5 Keys to Preventing Bone Stress Injuries in Runners

Bone stress injuries have a shockingly high incidence rate in running sports, with estimates of 4.9-21.1% in cross country runners each year (1). Having a history of bone stress injury (BSI) is a risk factor for future BSI’s, so we want to help our clients prevent them in the first place to have a long, healthy running career. Here we’ll review 5 keys to preventing BSI’s in runners.

Why do BSI’s happen?

When a bone is loaded sufficiently, a micro crack develops. When that micro crack develops it takes about 10 days for osteoclasts to arrive at the micro crack. Once those osteoclasts arrive they resorb (break down) that damaged bone which temporarily makes the bone more porous and less stiff. Typically, this resorption happens for about 21 days, so the bone is actually becoming increasingly vulnerable and sensitive to loading (2). Then the bone begins remodeling and bone mass is restored to pre-micro damage levels. However, if high levels of loading continue or even ramp up in volume and/or intensity when the bone is in a more porous, less stiff state, a vicious cycle is set in motion. The now porous and less stiff region of bone accumulates more stress, leading to further micro damage, which leads to increased porosity and decreased stiffness, eventually leading to a stress reaction. If this goes on long enough, this can lead to a stress fracture and potentially a complete fracture if not addressed. In short, BSI’s happen when repetitive loads on a bone outpace its ability to remodel and recover.

Where do BSI’s happen in runners?

In long distance runners, roughly half of BSI’s occur in the diaphysis of the tibia, while the remaining tend to occur in the femur, fibula, calcaneus, tarsals and metatarsals (1). Understanding the location of where BSI’s occur is crucial not only for diagnosis, but also for prevention, since a history of BSI is a strong risk factor for developing a future BSI. For example, if a runner previously had a tarsal BSI they may be more sensitive to running uphill and this type of training might need to be increased more conservatively in order to prevent a recurrence of injury to that area.

How do we prevent BSI’s in runners?

BSI’s are multifactorial, here we’ll focus on 5 key training considerations to decrease BSI risk:  

  1. Avoid major spikes in loading

As mentioned earlier, bone can remodel and adapt if loads are progressively increased. A commonly used paradigm is the “10% rule”. This guideline suggests that the workload should be increased by a maximum of 10% each week. Note, this guideline tends to work at a population level, which means it won’t fit all runners. For some runners this progression may be too fast, while others may be able to tolerate spikes in loading in excess of this guideline.

In general, there are two common situations where we see a large spike in loading:

  • The sedentary individual beginning running. In a study of military recruits, those with 1 month or less of running experience had an increased risk of suffering a BSI in basic training (3).

  • The track athlete during preseason. Research shows that collegiate level athletes have a 43% increased risk of BSI during the preseason, since they are likely ramping up training too quickly after taking time off from their sport (4).

Runners in these situations likely need a slower progression to reduce BSI risk. In addition, examining other BSI risk factors helps determine how conservative their increase in workload should be. Some risk factors to consider are: hormonal status, nutrition status, presence of a bone disease, and injury history (i.e. recent immobilization, history of BSI) (2).

2. Increase volume, then intensity

The workload placed on a bone is related to the volume (number of loading cycles) and the intensity (magnitude and/or rate of load). While we want to gradually increase both over time, bone is more sensitive to changes in intensity. Research shows that fracture risk rises at a much faster rate with increases in intensity as compared to increases in volume (2). So when considering changes in training, think volume first, then intensity.

3.Employ rest periods from running

To allow adequate recovery and adaptation, we want to include regular breaks from the repetitive loads of distance running. While this will vary on an individual basis, a starting point for cross country runners (who may be running high volumes year round), could be the following rest schedule (2):

  • Weekly: 1 day off
  • Every 3 months: 1-2 weeks off
  • Yearly participation should be limited to 9-10 months

Of course, runners with a lower training volume may not need as much rest, so that rest should be adjusted based on the individual’s target training and competition schedule. Also, to clarify, rest does not imply total rest from all training. We would still employ other forms of training in those rest periods such as swimming or biking to expose the body to a different loading profile than that of running.

4. Monitor environmental changes

Different environments imply a different direction and magnitude of loading. For example, running on trails and hills represents a different load pattern for the lower extremities, as compared to running on a flat treadmill. So just like intensity, any changes in environment should be introduced gradually. A general guideline is to introduce a new environmental change 1 day per week (e.g. if running 5 days per week on asphalt, trade 1 day per week for trail running rather than substituting all 5 road running days for trail running) (2). Also, as we discussed previously, if an athlete has a history of BSI, they may be more sensitive to certain surface changes (e.g. a tarsal BSI and uphill running).

