{"id":5138,"date":"2020-06-03T16:53:12","date_gmt":"2020-06-03T14:53:12","guid":{"rendered":"https:\/\/www.physiotutors.com\/?p=5138"},"modified":"2023-03-28T11:42:32","modified_gmt":"2023-03-28T09:42:32","slug":"isometrics-in-tendinopathy-a-wonder-weapon-to-decrease-pain","status":"publish","type":"post","link":"https:\/\/www.physiotutors.com\/isometrics-in-tendinopathy-a-wonder-weapon-to-decrease-pain\/","title":{"rendered":"Isometrics in tendinopathy \u2013 a wonder weapon to decrease pain?"},"content":{"rendered":"\n<p>Are isometrics the wonder weapon to decrease pain in tendinopathy? In this blog, we will discuss where the isometrics \u201ctrend\u201d came from and what the evidence says about it!<\/p>\n\n\n\n<p>In&nbsp;2015, <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/25979840\/\" target=\"_blank\" rel=\"noreferrer noopener\">Rio et al.<\/a>&nbsp;started a bit of a trend when they conducted a cross-over trial on 6 volleyball players with patellar tendinopathy. Their results were astonishing with all players experiencing an immediate decrease in pain from an average of 7\/10 on the NRS to 0 with only one of the 6 reporting a remaining pain of 1\u2013 for at least 45 minutes after the isometric contractions. The protocol they used was 5 sets with 45 seconds contraction in a leg extension machine and an effort of 70% of the maximal voluntary effort. They also found that isometrics were able to decrease cortical inhibition and an increase in strength of 19%. They compared the isometric intervention with an isotonic intervention and the effects seen in the isometric group could not be achieved in the isotonic group:<a href=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2020\/06\/Rio2015.jpg\"><\/a><\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img decoding=\"async\" width=\"1337\" height=\"796\" src=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2021\/09\/Rio2015.jpg\" alt=\"Rio2015\" class=\"wp-image-7690\"\/><figcaption class=\"wp-element-caption\">Figure from Rio et al. (2015)<\/figcaption><\/figure>\n\n\n\n<p id=\"caption-attachment-68894\">The same authors did a follow-up in-season&nbsp;study&nbsp;with jumping athletes two years later (<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/27513733\/\">Rio et al. 2017<\/a>) in which they compared an isometric program and an isotonic program to each other. In this study the results were a bit more heterogeneous with both groups with a greater immediate pain decrease in the isometric group:<\/p>\n\n\n\n<p id=\"caption-attachment-68894\"><a href=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2020\/06\/Rio2017.jpg\"><\/a><\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img decoding=\"async\" width=\"1307\" height=\"939\" src=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2021\/09\/Rio2017.jpg\" alt=\"Rio2017\" class=\"wp-image-7691\"\/><figcaption class=\"wp-element-caption\">Figure from Rio et al. (2017)<\/figcaption><\/figure>\n\n\n\n<p id=\"caption-attachment-68895\">A recent study by&nbsp;<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/31735531\/\" target=\"_blank\" rel=\"noreferrer noopener\">Holden et al. (2019)<\/a>&nbsp;looked at the effect of isometrics in patellar tendinopathy as well and did not find any analgesic effect:<a href=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2020\/06\/Holden2019.jpg\"><\/a><\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img decoding=\"async\" width=\"626\" height=\"480\" src=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2021\/09\/Holden2019.jpg\" alt=\"Holden2019\" class=\"wp-image-7692\"\/><figcaption class=\"wp-element-caption\">Figure from Holden et al. (2019)<\/figcaption><\/figure>\n\n\n\n<p id=\"caption-attachment-68891\">However, a high percentage of women and a relatively high average age is untypical for patellar tendinopathy, which is usually a disease of young jumping men. So it could be that the diagnosis of patellar tendinopathy was not correct in some cases. Now while those two studies were conducted for patellar tendinopathy, let\u2019s look if we can transfer these results to other tendons.