be adjusted by varying the intensity of the muscle contraction, often expressed as a percentage of the individual's maximal voluntary contraction (MVC).13 For instance, as demonstrated in video resources, holding a lunge or squat position engages the patellar and quadriceps tendons, with the load increasing as the hold is maintained or as the position becomes more challenging.34 This static loading allows for targeted stress on the tendon at a specific joint angle, potentially avoiding painful ranges of motion that might be encountered during dynamic exercises, particularly in the early stages of tendinopathy.26 The controlled nature of isometric loading might also be less likely to exacerbate symptoms compared to the dynamic lengthening under load characteristic of eccentric exercises. Isometric exercises encompass various types, including isometric presses (pushing against an immovable object), pulls (pulling against an immovable object), and holds (maintaining a specific posture), as well as variations that incorporate external weights (weighted isometrics) or rely solely on bodyweight (unweighted isometrics).27


Numerous research studies and clinical trials have investigated the effects of isometric exercises on pain levels in individuals suffering from various types of tendinopathy.11 A pivotal study in this area was conducted by Rio and colleagues in 2015.15 This research demonstrated a significant immediate and sustained reduction in pain in volleyball players with patellar tendinopathy following a single bout of heavy isometric quadriceps contractions, performed as 5 sets of 45-second holds at 70% of their maximal voluntary contraction.15 This finding was particularly noteworthy as it suggested a rapid analgesic effect associated with isometric loading in this specific tendinopathy.38 Further investigation into the mechanisms behind this pain relief revealed a potential neurological basis, with the study also finding a reduction in cortical inhibition following the isometric exercise protocol.38 However, subsequent research by O'Neill and colleagues 15 attempted to replicate Rio's protocol in individuals with Achilles tendinopathy but did not observe the same degree of immediate pain relief. In fact, the study found no meaningful reduction in pain in this population, suggesting that the analgesic effects of isometric exercise might be tendon-specific.15 Other studies have explored the use of isometric exercises for pain management in different tendinopathies. Malliaris et al. 14 proposed a rehabilitation progression that begins with isometric loading, particularly for managing pain in the early stages. Additionally, a study by Hoelting et al. 52 investigated the effects of both short- and long-duration isometric contractions on patellar tendon pain, finding that both protocols led to a reduction in pain. However, a systematic review and meta-analysis published in 2020 46 concluded that overall, isometric exercise does not appear to be superior to isotonic exercise for chronic tendinopathy, either immediately following treatment or in the short term. This review included studies on various tendinopathies, highlighting the variability in response to isometric exercise across different tendon locations and populations.46


Eccentric exercises involve the active lengthening of a muscle while it is under tension, typically occurring during the controlled lowering phase of a movement.11 This type of muscle contraction is often utilized in activities that require deceleration or the controlled descent of a load.31 Common examples of eccentric exercises used in tendinopathy rehabilitation include the heel drop for Achilles tendinopathy, where the calf muscle lengthens while controlling the lowering of the heel, and decline squats for patellar tendinopathy, where the quadriceps muscle lengthens during the downward phase of the squat.12 A key characteristic of eccentric contractions is their capacity to generate greater maximal force compared to concentric or isometric contractions at the same angular velocity.59 This higher force production has been a primary rationale for the traditional use of eccentric exercises in strengthening and promoting tendon adaptation.63 However, it is important to note that while the potential for higher tendon loads exists with eccentric exercises, the actual load experienced during typical rehabilitation protocols might not always reach these maximal levels, particularly in the early stages when pain often limits exercise intensity.63 Eccentric exercise is sometimes referred to as "negative work" because the muscle is actively resisting and absorbing energy from an external load as it lengthens.59


Research studies have extensively investigated the use of eccentric exercises in the management of tendinopathy.13 Notably, eccentric exercise protocols, such as the widely used Alfredson protocol for Achilles tendinopathy, are known to frequently provoke pain during the exercise itself.13 This pain can be significant enough to impact patient compliance and adherence to the prescribed exercise regimen.13 In some instances, individuals undergoing eccentric training might experience a temporary worsening of pain in the initial weeks before seeing improvement.60 The occurrence of reactive pain, defined as an increase in pain that lasts for more than 24 hours after exercise, is a key consideration in guiding the progression of eccentric loading.37 Despite the potential for initial discomfort, many studies have demonstrated the long-term effectiveness of eccentric exercises in reducing pain and improving function in various tendinopathies, including those affecting the Achilles tendon, patellar tendon, and lateral elbow.65 However, it is important to acknowledge that eccentric exercise is not universally successful, and a significant proportion of patients may continue to experience pain and functional limitations despite adhering to these protocols.44 Furthermore, systematic reviews that have compared eccentric exercise to other forms of therapeutic exercise have often found the evidence for its superior clinical effectiveness to be limited or questionable.63


