Tendinopathy Treatment: Eccentric Training vs Injection Options

When your tendon hurts-not just a quick twinge, but a persistent, dull ache that flares up every time you walk, run, or even stand for too long-you’re likely dealing with tendinopathy. It’s not inflammation. It’s not a sprain. It’s a degenerative breakdown of the tendon’s structure, often from overuse. And if you’ve tried rest, ice, or a cortisone shot only to see the pain come back, you’re not alone. Thousands of people face this every year, especially runners, jumpers, and anyone who puts repeated stress on their tendons. The good news? There’s a proven, non-surgical way to rebuild your tendon from the inside out-and it doesn’t involve needles or drugs. But it’s not easy. And it’s not quick.

What Tendinopathy Really Is (And Why Rest Doesn’t Work)

Tendinopathy happens when the collagen fibers in your tendon start to fray and disorganize. Think of it like a rope that’s been rubbed raw over time. The body tries to repair it, but the repair is messy. That’s why you feel pain, stiffness, and sometimes swelling. It’s not inflamed tissue-it’s damaged tissue trying to heal in the wrong way.

For years, doctors told people to rest. Stop running. Stop jumping. Wait it out. But studies show that doesn’t fix the problem. In fact, prolonged rest can make the tendon weaker. The tendon needs load-not avoidance-to heal. That’s why eccentric training became the gold standard. It’s not about avoiding pain. It’s about using the right kind of pain to trigger repair.

Eccentric Training: The Science Behind the Pain

Eccentric training means slowly lowering a weight while the muscle is under tension. For your Achilles, that’s the heel drop: standing on a step, rising up on both feet, then lowering down slowly on just the injured side. For your patellar tendon, it’s a single-leg decline squat on a 25-degree board. The key? Control. Slow. Controlled. 3 to 5 seconds down. No bouncing. No rushing.

Here’s what happens inside your tendon during this process:

• Stimulates tenocytes (tendon cells) to produce new collagen
• Improves collagen alignment, making the tendon stronger and more elastic
• Increases tendon stiffness by 15-20% after 8-12 weeks
• Reduces pain by rewiring how your nervous system perceives it

Studies show people with Achilles tendinopathy improve their VISA-A scores-used to measure function and pain-by 60-65% after 12 weeks of consistent eccentric training. Patellar tendinopathy patients see similar gains. But here’s the catch: you have to do it every day. No exceptions. And you have to do it even when it hurts.

How to Do Eccentric Training Right

There are two main protocols, depending on which tendon is affected.

Achilles Tendinopathy: The Alfredson Protocol

• Stand on the edge of a step or curb with your heels hanging off
• Use both feet to rise up onto your toes
• Slowly lower the injured foot down over 3-5 seconds
• Repeat 15 times, 3 sets, twice daily
• Do two versions: one with knee straight (targets gastrocnemius), one with knee bent (targets soleus)
• Rest 60-90 seconds between sets

Start with bodyweight. Once you can do this without severe pain, add weight-like a backpack with books. The goal is to reach 70-80% of your maximum effort by week 6.

Patellar Tendinopathy: The Decline Squat Protocol

• Stand on a 25-degree decline board (or use a thick book under your heels on a flat surface)
• Perform a single-leg squat, lowering slowly over 3-5 seconds
• Use a wall or railing for balance if needed
• Do 3 sets of 15 reps daily
• Progress to holding dumbbells once you can do it without sharp pain

Many people struggle with form here. If your knee caves inward or you lean too far forward, you’re not loading the tendon correctly. That’s why working with a physical therapist for the first 1-2 sessions is critical. Self-managed patients make technique errors 40% more often than those who get guidance.

Heavy Slow Resistance (HSR): The Less Painful Alternative

Not everyone can tolerate the initial pain of eccentric training. That’s where HSR comes in. Instead of doing 30 reps a day, you do 3 sets of 15 reps, three times a week, using a weight that’s 70% of your one-rep max. You lift slowly (3 seconds up), lower slowly (3 seconds down). The total volume is lower, but the load is higher.