<br>Looking at the Achilles tendon,&nbsp;<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/29974171\/\" target=\"_blank\" rel=\"noreferrer noopener\">Seth O\u2019Neill et al. (2018)<\/a> did a study in which they had a group of patients with Achilles tendinopathy performing isometric contractions of the plantar flexors. They found no immediate pain relief nor improved motor output in patients with Achilles tendinopathy:<a href=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2020\/06\/ONeill2018.jpg\"><\/a><\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img decoding=\"async\" width=\"666\" height=\"526\" src=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2021\/09\/ONeill2018.jpg\" alt=\"Oneill2018\" class=\"wp-image-7694\"\/><figcaption class=\"wp-element-caption\"> Figure from O&#8217;Neill et al. (2018) <\/figcaption><\/figure>\n\n\n\n<p id=\"caption-attachment-68892\">A study by&nbsp;<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/30203866\/\" target=\"_blank\" rel=\"noreferrer noopener\">Riel et al. (2018)<\/a>&nbsp;examined the effects of isometrics, isotonics, and walking on pain for plantar fasciitis. They found that there was no change in pain for any of the groups before to after the exercises:<a href=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2020\/06\/Riel2018.jpg\"><\/a><\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img decoding=\"async\" width=\"608\" height=\"548\" src=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2021\/09\/Riel2018.jpg\" alt=\"Riel2018\" class=\"wp-image-7695\"\/><figcaption class=\"wp-element-caption\"> Riel et al. (2019)<\/figcaption><\/figure>\n\n\n\n<p id=\"caption-attachment-68893\">At last,&nbsp;<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/26889612\/\" target=\"_blank\" rel=\"noreferrer noopener\">Coombes et al. <\/a>(<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/26889612\/\" target=\"_blank\" rel=\"noreferrer noopener\">2016<\/a>)&nbsp;looked at isometrics on lateral epicondylalgia. In their study, isometric contractions above the patients\u2019 pain threshold actually increased their pain levels after the exercise, while isometric contractions below the patients\u2019 pain threshold had no effect compared to a control group:<a href=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2020\/06\/Coombes2016.jpg\"><\/a><\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img decoding=\"async\" width=\"595\" height=\"360\" src=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2021\/09\/Coombes2016.jpg\" alt=\"Coombes2016\" class=\"wp-image-7696\"\/><figcaption class=\"wp-element-caption\"> Figure from Coombes et al. (2016) <\/figcaption><\/figure>\n\n\n\n<p id=\"caption-attachment-68890\">Another study from&nbsp;<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/27823901\/\" target=\"_blank\" rel=\"noreferrer noopener\">Stasinopoulos et al. (2017)<\/a>&nbsp;compared three exercise groups in the treatment of lateral epicondylalgia: One group performed eccentric training, another eccentric-concentric training<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/27823901\/\" target=\"_blank\" rel=\"noreferrer noopener\">,<\/a> and the third group combined eccentric-concentric training with isometrics. The authors argued that most grip activities require isometric contraction of the wrist flexors and extensors, so adding isometric exercises for LE makes absolute sense. They found that adding concentric led to superior results at pain, function, and grip strength at 4 and 8 weeks:<a href=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2020\/06\/Stasinopoulos2017.jpg\"><\/a><\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img decoding=\"async\" width=\"1241\" height=\"377\" src=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2021\/09\/Stasinopoulos2017.jpg\" alt=\"Stasinopoulos2017\" class=\"wp-image-7697\"\/><figcaption class=\"wp-element-caption\"> Table from Stasinopoulos et al. (2017) <\/figcaption><\/figure>\n\n\n\n<p id=\"caption-attachment-68896\">However, the follow-up time of the study was rather short and should at least have been 12 weeks. On top of that, the combined isometrics group performed a higher exercise volume with more time under tension which could explain the superior results.<\/p>\n\n\n\n<p>So while isometrics are certainly no magic bullet, what role do they play in tendinopathy rehab? First of all,&nbsp; isometrics are a great option to start exercising if everything else is too painful \u2013 and this is not only limited to tendinopathy but other conditions as well. Be aware that they must progress to isotonic exercises because you want to recover muscle function over the full range of motion instead of just 1 angle. So move on as soon as a patient is able to tolerate isotonic loads.