A direct comparison of the findings from studies on isometric and eccentric exercises reveals distinct patterns regarding pain, function, and the potential for symptom exacerbation.11 In terms of pain reduction, isometric exercises, particularly heavy isometric contractions, have shown promising immediate analgesic effects, especially in patellar tendinopathy, potentially mediated by neurological mechanisms.38 In contrast, while eccentric exercises have demonstrated long-term pain reduction in various tendinopathies, they frequently cause pain during and after exercise, particularly in the initial stages of treatment.13 The immediate pain relief observed with isometric exercises in responsive tendinopathies is a notable advantage, although this effect may not be consistent across all tendon locations.15 Regarding functional improvement, both isometric and eccentric exercises have been shown to lead to gains over time.39 However, some evidence suggests that heavy slow resistance training, which includes both concentric and eccentric phases, might be more effective for long-term functional improvement compared to isolated isometric exercises.47 Considering the potential for symptom exacerbation, eccentric exercises, with their higher forces and muscle lengthening under load, might carry a greater risk of aggravating symptoms, especially when rehabilitation is initiated on a highly irritable tendon.16 Isometric exercises, being static and allowing for lower initial intensity, might pose a lower risk of exacerbating symptoms, potentially offering a safer starting point for therapeutic loading.13

In the early stages of tendinopathy rehabilitation, particularly when the tendon is highly irritable and painful, isometric exercises offer several theoretical advantages over eccentric exercises.11 Firstly, isometric exercises can be initiated at lower intensities, allowing for a more gradual and controlled introduction of mechanical load to the tendon.14 This might be better tolerated by a sensitive tendon compared to the potentially higher mechanical stress imposed by the lengthening contractions inherent in eccentric exercises, reducing the risk of further tissue irritation or damage. Secondly, isometric exercises have demonstrated the potential for immediate analgesic effects in some tendinopathies, most notably patellar tendinopathy.13 This pain-relieving property can be invaluable in the early stages, improving patient comfort and facilitating greater participation in the rehabilitation process. Furthermore, isometric exercises can be performed at specific joint angles that minimize pain, allowing for targeted muscle activation without exacerbating discomfort.26 Thirdly, research suggests that isometric exercises might have the capacity to reduce cortical inhibition associated with tendon pain.38 This potential to address neurological factors early in rehabilitation could contribute to more effective long-term outcomes by helping to restore normal motor control and muscle activation around the affected tendon. Fourthly, isometric exercises serve as a safe and controlled means of introducing mechanical load to the injured tendon, helping to gradually build tissue tolerance before progressing to the potentially higher demands of dynamic exercises like eccentrics.11 This step-wise approach can help prevent symptom exacerbation and promote a more positive rehabilitation experience for the patient. Finally, isometric exercises can often be performed in positions that minimize or avoid compression of the tendon, which can be a significant source of pain, particularly in insertional tendinopathies.13


In conclusion, the evidence suggests that while eccentric exercises play a crucial role in the long-term management of tendinopathy, particularly in promoting tendon remodeling and strength gains, isometric exercises offer compelling benefits, especially in the early stages of rehabilitation. Their potential for immediate pain relief, lower initial stress on the tendon, and possible positive effects on cortical inhibition make them a valuable tool for managing tendinopathy, particularly when the tendon is highly irritable. While eccentric exercises remain important for later-stage rehabilitation, prioritizing isometric exercises initially can provide a more comfortable and potentially more effective starting point for many individuals with tendinopathy. Ultimately, the selection and sequencing of exercises should be tailored to the individual patient, considering the specific tendinopathy, their pain levels, and their tolerance to different types of loading. Future research should continue to explore the optimal parameters and role of isometric exercises in the comprehensive management of various tendinopathies.

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Modern Manual Therapy Online Seminar - UQ & LQ Assessment

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  • Evaluation Techniques: Master the principles of Eval, Reset, and Stabilize for optimal results.
  • Movement Screening: Learn to perform effective evaluations using movement screening and repeated motions.
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