A 2015 study comparing HSR to eccentric training for Achilles tendinopathy found both methods led to the same improvement in pain and function. But here’s the kicker: 87% of people stuck with HSR, while only 72% stuck with eccentric training. Why? Less pain on day one. If you’ve tried eccentric training and quit because it was too painful, HSR might be your better option.

Isometric Exercises: Quick Pain Relief When You Need It

Before a workout, before a long walk, or if you’re in too much pain to start eccentric training-do isometrics. That means holding a muscle contraction without movement. For Achilles, stand on the step, rise up, then hold the top position for 45 seconds. For patellar, do a wall sit with your knees at 90 degrees and hold.

Studies show isometrics can reduce pain by 50% within 45 minutes. That’s faster than any injection. It doesn’t fix the tendon, but it gives you breathing room. Use it as a bridge to get you to the point where you can start eccentric training.

Injection Options: What Works and What Doesn’t

When conservative methods fail, injections are often the next step. But not all injections are equal.

Corticosteroid Injections

These give fast relief-30-50% pain reduction in the first 4 weeks. That’s why so many doctors offer them. But here’s the truth: at 6 months, 65% of people who got cortisone needed another treatment. Only 35% of people who did eccentric training did. Cortisone masks the pain. It doesn’t fix the tendon. And repeated shots can weaken the tendon further.

Platelet-Rich Plasma (PRP)

PRP sounds promising: you draw your own blood, spin it to concentrate the platelets, and inject it into the tendon. The theory? Your body’s healing factors will jump-start repair. But the data? Weak. A 2020 review found PRP only improved outcomes by 15-20% over placebo. It’s expensive, not covered by most insurance, and not worth it for most people.

Other Injections (Dry Needling, Prolotherapy, etc.)

No strong evidence supports these. They’re often marketed aggressively, but studies don’t back them up. Stick to what’s proven: exercise first, injections only if needed.

Why Most People Fail (And How to Succeed)

Here’s the hard truth: 30% of people don’t respond to eccentric training. Why?

• They stop too soon. You need 12 weeks minimum to see structural changes.
• They do it wrong. Poor form = no benefit.
• They expect immediate results. Pain doesn’t vanish in a week.
• They ignore pain signals. Some pain is okay. Too much isn’t.

Here’s how to avoid failure:

• Use an app like Tendon Rehab (version 3.2, 2023) to track reps and get feedback
• Work with a physical therapist for the first 2 sessions to nail your form
• Use a pain scale: 2-5/10 during exercise is acceptable. Above 7/10 or pain lasting more than 24 hours means you’ve gone too far
• Combine isometrics before activity to manage flare-ups
• Don’t rush back to running or jumping. Gradually reintroduce activity after 12 weeks

People who succeed don’t just do the exercises. They track progress. They adjust. They listen to their body. And they don’t quit when it gets hard.

What’s Next? The Future of Tendinopathy Treatment

Research is moving beyond one-size-fits-all protocols. New studies are testing personalized load tolerance assessments-measuring exactly how much load your tendon can handle before it breaks down. Early results show this approach improves outcomes by 25%.

There’s also emerging work on peptides that activate tendon cells (TAP-421), with clinical trials starting in early 2024. But these are years away from being widely available. For now, the best tool you have is still exercise.

And it’s not just about the tendon. Experts now say tendinopathy is often tied to overall load management-how much stress your whole body takes on. Sleep, stress, nutrition, and movement patterns all play a role. Fixing the tendon means fixing your whole system.

Final Takeaway: Exercise Is the Only Long-Term Fix

Corticosteroid shots? They’re a band-aid. PRP? Not worth the cost. Surgery? Only if everything else fails.

The only proven, lasting solution is eccentric training-or HSR if the pain is too much. It takes discipline. It takes time. But the results? Lasting. People who complete the program report not just less pain, but no recurrence after 2 years. They get back to running, jumping, playing with their kids, living without fear.

If you’ve been stuck in the cycle of pain → injection → temporary relief → pain again, it’s time to try something different. Start today. Not tomorrow. Not next week. Today. One set. One rep. Slow. Controlled. And keep going.