There are three key things you’re trying to accomplish with resistance exercise when recovering from a Tennis Elbow tendon injury, whether it’s Tendinosis, Tendonitis or a tendon tear:
- Strengthening your muscle,
- Healing your tendon (Esp. the ‘Remodeling’ stage of your healing process)
- And strengthening your tendon (after your healing is finished)
The following video covers these three exercise goals in detail:
Let’s look at each of these important Tennis Elbow Exercise goals in detail. (Although, for simplicity's sake, the two tendon goals are so similar they could be thought of as one.)
Podcast: The Goals Of Tennis Elbow Rehab Exercise
Goal #1 Strengthening Your Muscle
The first is pretty straightforward; you are trying to strengthen the muscle part of your muscle-tendon team.
Keep in mind that you also want encourage lengthening of your muscle, through stretching, since tension AND weakness usually go hand in hand in Tennis Elbow and other Tendon injuries.
I’ve seen cases, more often in people who do heavy physical work, where the problem is almost all tension – and cases, more often in people who do computer work or something similar, where it’s almost all weakness.
Muscle strengthening is the “easiest” goal of the three, since muscles get stronger much faster than tendons…
And they are more forgiving about when and how much you challenge them with exercise.
Muscles adapt quickly in two ways: First they get more efficient, and then they get bigger.
Muscular strength is determined by both your muscle mass (size and density) and your coordination (the ability to control your muscle efficiently, which actually has to do with your nervous system.)
Most if not all of the early strength gains (approx. first 6 weeks) that one experiences either in rehab or in general fitness come from an increase in coordination – not mass.
Your muscle with its tendons at either end (connecting it to the bones it pulls on) is considered a single unit, since it functions as one. Your muscles and tendons are composed of two very different tissues, however.
The muscles cells themselves play the active role in producing the force that pulls on the tendon. The tendon is passive like a rope and made mostly of collagen, a protein, which is where things get tricky.
Goal #2 Remodeling Of Your Muscles And Tendon
This is where it gets challenging, because there’s a quantum leap between strengthening your muscles, and strengthening and remodeling your tendons when you have a tendon injury.
When you truly have Tennis Elbow, by definition you have a tendon injury, and there’s a good chance you have some injury to the muscle(s) as well – especially where your muscle transitions into your tendon. (See image)
So, this Remodeling process we’re about to talk about may apply to both your muscle and tendon. Remodeling means what it sounds like. As with home improvement remodeling, it’s the remaking or improving of stuff that’s not up to snuff.
Muscles and tendons have a similar (but not identical) healing process that has three distinct phases or stages:
- First is the inflammatory stage (Yes, it’s actually necessary!)
- Next comes the repair stage (or proliferation stage)
- Followed by the remodeling stage
Exercise is most important during the remodeling stage, although it can also be very helpful during the mid to latter part of the repair stage – if done wisely and conservatively.
Think of exercise as the last step in a 3-step sequence, although it doesn’t have to be a perfect 1-2-3 progression, because you can start exercising during step 2 (repair.)
The point is that as healing progresses, exercise becomes more and more important, eventually becoming the priority.
What your body is trying to do through the remodeling process is to take the initial collagen that forms during the repair stage, which is not strong and not well aligned, (it’s random at first) and replace or “remodel” it into better, stronger collagen that’s aligned with the rest of the muscle and tendon fibers.
Now, wouldn’t it make sense that there would have to be some repair and some new collagen created in the second stage in order to make it better and stronger in the third?
If you haven’t made much progress in the first two stages of healing then you may have a very hard time trying to skip ahead to the third. Not to say that it can’t be done.
There is evidence that exercise – especially of the eccentric variety has some effect on the repair stage as well, which I cover in the eccentric exercise article.
The question is: does it make sense to try and exercise your way through the whole process without asking if there’s something you can do to more effectively stimulate and help the repair stage?
Is there a higher priority in the earlier part of the healing process that you’ll make more progress by focusing on? Yes. I will suggest that there is. More on that in a bit…
Goal #3 Increasing The Tensile Strength Of Your Tendon
When we compare muscle strength to tendon strength we’re talking about two different kinds of strength.
Muscles produce force and tendons transmit that force to the bones they act on or move.
Tendons need something called ‘tensile’ strength. It’s the ability to handle being “pulled on” without tearing, like a rope.
And the process of strengthening tendons compared to muscles is completely different.
