by Merrick Lincoln, DPT
How to Keep Lifting With Tendon Pain
Here's what to do if achy joints are forcing you to take time off. Stop the most common lifting injury dead in its tracks and keep making gains.
Lifting: It ain’t always peaches and creatine. Training injuries happen. It’s the ability to navigate these injuries that differentiates successful lifters from perennial amateurs.
While we can define injury as a “musculoskeletal problem that causes one or more missed workouts,” most of the time, an injury occurs without any formal diagnoses. Tendon problems are the most common.
“Tendonitis” refers to a tendon issue causing pain and some degree of intolerance to mechanical loading, such as lifting. Although the suffix “-itis” refers to inflammation, research has shown that inflammatory processes are not a defining feature of these tendon problems. (1)
The preferred term is “tendinopathy,” but let’s just call it a tendon problem for now.
What Are Tendons, Exactly?
They’re the structures that fasten muscle to bone, but they’re not inert. Tendons store and return massive amounts of elastic energy during lifting and athletic activities.
The first sign of a tendon problem is typically a dull ache or tenderness near the end of a muscle toward where it meets the bone. The pain is mechanical and predictable; it can worsen during lifting. However, on occasion, it may improve as you warm up.
Let’s get into the basics of tendon rehabilitation using load management. This will include a library of dead-stop exercises that can curtail tendon problems before they become full-blown injuries.
If you’re not interested in learning how to manage tendon problems, a physical therapist like me will be happy to take your money in the future. You can still skip ahead to the exercise videos.
Dealing With Tendon Problems
Tendon health exists on a continuum. On one end, you have healthy tendons, which can withstand extremely high forces, store mechanical energy, and return this mechanical energy during dynamic exercise.
On the other end is a degenerative tendon. Degenerative tendons have structural changes and have lost the capacity to store and release energy. Interestingly, this severe stage is typically non-painful. (1)
A lifter’s painful tendon problem probably lies somewhere between these two extremes. It’s called reactive tendinopathy. (1) The presence of reactive tendinopathy indicates the tendon’s current intolerance to these variables: volume, frequency, and/or intensity of loading.
Most tendon problems are considered self-limiting, which is medical speak for “if you keep that shit up, eventually you’ll have to stop.” Perhaps counter-intuitively, complete rest is rarely a good option. And you’re going to want to keep lifting, or else you risk losing gains. However, grinding through tendon pain will only make it worse.
Managing tendon problems is like disciplining a misbehaving toddler. It takes the right balance of firmness and compassion. Tendons respond to load, particularly the end-to-end pulling exerted upon them by contracting muscles (or tensile load). When load exceeds capacity, tendons get pissed off.
On the other hand, when load is chronically reduced, the tendon fails to build capacity and will eventually degenerate. When load is just right, adaptations and repair are optimized, and tendons get stronger.
The solution is load management. You’ll need to make one or more changes:
- Reduce volume
- Reduce training frequency
- Reduce intensity of the load
Reducing volume in isolation may not be enough, especially if every set provokes worsening tendon pain. Reducing frequency requires missed workout(s), which is equivalent to throwing in the towel and admitting injury. And remember, rest is rust. Not repair.
Finally, consider reducing intensity. Reducing intensity may mean backing off the weight, but that’s not the only approach. Any change that reduces tensile load on the tendon is an intensity regression. Although reduced intensity might bring to mind images of little pink dumbbells, this doesn’t have to be the case.
That’s where dead-stop training comes in.
Dead-Stop Training To Fight Angry Tendons
“Dead-stop” refers to a technique that imposes a pause between the eccentric (lowering) and concentric (lifting) parts of a lift. Unlike a paused rep, the dead-stop technique allows you to briefly release tensile load from the working muscles and tendons.
Dead-stop training has unique implications to muscle-contraction physiology and has numerous potential uses. You can make gains by focusing on dead-stop training as a load management technique.
In this case, it’s specifically an exercise modification for the lifter who’s starting to notice the all-too-familiar ache of tendon pain. Try these variations when your typical lifts start irritating your tendons.
What To Do For Arms
Dead-Stop Semi-Squat Biceps Curl
Dead-Stop Skull Crusher
What To Do For Shoulders And Chest
Dead-Stop Seated Overhead Press
Notice I have set the rack safeties a bit higher than the bottom position of a typical overhead press. The shoulders better tolerate this shortened range of motion.
This dead-stop lateral raise demonstrated by Gareth Sapstead feels challenging even with light weights.
Dead-Stop Seated Plate Front Raise
Dead-Stop Bench Press from Pins
Eric Bach demonstrates this version.
Hand-Release Push-Up
This one is demonstrated by Charley Gould.
What To Do For Back
Although tendon problems are uncommon in the back muscles, tendon pain at the elbow or rotator cuff may come up during pulling exercises. Try these dead-stop variations.
Dead-Stop Bench-Supported Dumbbell Row
Dead-Stop Pendlay Row
What To Do For Legs
Anderson Squat
For a dead-stop squat variation, this version demonstrated by Jason Brown from blocks or pins is phenomenal.
Box Squat
Or you can switch to box squats, which naturally require a dead stop and tend to be more knee-friendly.
What To Do For Legs (With Quad Tendon Pain)
Problematic tendons don’t tend to tolerate compression. Compression is a different type of load than tension. It’s typically created as a tendon is pulled over a bone.
Compression forces at the quadriceps tendon are highest when you squat deeply. You may need to initially limit the depth of the dead-stop squat variation of choice.
For quadriceps tendon problems, it’s wise to do some single-leg biased work. This is because of the natural tendency to off-load the problematic side during double-leg exercises.
Dead-Stop Rear Foot Elevated Split Squat
Notice how I’ve limited the range of motion by placing a plate and a knee pad under my knee to limit depth and thereby reduce tendon compression load.
What To Do For Legs (With Ham Tendon Pain)
Deadlifts? While they’re inherently dead-stop, they can be painful for those with a high hamstring tendon problem. Why? Again, consider the role of compression.
When loaded in deep hip flexion, like the bottom of a deadlift, the high-hamstring tendons experience compression as they’re pulled over your seat bones. So, if hamstring tendon pain presents at the seat-bone during deadlifts, it’s best to switch to an exercise that trains the hamstrings at the knee, while the hips remain extended, such as prone leg curls and Nordic curls.
Dead-Stop Nordic Curl
The Nordic curl requires lowering your body from a tall-kneeing position toward the floor with an eccentric contraction of the hams across the knee while keeping your hips extended. Demand on the hamstrings increases as the angle between the torso and the ground gets smaller. Upon reaching a certain angle, you’ll no longer be strong enough to control the motion. This is called the “break angle.”
When starting Nordics for tendon rehab, don’t lower yourself to the break angle. Instead, catch yourself well before the point of failure on a stack of plates. As you get stronger and can tolerate the maneuver with acceptable levels of tendon pain, you may increase the challenge (and tendon loading) by lowering the plate stack. Nordics are challenging, so start with a small range of motion.
Need More?
Now that you’ve seen some examples of dead-stop exercises, you should be able to set up your own. Here are some things to keep in mind:
- The setup should allow you to safely release muscular tension at the target muscle group’s lengthened position. For example, if your heel cord is hurting with your normal calf training, you might try dead-stop calf raises from the ground or off a lower block, allowing your heels to rest briefly on the floor between reps.
- Shorten the range of motion for exercises where demand on the target muscle group is minimal in the lengthened position. This promotes a higher quality concentric contraction by reducing your ability to generate momentum. Examples include the dead-stop hammer curl, dead-stop biceps curl, dead-stop plate front raise, and the dead-stop dumbbell lateral raise, which you saw above.
To become even more self-sufficient in managing your musculoskeletal health, keep reading.
How Can Dead Stop Training Help?
You may have heard the buzz surrounding eccentric exercise for tendon problems. However, recent evidence questions the superiority of eccentric training relative to traditional exercise for tendon problems. (4)
Eccentric exercise is a loading option that can be effective when correctly applied. However, the reactive tendinopathy stage (when you first start to feel tendon pain) is not the time for high-intensity eccentric training. (1)
For recent onset tendon pain, dead-stop training can be used to reduce tendon loading intensity. Think of it as a small step back (or regression) from your normal training. Yes, you’ll have to lower the weight for successful completion of dead-stop exercises – likely by 10-25 percent. This obviously reduces mechanical loads experienced by the tendons while still providing you with the opportunity to perform challenging lifts.
In addition to lowering the working weight, dead-stop training reduces peak tension loads on the tendon by off-loading at the end range and extinguishing the stretch-shortening cycle.
Here’s the mechanical basis of off-loading at end-range: Total tensile-load experienced by a muscle and its tendons is the sum of passive and active tension. Based on the length-tension relationship, the greatest amount of passive tension through the involved muscles and tendons occurs at long muscle lengths.
Typically, this is the bottom position of an exercise. When performing a dead-stop exercise, you off-load the muscles and tendons at the longest muscle lengths. This feature alone greatly reduces the tension load experienced by the tendon.
The second mechanism of dead-stop training is the elimination of the “spike” in muscle and tendon tension that typically occurs with the stretch-shortening cycle (SSC). The SSC is a neuromuscular phenomenon that engages the stretch-reflex to enhance tension via rapid and well-timed transitions between the eccentric and concentric phases of a lift.
At long muscle lengths, maximum passive tension ends with a reflex-potentiated muscle contraction. This is a recipe for very high tensile loads. Accordingly, the SSC is extremely mechanically demanding for involved tendons.
For the lifter who’s just beginning to feel the onset of a tendon problem, short-term elimination of the SSC from training may be the most appropriate regression. Dead-stop training is a great way to accomplish this without completely bastardizing your workout.
Another Tool In Your Toolbox
I’ve found that if I catch a tendon problem early enough, one or two dead-stop training sessions are all I need before I’m ready to progress back to traditional training. However, long-standing or severe tendon problems may require additional regressions in intensity, volume, and/or frequency.
Dead-stop training is not a panacea, simply a tool. Switching your normal exercises for these variations has only manipulated one variable of load management. You might also need to explore reducing volume or frequency.
Most importantly, the general pattern of pain should improve – not worsen – over time. If not, it’s time to get some help from a qualified sports medicine specialist.
Note: The information provided here is for educational purposes only and does not constitute individualized medical or rehabilitation advice. No client-provider relationship is implied.
References
References
- Cook JL et al. Revisiting the continuum model of tendon pathology. Br J Sports Med. 2016 Oct;50(19):1187-91. PubMed.
- Silbernagel KG et al. Continued sports activity, using a Pain-Monitoring Model, during rehabilitation in patients with Achilles tendinopathy. Am J Sports Med. 2007 Jun;35(6):897-906. PubMed.
- Littlewood C et al. **Exercise for rotator cuff tendinopathy: a systematic review.**Physiotherapy. 2012 Jun;98(2):101-9. PubMed.
- Dejaco B et al. Eccentric versus conventional exercise therapy in patients with rotator cuff tendinopathy: a randomized, single blinded, clinical trial. Knee Surg Sports Traumatol Arthrosc. 2017 Jul;25(7):2051-2059. PubMed.