Tendonitis affects both upper and lower limb tendons. Examples include tennis elbow, golfer’s elbow, patellar tendonitis, Achilles tendonitis and high hamstring tendonitis. Although exercise therapy has the most success in improving tendonitis pain, many people struggle to return to their sport. Recently, an exciting rehab approach – Tendon Neuroplastic Training – has shown promising signs of improving the effectiveness of exercise for tendonitis. What is Tendon Neuroplastic Training, and how do you add this treatment to your current programme?

How do we currently treat tendonitis? 

Generally, tendonitis treatment consists of reducing or stopping the offending activity (running or sport), exercise therapy (such as calf raises or quadriceps exercises) to strengthen the tendon and muscles around the tendonitis, and pain-reducing treatments. Examples of pain-lowering treatments include tablets, shockwave and tendon injections. Although most people improve with this treatment, a sizeable minority struggle to return to sports or activities.

Tendon neuroplastic training: why you should add this treatment to tendonitis

Tendon neuroplastic training is a novel concept whereby people can change how they do strengthening exercises. Rather than exercise affecting the tendon or muscles, tendon neuroplastic training targets the nervous system.

What is neuroplasticity? 

Neuroplasticity is the term used to describe changing neuronal connections in the brain and spinal cord response to a stimulus such as an exercise. The brain grows new connections and can rewire old connections. The brain and spinal cord can often undergo neuroplasticity due to an injury or physical or mental stimulation (such as learning).

What is motor control?

diagram showing motor control of lower leg muscles


Motor control is the ability to carefully and seamlessly control muscle contraction. For example, when we perform a squat, our brain sends messages to the quad muscle to contract in a controlled fashion. However, recent research has suggested that this careful control is disrupted in chronic tendonitis. Think of a driver who moves from 1st gear to fourth gear causing the car to jerk forward. In chronic tendonitis, the ability to control muscle contraction is disrupted, making it difficult for the muscle to respond to signals from the brain.

So, the key to improving tendonitis is to make a muscle stronger and improve muscle contraction’s smoothness without jerkiness.

How do we improve motor control of our muscles and tendons?

We think external-paced strength training improves motor control (making the muscles contract smoother).  For training, we ususally use a pacemaker called a metronome to control the pace of contraction. For example, when we perform a weighted squat, we use a metronome to tell us how quickly we should move up and down. Generally, we set the metronome to beep every three seconds, so we take three seconds to go up and three seconds to go down. The important point is that we allow the metronome to set the pace, which improves motor control of the muscles by our brain.

One other benefit of metronome training is that it keeps us engaged in the exercise, stops us from wandering off, and keeps our thoughts on the task at hand.

The good news is that metronomes are built into a phone app you can use in a gym or weight-training room.

metronome app for tendon neuroplastic training

Tendon neuroplastic training: practical examples 

There are many ways to set the metronome, but my favourite is setting a beep every three seconds. When you hear a beep, you change the direction of movement. For example, when doing calf raises, a beep signals you should start a calf raise. You keep going upwards until your second beep after 3 seconds, meaning you should stop and go back down. And then, you repeat the movement up and down to the ongoing beeps every three seconds. A metronome beep paces each change.

In advanced Achilles, patellar or hamstring tendon rehab, you can also use a metronome when introducing running on stairs or on the road. For example, you can start at 80 beats per minute. Then, increase to 1oo beats per minute as your pace quickens.

Which tendons are suited to tendon neuroplastic training? 

Generally, most lower limb tendons are suited to tendon neuroplastic training. Examples include Achilles, patellar and hamstring origin tendons. However, we can also use this training in upper limb tendons such as tennis or golfer’s elbow. You should speak to your physiotherapist or sports doctor about metronome training.

Other commonly asked questions about metronome training:

Could adding tendon neuroplastic training shorten tendonitis rehab?

Perhaps. It’s not just about getting as strong as possible but also about controlling muscle contraction (called motor control).

Final word from Sportdoctorlondon about tendon neuroplastic training

It seems there is more to tendonitis rehab than getting the muscles stronger. We think motor control – the ability to contract the muscles smoothly – is also important. External strength pacing using a metronome is a great way to improve motor control, increasing the success of tendonitis rehab.

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