What’s The Best Way To Build Tendon Strength?

Matt Casturo, DPT, CSCS, of ‘The Movement System’ YouTube channel explains the difference between ‘muscle protein synthesis’ and ‘collagen synthesis,’ which is essential to understand – especially for those who need to recover from a tendon injury, like Tennis or Golfer’s Elbow.

Video: Matt Casturo, of ‘The Movement System,’ explains the difference between muscle and tendon growth and Isometric vs Eccentric Exercise

Watch the video on YouTube

When you’re suffering from a chronic tendon injury like Tennis Elbow or Golfer’s Elbow, one of the essential elements for a full, LASTING recovery is tendon strengthening.

This video is not specifically about chronic tendon injuries so we should first ask the question of When IS the right time to begin rehab exercises and start strengthening our tendons when facing Golfer’s or Tennis Elbow?

My position has always been that too many tendon injury sufferers are starting their rehab too soon (This is not universal – only general) and that many, if not most, would do better by prioritizing stimulation and mobilization with advanced Massage Therapy techniques and progressing to a less reactive state before starting rehab exercises.

Here is my overview of Tennis / Golfer’s Elbow rehab exercise principles.

However, when it comes time to strengthen your tendon, there are some key takeaways from this excellent video.

In a related topic there are also major, potential differences in muscle and tendon growth rates that are sports-specific. Article and video here: Disparities between Muscle and Tendon Growth

Key Points On Tendon Strengthening

• Tissues (muscle, tendon, ligament) respond / adapt to loads / stress
• Mild to moderate recurring stressors / loads cause micro damage
• Micro-tearing / damage incurs an inflammatory response and subsequent healing
• The healing / remodeling process leads to a larger, stronger tendon / ligament
• Isometric Exercises may be more appropriate for the early rehab phase of tendinopathies
• Eccentric Exercises (+ heavy, slow-resistance exercises) are needed to build tendon strength and should be prioritized over Isometrics once progress has been made with Isometric Exercises

And here are the thoughts I would like to add…

Muscles And Tendons Made Of Different Components

One of the first important distinctions between muscles and tendons to be aware of is that muscles (the active part that actually produces the contraction) is that they are cellular in nature.

• Muscle are made of living, “breathing” cells. They are Oxygen and nutrient / glucose- consuming little powerhouses, which is why they need such a large blood supply.
  
  
• By comparison, tendons are not “alive.” They are mostly composed of collagen, the most common structural protein in the body.

(Tendons are mostly “passive” structural tissues. They connect your muscles to your bones allowing your muscles to pull on those bones and move your joints. They transmit or carry forces – but do not produce them, which is also why they don’t have or need as much of a blood supply.)

Tendons do have cells that maintain and repair them, otherwise they would have no to way to heal and regenerate. ‘Tenocytes’ and ‘Fibroblasts’ (types of Stem Cells) synthesize new collagen within the tendon for that purpose.

Muscles And Tendons Adapt, Heal & Strengthen Differently

Muscles adapt to increased loads by producing more cells, which, in turn, can produce more force / do more work to handle the increased load.

Tendons, conversely, HAVE cells in them, ‘Tenocytes’ and ‘Fibroblasts,’ which synthesize new collagen fibers to either replace worn out or damaged tendon fibers – or to strengthen the tendon.

And, for whatever evolutionary reason, this tendon Collagen Synthesis adaptation process lags behind that of the muscle’s speed of adaptation and growth.

(And this disparity seems to increase as we get older, which may partly explain why tendon disorders become more common as we age – AND why we need to be careful about the rate at which we increase the intensity of and weights / loads in our exercise programs as we get older to allow our tendons to “catch UP!”)

Muscle Strengthening And Healing

In a perfect world, we want to consistently train / load our muscles to the point where the threshold to trigger an adaptive strengthening response is reached – but no more.

We do NOT want to OVERload our muscles to the point where they TEAR.

(The “good” strength-adaptive damage that occurs to muscles in response to exercise happens on a cellular, microscopic level and may be referred to as “micro-tearing” but I don’t like this term. If it is a form of tearing at all, it’s definitely not a real tear like a sprain or a strain.)

Healing is not the same as strengthening. Muscles (and tendons) heal from major “macro” tears, like strains, by producing Scar Tissue, which is never quite as strong as the original, uninjured muscle.

A torn muscle (or any tissue) must heal in stages: First, an inflammatory response – Second, the proliferation of scar tissue and, finally – Third, the remodeling stage where the scar tissue is “perfected” realigned and strengthened.

Tendon Healing And Strengthening

Tendons go through the same stages of healing as muscles when torn, involving scar tissue formation in the second stage – (Their recovery from major tears / ‘strains,’ however, is even more challenging and less certain.)

But the process of tendon strengthening is different than muscles.

Since tendons are made of mostly collagen fibers, aligned in tight bundles (like a rope) the strengthening process involves the synthesis of new collagen to increase the quality and density (and sometime the total mass) of collagen in the tendon.

Those Tenocytes and Fibroblast stem cells, mentioned earlier, crank out new collagen to replace, upgrade and increase the tendon’s size and strength.

More + better fibers = stronger rope. More + better collagen protein fibers = stronger tendon.

The remodeling process is also key. The quality and the alignment of the collagen fibers needs to be gradually improved and this is largely a mechanical process.

The right amount of tension and load consistently applied by way of the right exercise at the right frequency is essential – especially if we’re talking about the rehab process in recovering from a tendon injury!

• “Normal” tendon strengthening – Synthesizing new collagen in a tendon in response to regular, measured exercise / proper tendon loading = A relatively easy process in healthy people, vs:
  
  
• Healing / recovering from a  tendon injury – Especially when it comes to chronic tendon injuries because their very nature is one of collagen degeneration / decay (Tendinosis) = Often very challenging!

Isometric And Eccentric Exercises In Tendon Healing

I agree with Matt’s perspective in the video that Isometric Exercises may be the safest and most appropriate form when an athlete is “in season” and performing heavily, to strengthen without over training.

AND particularly for those people in the early stages of rehab with a tendon injury – whether it’s an acute injury (like a tear / sprain / strain) OR a chronic injury like Tennis or Golfer’s Elbow or a Rotator Cuff Tendinopathy.

And I agree that Eccentric Exercises are certainly valuable and essential for building both muscle and tendon strength.

However, in my experience, many (most?) Golfer’s and Tennis Elbow sufferers seem to be better off if they defer rehab exercises at first.

It’s all too easy to overload a weakened, degenerated tendon and cause a lot of unnecessary pain and frustration.

What’s desperately needed at first in chronically injured tendons with degenerated collagen (Tendinosis – the most common pathology in Tennis and Golfer’s Elbow) is a lot of stimulation.

If you can first stimulate a healing response (which should involve some inflammation – It’s the first stage of healing) with hands on techniques…

And do some work to release the built-up adhesions in the muscle attached to the tendon (which are restricting and constantly “dragging” on the tendon)…

THEN (in my experience) you can get to the next two stages of healing (2. Proliferation / collagen synthesis and 3. Remodeling) where you’re out of the most reactive phase and you can then proceed with rehab exercise.

At that point, I don’t believe it matters as much what type of exercise you do (Concentric, Eccentric, Isometric) as long as you proceed carefully and make a slow, measured progression!

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