Muscles get stronger rather quickly. They adapt to the increased demand placed on them:
First by becoming more efficient through improved coordination, (which is actually a function of your nervous system, not your muscle itself)…
And then eventually by producing more muscle cells that add to the size and sheer power of your muscle.
A tendon, on the other hand, is supposed to sense and adapt to the increasing forces generated by the muscle by slowly improving the quality of the collagen protein and the bonds between those protein strands.
“Tendons are able to respond to mechanical forces by altering their structure, composition, and mechanical properties – a process called tissue mechanical adaptation.”
Mechanobiology of Tendon, J Biomech. 2006;39(9):1563-82. Epub 2005 Jul 5. Wang JH.
More about how tendons adapt to force
It’s clear that the right amount, form and timing of exercise stimulates and stresses the tendon in a healthy way encouraging it to adapt and get stronger.
(This process probably sounds a lot like the ‘Remodeling Stage’ we talked about earlier – It is practically the same thing, but in this case it may help to think of it as the process of getting stronger from an already healthy state – as compared to the process of rehab and recovery from an injured state.)
The Challenge Of Tendinosis: Is Exercise Alone Enough?
The problem with moderate to severe Tennis Elbow is that the reverse of this has been happening to your tendon (keeping in mind that it’s usually Tendinosis. Forget TendonITIS.)
The gradual breakdown of the collagen protein and other components of your tendon that give it ‘tensile strength’ and make it the strong “rope” that it is.
Have you ever noticed what happens to rubber bands when they get really old?
If you’ve ever had one break and crumble on you, then you probably noticed that the rubber had deteriorated and become brittle and weak.
That’s the best analogy I have for what happens to tendons whether it’s Tennis Elbow or some other chronic tendon injury (It’s called Tendinosis.)
So the most important goal in the healing and rehab of these kinds of injuries is the reversal of that degeneration process and the regeneration and strengthening of that tendon.
My question is, is exercise the most efficient way to go about this? Should it be your highest priority?
It looks like medical researchers keep looking for the perfect formula of exercise that’s going to reverse degeneration, stimulate healing and repair and strengthen the tendon:
“…the duration, frequency, magnitude and type of mechanical stimulation applied to a tendon greatly affect the outcome of the loading regime.
Therefore, the amount of loading [exercise] necessary to improve and/or accelerate the healing process without causing damage to the healing tissue remains unclear.”
Oxford Journals Medicine Rheumatology - (Link above)
To simplify: The type of exercise as well as how often, how hard, and the amount of time spent doing it have a great deal to do with how effective it is.
But is seems that researchers find that there are so many variables that they still don’t know what’s ideal!
Once again, I pose the question: “Is exercise the most efficient way to heal your tendon?”
(There's also a lot of talk about Eccentric Exercise for Tennis Elbow in particular.)
But, from my understanding, exercise is not the the most important factor in recovering from this injury. There’s a key prerequisite and a higher priority.
There has to be an ongoing repair and regeneration process happening for weeks and sometimes months (in moderate to severe cases)
And although exercise alone has been shown to stimulate that regeneration process in the tendon to some extent – In my experience, I’ve never seen it as the best way to get the healing process going strong or to keep it going.
The best way I know of – especially non-invasively – is the very focused, specific manipulation of the tendon through hands-on therapies.
In other words advanced massage techniques referred to as ‘Manual Therapy’ in the Physical Therapy world (Manual=done by hand.)
Unfortunately, although they have a name for it they seldom have the time to actually do it in a typical Physical Therapy session.
This is the heart of what I teach members here at Tennis Elbow Classroom. (See below.)
I believe this is the missing link that often goes unstudied and unacknowledged in medical research.
And in the Internet space it seems that too often there’s a mad dash to find the magic-bullet tool / exercise device gimmick that will shortcut the healing and/or skip ahead to the strengthening process.
Some Tennis Elbow sufferers may have great success with exercise alone, but my guess is they’re most likely in the early stages of it before much if any damage has occurred.
It doesn’t seem to work very well once you have a full-blown moderate-to-severe injury. I’ve seen so many cases where people have tried to exercise their way out of pain and it wasn’t enough.
So, I invite you to learn the best self-treatment "massage" techniques from a real Neuromuscular Therapist who treats Tennis Elbow every day. I'm standing by ready to be your tutor! Check out the program: