INJURY & REHAB: Train the brain to beat tendon pain

An innovative approach to treating tendinopathy targets the brain as well as the body to get clients back on track with their training sooner.

Tendon pain can be persistent and tricky to manage. Any therapist or trainer who has been in the business for a while will know that once symptomatic, tendons can be slow to improve and easy to aggravate. Recurrence rates can be high, and some tendons remain unresponsive to conservative management, which affects compliance and adherence to training.

Until fairly recently, the mainstay of tendon rehabilitation had been an eccentric training approach. Isometric exercises were introduced to reduce pain and aggravation, and heavy slow resistance protocols allowed a more safe production of strength and load capacity.

More recently a new tendon management approach has been introduced by the Monash University Tendon Research Group coined TNT (tendon neuroplastic training).

The change is the brain

So what’s changed? The key difference with the new technique is that it is not movement-based (which may increase tendon pain and can therefore be harder for people to comply with). Rather than just focusing on strength and building up the load capacity of a muscle-tendon unit, TNT also addresses the deficits of motor control.

The implication here is that with chronic and recurring pain conditions there is an altered pattern of corticospinal control and recruitment of muscles which may lead to recalcitrance and symptomatic recurrence. This may help to explain why the research team reported that more than 50 per cent of people who stop sport because of tendon pain still suffer from that tendon pain 15 years later. This new approach proposes that a painful experience is not necessarily indicative of structural damage occurring at the site of the tendon pain!

The change in focus to include brain training rather than just strength training is consistent with current advances in the area of pain research; the persistence of pain can be more about the brain and its response to perceived threat than it is about the local site of structural pathology.

TNT involves strength training which is known to be good for tendons and muscles. In addition to this, it includes stimulation of the brain externally while the exercise is performed. Rather than simply holding a muscle contraction or moving through a range, a pose is held while the client is concurrently stimulated with a metronome or voice recording providing an external pacing. External pacing has been shown to be superior to self-pacing for improving excitability and releasing inhibition.

How effective is it?

Isometric exercise used in the protocol can induce an immediate analgesic effect that can last up to 45 minutes. That’s right, a painkiller that is all natural and works immediately.

This can be an extremely useful tool to have a client execute immediately before a training session. Doing so would reduce their symptoms enough for them to be able to maximise their involvement in the session. This means that tendon pain no longer needs to restrict athletes and clients from participating in their chosen sport or activity!

It also adds to the client’s experience by enabling them to exercise the area and potentially introduce more movement variability options to the affected muscle-tendon complex. This is a great benefit, because a lack of movement variability seems to be an important factor in the development of chronic pain. The more pain-free movement options that the body is able to access, the less likely it is to travel down the one painful path, thereby reducing the risk of recurrence. For the client, it also engenders the simple yet powerful appreciation that they can continue to exercise.

For the trainer, it is exciting to note that research on the quadriceps muscle found that there was also a 19 per cent increase in muscle strength over a four-week period.

So, how effective is TNT? As ACDC sang, it’s dynamite.

Using TNT with your clients

When applying the TNT approach with clients suffering tendinopathy pain, a high load is required so that sufficient activity is generated in the muscle tendon complex. Light resistance is not effective. However, the effort exerted should not be so high that it induces pain. Keep in mind that the exercise is supposed to create an analgesic effect, so experiencing pain while it’s done is not appropriate.

  • Direct the client to perform the appropriate isometric exercise.
  • Ask them to tune in to a metronome during the exercise, counting with the beat if they wish. Alternatively, you can provide an external verbal pacing.
  • Advise the client to aim to hold the contraction with maximal pain-free effort for 30 to 60 seconds. If the client cannot do so without experiencing pain, then this is not the appropriate exercise for them at this stage.
  • Allow for a 1-minute recovery between each isometric contraction. Repeat isometric contractions, interspersed with rest breaks, for as long as there is no pain or discomfort.
  • If the client becomes aware of, or distracted by, discomfort that could be leading to pain, they should stop the exercise. Practitioners should avoid sensitising the nervous system with repeated aggravating tasks.

Other TNT tips

  • Remember that the intent of training is to regain neural control, so it’s not appropriate for the limb to shake with effort!
  • This is not a training program for balance, so clients may hold onto furniture for assistance if needed.
  • If the exercise causes pain before 30 seconds is up, then the training load is too high; make the exercise easier by decreasing resistance. If the contraction can be held easily for more than 60 seconds, the training load is too low.
  • TNT can be utilised throughout the whole body. Be sure to consult a physiotherapist or health professional for additional assistance.

TNT for patella tendon pain

In the case of training clients with patella tendon pain, the following approach is appropriate:

  • Tie a heavy therapy band or tubing to a stable upright.
  • Place the band around the knee and step back away from the upright until sufficient tension is generated on the band.
  • Extend the knee against the resistance of the band in standing, and hold the contraction isometrically. A slow build-up and hold of heavy resistance engages muscle activity and minimises the risk of tendon pain exacerbation.
  • Count with a metronome (backwards for a mental challenge) for 30 to 60 seconds. An externally paced hold of the contraction, particularly with mental distraction (counting), creates an alternative program for cortical control of muscles involved in the contraction. Once the contraction is made, there is no need for the client to think about the muscle or tendon in particular, but rather, to just hold the position under heavy load. This type of training begins the process of muscle activation that is automatic rather than a conscious contraction.
  • There should be effort with the contraction but no pain. At the end of the contraction, the client should notice that the affected muscle tendon complex feels less irritable, more strong, more stable or easier to control. With symptoms more under control, the client will be better able to participate in, and enjoy, training.

TNT offers a new dimension to training clients with tendon pain and builds on the foundation of previous research. It can be used as a tool to enhance compliance with training or as part of a self-directed and active self-management program.

Stay tuned: with continuing research into the mechanisms responsible for tendon rehabilitation, more advances in this area could be on the horizon.


Thuy Bridges, BAppSc (Physio) is the Director of PhysioWISE physiotherapy and Pilates clinics in Sydney, author of Length, Strength and Kinesio Tape and an educator of dynamic presentations to health, movement and fitness professionals worldwide. physiowise.com.au