5. Modify running technique

Technique can significantly impact the magnitude and direction of lower extremity loads in running. A relatively easy and effective technique modification is to increase step cadence by 5-10%. Research shows that this reduction in stride length leads to decreased braking forces upon landing, resulting in a lower magnitude of load on the lower extremities (2).


In summary, here are 5 training tips to prevent bone stress injuries in runners:

  1. Avoid major spikes in loading
  2. Increase volume, then intensity
  3. Employ rest periods on a weekly, monthly, and yearly basis
  4. Monitor environmental changes and introduce new training surfaces gradually
  5. Modify technique-consider increasing step cadence


  1. Warden, S. J., Davis, I. S., & Fredericson, M. (2014). Management and prevention of bone stress injuries in long-distance runners. The Journal of orthopaedic and sports physical therapy44(10), 749–765. https://doi.org/10.2519/jospt.2014.5334
  2. Warden, S. (n.d.). Bone Stress Injuries: causes, diagnoses, prevention and management [Online Course]. PhysioNetwork. https://www.physio-network.com/masterclass/bone-stress-injuries/
  3. Shaffer, R. A., Brodine, S. K., Almeida, S. A., Williams, K. M., & Ronaghy, S. (1999). Use of simple measures of physical activity to predict stress fractures in young men undergoing a rigorous physical training program. American journal of epidemiology149(3), 236–242. https://doi.org/10.1093/oxfordjournals.aje.a009797
  4. Rizzone, K. H., Ackerman, K. E., Roos, K. G., Dompier, T. P., & Kerr, Z. Y. (2017). The Epidemiology of Stress Fractures in Collegiate Student-Athletes, 2004-2005 Through 2013-2014 Academic Years. Journal of athletic training52(10), 966–975. https://doi.org/10.4085/1062-6050-52.8.01

How to Dose Strength Training for Older Adults

With an aging population, we as physios see more and more older adults. However, a common issue is that we under-dose exercise, especially strength training. This issue has become so prevalent that the American Physical Therapy Association’s “Choosing Wisely” campaign recommends “Don’t prescribe under-dosed strength training programs for older adults” (1). In this article we’ll explore why proper dosage is important, why many physios under-dose, and how to properly dose strength training exercises.

Why is Proper Dosage of Strength Training Important?

With age, there is a loss in muscle strength and power, which can lead to decreased function and increased fall risk. It is estimated that after the 6th decade of life there is a 3.6% loss in muscle strength each year (2). Functionally, this means that older adults exert considerably more effort to perform daily tasks. For example, research shows that to rise from a chair, a young person works at 42% relative effort while an older adult works at 80% relative effort (3). Thankfully, with strength training (and other forms of exercise like balance and cardiovascular training) we can increase that capacity so that older adults can function and live better.

If strength training is so important for older adults that begs the question…

Why Don’t Physios Properly Dose Strength Training for Older Adults?

Physios often don’t properly dose strength training because:

  • We don’t want to cause injury to older adults

There is a valid concern regarding injury risk with older adults. Many older adults have complex medical histories, musculoskeletal pathologies like arthritis or osteoporosis, decreased tissue elasticity, and decreased recovery capacity. However, research shows that older adults can safely perform and benefit from strength training. For example, in a study where the average participant age was 90 years old, subjects performed strength training exercises at an intensity of 80% 1-Rep Max (% 1RM). The participants suffered no injuries and experienced strength gains of up to 174% from their baseline (4). As with ANY patient we can find a safe, tolerable starting point of strength training for older adults.

  • We don’t want to risk causing adverse cardiac events with older adults

Any good physio doing a medical history will note that older adults tend to have more complex medical histories than younger ones. However, our expertise is designing programs specifically for complex patients. No matter the condition, your patient can exercise at a relatively high intensity. Monitoring of vital signs, patient symptoms and the use of scales like “Rating of Perceived Exertion” are crucial. For details on safe exercise parameters check out the Masterclass “Exercise Prescription in Aging Adults” by Dr. Mariana Wingood here.

  • We believe that older adults don’t need to exercise intensely

We often assume high intensity exercise is the domain of young athletes, while older adults should be given “gentle” exercises. Unfortunately, this doesn’t help older adults perform activities of daily living or participate in hobbies or sports. As we discussed before, tasks like a sit to stand can become quite challenging so we need to sufficiently load our patients with exercise in order to function and live better. Our job is to educate them on the benefits of exercise and help them find a mode of exercise that fits their unique situation.