<\/p>\n\n\n<div class=\"quote-with-background\" style=\"\">\n    <div class=\"quote-with-background__in\">\n\n        <svg width=\"30px\" height=\"25px\" viewBox=\"0 0 30 25\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\">\n            <g id=\"Design\" stroke=\"none\" stroke-width=\"1\" fill=\"none\" fill-rule=\"evenodd\">\n                <g id=\"08-blog-redesign\" transform=\"translate(-191.000000, -2974.000000)\" fill=\"#7973FF\" fill-rule=\"nonzero\">\n                    <g id=\"Group-7\" transform=\"translate(80.000000, 2893.000000)\">\n                        <g id=\"\u201c\" transform=\"translate(111.000000, 81.000000)\">\n                            <path d=\"M6.4,25 C4.42666667,25 2.86666667,24.3743344 1.72,23.1230032 C0.573333333,21.871672 0,20.2609159 0,18.2907348 C0,17.2790202 0.173333333,16.2539936 0.52,15.215655 C0.866666667,14.1773163 1.49333333,12.513312 2.4,10.2236422 L6.48,0 L12.8,0 L10,12.5399361 C11.9733333,14.0841321 12.96,16.001065 12.96,18.2907348 C12.96,20.2076677 12.3466667,21.8051118 11.12,23.0830671 C9.89333333,24.3610224 8.32,25 6.4,25 Z M23.44,25 C21.4666667,25 19.9066667,24.3743344 18.76,23.1230032 C17.6133333,21.871672 17.04,20.2609159 17.04,18.2907348 C17.04,17.2790202 17.2133333,16.2539936 17.56,15.215655 C17.9066667,14.1773163 18.5333333,12.513312 19.44,10.2236422 L23.52,0 L29.84,0 L27.04,12.5399361 C29.0133333,14.0841321 30,16.001065 30,18.2907348 C30,20.2076677 29.3866667,21.8051118 28.16,23.0830671 C26.9333333,24.3610224 25.36,25 23.44,25 Z\" id=\"Shape\"><\/path>\n                        <\/g>\n                    <\/g>\n                <\/g>\n            <\/g>\n        <\/svg>\n       <div class=\"quote-with-background__content heading-three\">\n            <p class=\"heading-four\">Isometrics do not seem to be a magic bullet to decrease pain, but they can be a great starting point for rehab if patients do not tolerate isotonics yet<\/p>\n       <\/div>\n       <div class=\"quote-with-background__info\">\n                   <\/div>\n    <\/div>\n<!--    <div class=\"quote-with-background__background\">-->\n<!--        <svg width=\"100%\" height=\"100%\" viewBox=\"0 0 849 447\" version=\"1.1\" preserveAspectRatio=none xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\">-->\n<!--            <g id=\"Design\" stroke=\"none\" stroke-width=\"1\" fill=\"none\" fill-rule=\"evenodd\">-->\n<!--                <g id=\"08-blog-redesign\" transform=\"translate(-80.000000, -2893.000000)\" fill=\"#F1F5FD\">-->\n<!--                    <g id=\"Group-7\" transform=\"translate(80.000000, 2893.000000)\">-->\n<!--                        <polygon id=\"Rectangle\" transform=\"translate(424.500000, 223.500000) scale(-1, 1) translate(-424.500000, -223.500000) \" points=\"0 99.703192 849 -4.43831367e-13 849 347.296808 0 447\"><\/polygon>-->\n<!--                    <\/g>-->\n<!--                <\/g>-->\n<!--            <\/g>-->\n<!--        <\/svg>-->\n<!--    <\/div>-->\n<\/div>\n\n\n\n<p><br>What can be derived from all of those studies is that isometrics do seem to work really well in some subjects and can actually make things worse in other subjects. To keep it simple, give them a try with the patient in front of you and if they respond favorably, keep doing them, if they don\u2019t move on.<br>While 45 minutes of pain relief might not be a goal that is important in the average patient, this might be useful for athletes as a warm-up to decrease pain during the ensuing exercise session or competition. Isometrics are also less tiring for athletes in-season compared to isotonic exercises. One can surely argue if it is desirable to achieve short-term pain reduction in order to load a painful tendon during sporting activities and if this might actually lead to detrimental effects.<\/p>\n\n\n<div class=\"cta\" style=\"\">\n    <div class=\"cta__in\">\n        <div class=\"left\">\n            <div class=\"cta__content text-color-light\">\n\t\t\t\t\t\t\t\t\t<h2 class=\"own-size\">THE BIG 3 &#8211; ADVANCED REHABILITATION OF HAMSTRING, QUADRICEPS, AND CALF MUSCLE- AND TENDON INJURIES<\/h2>\n\t\t\t\t\t                <p>Claim your seat on our online course\u00a0<strong>\u201cThe Big 3 \u2013 Advanced Rehab of of Hamstring, Quadriceps &amp; Calf muscle and Tendon Injuries\u201d<\/strong>\u00a0To\u00a0Improve your\u00a0Rehab, Reduce Injury Risk and Optimize Return to Play!