How to Properly Dose Strength Training

Here are three practical tools to dose strength training for your older clients:

  1. Select a sufficient intensity for strengthening

To improve strength we need to train in the intensity range of 60-85% 1RM, with higher intensities resulting in greater strength gains. An intensity of 60% represents the minimum to get stronger, while the 70-85% range is optimal for strength adaptations (2).

Now, we can test % 1RM, however this can become quite time consuming when performing a variety of exercises (e.g. assessing % 1RM for a leg press, lunge, bench press, lat pull down, etc.). Also, strength fluctuates based on a variety of factors, such as how well-rested the client is. Lastly, clients will get stronger over time (with rapid gains in the first few weeks of training), so the original % 1RM will not always match the client’s abilities for a given session. Unless your client is a powerlifter, comprehensive % 1RM testing is unnecessary.

Instead, we can use a target rep range and “Rating of Perceived Exertion” (RPE) to achieve that intensity. Aim to work in the range of 6-15 repetitions (2). Loads that can be performed for 6 reps approximate 85% 1RM and loads that can be lifted for 15 reps approximate 60% 1RM. I would recommend starting clients with higher rep sets of 15 and then over several weeks working down to lower rep sets of 6, if appropriate and tolerated. However, we won’t be taking sets to absolute failure. Instead, we’ll use RPE to make sure we are working in that 60-85% 1RM range, which rolls into the next point…

  • Use RPE to prescribe and monitor intensity

RPE is a measure of exercise intensity originally developed for cardiovascular exercise, which has since been validated for resistance exercise. There are several valid scales to measure RPE. Here we’ll use the OMNI Resistance Exercise Scale (OMNI-RES), which has been validated for use in older adults (5). See the figure below with the scale and descriptions of each level.

OMNI-Resistance Exercise Scale of Perceived Exertion

Adapted from Gearhart et al, 2009

First, explain the scale to them and show them a printed version of the OMNI-RES. Then to assess RPE, simply ask the patient to rate their level of exertion at the end of the set. Note that the RPE for light and heavy loads can be the same depending on how close to muscle failure the client gets. Research shows that 30 % 1RM and 80% 1 RM loads had a similar level of RPE when sets were taken to absolute muscle failure (6).

As mentioned earlier, we don’t often want to push until absolute muscle failure. We should work up to an RPE of 6-8 (“somewhat hard” to “hard”) within that 6-15 rep range, to ensure we are applying enough load to get our clients stronger.

Some clients may be started at sets with greater than 15 reps and intensities of less than 6 RPE and that is ok. However, if appropriate and tolerated, they should be progressed into the 6-15 rep range with RPE’s of 6-8 to reach the 60-85% 1RM intensity that is optimal for strengthening.

  • Assess strength adaptations over time

Over time, an appropriate response to strength training is the ability to perform a given rep/load combination more easily. Then because the client has gotten stronger, the reps/load for an exercise can be increased.

For example, a client performs 10 reps on the bench press with 65 lbs at RPE 7. Within a few sessions the client performs the exact same rep/load combination but rates it at RPE 6. The exercise with the same rep/load combination (65 lbs for 10 reps) has gotten easier (i.e. decreased RPE), which means the client has gotten stronger. Since the client has gotten stronger, it would be appropriate to increase the load by 2.5-10%, to accommodate the client’s increased fitness level and keep driving strength gains.

However, if they perform a given rep/load combination for several weeks and the RPE increases (i.e. the exercise is feeling more challenging) or stays the same, this could mean that the client is NOT getting stronger on that exercise. In this case, it might be time to revise the strength training program and/or examine other factors like recovery and nutritional status.  

This requires some judgement of how quickly progress should be seen. However, over time the client should be able to perform more reps with heavier loads, with a similar level of RPE.

In addition to measuring the strength adaptations to specific exercises, we should also use functional assessments of strength such as the bicep curl test, heel raise test, and sit to stand.