<\/p>\n                                        <div class=\"cta__button\">\n                                <a href=\"https:\/\/study.physiotutors.com\/course\/the-big-3-advanced-rehabilitation-of-hamstring-quadriceps-and-calf-muscle-and-tendon-injuries\/\" class=\"button button-five\" target=\"_self\">\n                                    Learn More                                <\/a>\n                            <\/div>\n                                    <\/div>\n        <\/div>\n                        <div class=\"right\">\n                    <img decoding=\"async\" src=\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2022\/08\/The-Big-3-mockup-full.png\" alt=\"\"\/>\n                <\/div>\n                <\/div>\n<\/div>\n\n\n\n<p>Alright, this was our blog on isometrics for tendinopathy. If you were surprised by the results, you will love our blog on&nbsp;<a href=\"https:\/\/www.physiotutors.com\/7-crucial-facts-you-didnt-know-about-tendons\/\" target=\"_blank\" rel=\"noreferrer noopener\">7 facts about tendinopathy you didn\u2019t know<\/a>! Thanks so much for reading.&nbsp;<\/p>\n\n\n\n<p><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong><em>References:<\/em><\/strong><\/h2>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/26889612\/\" target=\"_blank\" rel=\"noreferrer noopener\">Coombes BK, Wiebusch M, Heales L, Stephenson A, Vicenzino B. Isometric exercise above but not below an individual\u2019s pain threshold influences pain perception in people with lateral Epicondylalgia. The Clinical journal of pain. 2016 Dec 1;32(12):1069-75.<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/31735531\/\" target=\"_blank\" rel=\"noreferrer noopener\">Holden S, Lyng K, Graven-Nielsen T, Riel H, Olesen JL, Larsen LH, Rathleff MS. Isometric exercise and pain in patellar tendinopathy: A randomized crossover trial. Journal of Science and Medicine in Sport. 2020 Mar 1;23(3):208-14.<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/29974171\/\" target=\"_blank\" rel=\"noreferrer noopener\">O\u2019Neill S, Radia J, Bird K, Rathleff MS, Bandholm T, Jorgensen M, Thorborg K. Acute sensory and motor response to 45-S heavy isometric holds for the plantar flexors in patients with Achilles tendinopathy. Knee Surgery, Sports Traumatology, Arthroscopy. 2019 Sep 1;27(9):2765-73.<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/25979840\/\" target=\"_blank\" rel=\"noreferrer noopener\">Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British journal of sports medicine. 2015 Oct 1;49(19):1277-83.<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/27513733\/\" target=\"_blank\" rel=\"noreferrer noopener\">Rio E, Van Ark M, Docking S, Moseley GL, Kidgell D, Gaida JE, Van Den Akker-Scheek I, Zwerver J, Cook J. Isometric contractions are more analgesic than isotonic contractions for patellar tendon pain: an in-season randomized clinical trial. Clinical Journal of Sport Medicine. 2017 May 1;27(3):253-9.<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/31076398\/\" target=\"_blank\" rel=\"noreferrer noopener\">Silbernagel KG, Vicenzino BT, Rathleff MS, Thorborg K. Isometric exercise for acute pain relief: is it relevant in tendinopathy management?.<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/30203866\/\" target=\"_blank\" rel=\"noreferrer noopener\">Riel H, Vicenzino B, Jensen MB, Olesen JL, Holden S, Rathleff MS. The effect of isometric exercise on pain in individuals with plantar fasciopathy: a randomized crossover trial. Scandinavian journal of medicine &amp; science in sports. 2018 Dec;28(12):2643-50.<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/27823901\/\" target=\"_blank\" rel=\"noreferrer noopener\">Stasinopoulos D, Stasinopoulos I. Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. Journal of Hand Therapy. 2017 Jan 1;30(1):13-9.<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":35,"featured_media":15746,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","footnotes":""},"categories":[280],"tags":[284,287,283,285,282,291,290,288],"tracking_tag":[],"class_list":["post-5138","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-muscle-tendon","tag-achilles-tendinopathy","tag-isometrics-in-tendinopathy","tag-patellar-tendinopathy","tag-tendinitis","tag-tendinopathy","tag-tendinosis","tag-tendon-pain","tag-tendon-rehab"],"acf":{"sections":[{"acf_fc_layout":"featured-related","heading":"Related blog posts","subheading":"","content_editor":"","featured_or_related":"related","posts":null,"button_type":"internal_link","button_label":"","button_style":"button-one","button_internal_link":"","button_anchor":"","button_url":"","button_file":null}]},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Isometrics in tendinopathy \u2013 a wonder weapon to decrease pain?<\/title>\n<meta name=\"description\" content=\"Isometric exercise for tendinopathy - a wonder weapon to decrease pain? 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