Wrapping Up

Strength training is vital for the older adult and needs to be properly dosed. To best dose strength exercises you now have three tools:

>Ideal intensity range: 70-85% 1RM, with a rep range of 6-15 reps

>Intensity monitor: RPE, aim for a rating of 6-8 (“somewhat hard” to “hard”)

>Measure of strength adaptations: client response to individual exercises and functional strength assessments


  1. Five Things Physical Therapists and Patients Should Question. (2018). Choosing Wisely. https://www.choosingwisely.org/societies/american-physical-therapy-association/
  2. Fragala, M. S., Cadore, E. L., Dorgo, S., Izquierdo, M., Kraemer, W. J., Peterson, M. D., & Ryan, E. D. (2019). Resistance Training for Older Adults: Position Statement From the National Strength and Conditioning Association. Journal of strength and conditioning research33(8), 2019–2052. https://doi.org/10.1519/JSC.0000000000003230
  3. Hortobágyi, T., Mizelle, C., Beam, S., & DeVita, P. (2003). Old adults perform activities of daily living near their maximal capabilities. The journals of gerontology. Series A, Biological sciences and medical sciences58(5), M453–M460. https://doi.org/10.1093/gerona/58.5.m453
  4. Fiatarone, M. A., Marks, E. C., Ryan, N. D., Meredith, C. N., Lipsitz, L. A., & Evans, W. J. (1990). High-intensity strength training in nonagenarians. Effects on skeletal muscle. JAMA263(22), 3029–3034.
  5. Gearhart, R. F., Jr, Lagally, K. M., Riechman, S. E., Andrews, R. D., & Robertson, R. J. (2009). Strength tracking using the OMNI resistance exercise scale in older men and women. Journal of strength and conditioning research23(3), 1011–1015. https://doi.org/10.1519/JSC.0b013e3181a2ec41
  6. Naclerio, F., Rodríguez-Romo, G., Barriopedro-Moro, M. I., Jiménez, A., Alvar, B. A., & Triplett, N. T. (2011). Control of resistance training intensity by the OMNI perceived exertion scale. Journal of strength and conditioning research25(7), 1879–1888. https://doi.org/10.1519/JSC.0b013e3181e501e9

How To Do Your First Pull-Up

The pullup is a simple exercise, yet seems impossible to achieve for so many. When I was dealing with chronic shoulder pain (for almost a decade) I dreamed of what it would be like to do a pullup. And it felt incredible to nail my first pullup. Then came the fun of doing more reps and performing weighted pullups.

In this article, we’ll go through how to master your first pullup.

While many programs exist online, this one is different in that we’ll be keeping in mind:

  1. Reducing the risk of injury due to loading joints too quickly
  2. Setting you up to progress to multiple pullups

This program will take roughly 3 months and you’ll need: an assisted pullup machine, lat pulldown (or machine row), and dumbbells.

There will be 2 workouts per week, A and B, each with 2 exercises. The workouts should be performed with 2 days of rest in between each session. So an example schedule could be to perform workout “A” on Monday and workout “B” on Thursday.

Assisted pullupLat pulldown (or machine row)
Bicep curlFlexed arm hang/eccentric pullup

Purpose of Each Exercise and How to Perform:

Here we’ll cover why we perform each exercise and links on how to perform each one correctly:

Assisted pullup: this most closely mimic the movement pattern of the pullup and allows us to safely practice the full motion as you progress towards a full unassisted pullup.

Bicep curl: this accessory exercise builds the necessary pulling strength and tissue capacity to perform pullups.

Lat pull down (or row): this is a compound pull that builds the requisite strength and tissue capacity needed for pullups.

Flexed arm hang: your pulling muscles have more strength and endurance in the top position holding your head above the bar, as compared to pulling up from the bottom dead hang position of the pullup. So before you can actually pull yourself up to the bar, we can use the flexed arm hang to practice handling your full body weight. Note that if you can’t perform the flexed arm hang for at least 10 seconds then just perform the other 3 exercises (assisted pullup, bicep curl, and lat pulldown) until you can perform the flexed arm hang for at least 10 seconds.

Eccentric pullup: similar to the flexed arm hang, your pulling muscles have more strength in the lowering down portion of the pullup than the upward pulling motion. So after you’ve mastered the flexed arm hang for 3 sets of 60 seconds, we’ll progress to eccentric pullups, where you’ll start at the top position of the pullup and slowly lower your body down to the floor over 4 seconds.

How to Progress Each Exercise:

Over the course of 3 months, we’ll progress each exercise in slightly different ways. The assisted pullup and hang/eccentric pullup will be progressed to more closely match the high strength needs of performing your first pullup. On the other hand, the bicep curl and lat pulldown will stay at higher reps with more moderate loads to develop the strength endurance necessary for performing multiple pullups later on.

WeekAssisted PullupBicep CurlsLat PulldownHang/Eccentric Pullup
1-43×10, decrease assistance while leaving 2 RIR2×10, add weight while leaving 2 RIR3×10, add weight while leaving 2 RIRHang: 3×10 sec, leaving at least 5 seconds in reserve
5-83×8, decrease assistance while leaving 2 RIR2×10, add weight while leaving 2 RIR3×10, add weight while leaving 2 RIRHang: Work up to 3×60 seconds, leaving at least 5 seconds in reserve
9-123×5, decrease assistance while leaving 2 RIR2×10, add weight while leaving 2 RIR3×10, add weight while leaving 2 RIR3×5, eccentric pullup (4 second lower), leave 1 RIR

With the 3 month plan outlined, here are a few key definitions and notes:

-Sets and reps: For each exercise, the sets and reps are written as “sets x reps”, so “3×10” means 3 sets of 10.

-RIR: This means “reps in reserve”. When performing exercises to improve strength we don’t want to work until full muscle failure regularly. Instead we will work to a point where we still have 1-2 reps left in reserve at the end of each set. For example, if you perform 10 unassisted pullups with 40 lbs of assistance, but you probably could have done 12 reps that means that you still have 2 reps in reserve (2 RIR). Of course, this is a rough estimate and sometimes you might over or undershoot and that is ok. You’ll get better with time at estimating how many reps you have left at the end of each set. On a similar note, we’ll use 5 seconds as our reserve for the flexed arm hang. So if you perform the flexed arm hang for 15 seconds, but you could have held on for 20 seconds, that is a good intensity level for you.

-How to progress exercises: As your strength improves, we’ll have to progress each exercise. For the bicep curl and lat pulldown, we will gradually add weight, while still keeping 2 RIR. I would recommend doing the smallest weight increases possible each time. For the assisted pullup, we will gradually decrease the amount of assistance for the movement. Lastly, for the flexed arm hang, aim to increase by 5-10 seconds for each set.

Note that we want to progress while still staying within the RIR recommendations for each exercise. For example, imagine that you perform a 10 lb bicep curl for 10 reps with 2 RIR. Then at the next session, you perform a 12.5 lb bicep curl for 10 reps with 0 RIR (going all the way to muscle failure). You haven’t really gotten stronger, you’ve just forced yourself to use a heavier weight. Being stronger would mean performing a 12.5 lb bicep curl for 10 reps with 2 RIR.

For all of the exercises, you’ll likely be able to progress every week for the first 4-6 weeks. After that point, you may have to progress every other week.

-How to include these exercises in a workout: Perform these exercise at the beginning of a workout. If you perform these after other exercises, you will be fatigued and performance will be less than optimal.

-Rest between sets: Rest for 2-3 minutes between each SET of an exercise. While it can be tempting to rush through, you’ll be able to get more reps and use increasingly heavier loads if you rest sufficiently between each set.

Wrapping Up

By the end of the 12 weeks, if you can perform 3×5 assisted pullups with the minimum resistance (usually 10 lbs) and can perform 3×5 eccentric pullups, you should be ready to perform a full pullup.

Of course, how close you get to a pullup in 3 months depends on many factors such as body size (pullups tend to be easier for lighter, shorter people), how much training you have done before, your recovery (fatigue from other physical activity, sleep quality, stress levels, etc.), and your nutrition status (ensuring you’re consuming sufficient calories and protein).

The pullup will take time to master, but with this program you’ll be able to safely progress to your first pullup and be setup to do many more after that.

Tendon Neuroplastic Training 101 – A Novel Approach to Tendon Rehab

Patients and physiotherapists alike struggle to manage tendinopathy and its nasty habit of recurrence. Fortunately, the field keeps evolving and here we’ll discuss a novel approach to tendon rehab called “Tendon Neuroplastic Training”, which targets an often overlooked issue in tendinopathy-motor control.

But First, What is Tendinopathy?

Tendinopathy is a broad term that covers the pain and impaired performance related to overuse of a particular tendon. Most people have heard of “tendinitis” which implies an inflammatory response. However, tendinopathy is a more useful term since there are many ways a tendon can be irritated, which can include degenerative and inflammatory pathways (see Dr. Peter Malliaras’ post for more on this). A whole article could be written on staging tendon dysfunction, so for simplicity we’ll stick with the catch-all term “tendinopathy”.

Photo by Andrea Piacquadio on Pexels.com

How Do We Currently Treat Tendinopathy?

Current rehab protocols focus on changing tendon mechanical properties, improving muscle performance, managing load, pain management (i.e. modalities and manual therapy), interventions that affect local tissue (e.g. corticosteroid injection), and changing kinetic chain biomechanics. However, many treatments fail to adequately address the motor control of the muscle linked to the irritated tendon.

Why Focus on Motor Control?

In many tendinopathies there are changes in motor control of the muscle linked to the tendon in question, which can persist, even when pain is decreased and strength is improved (1). One of the main changes is in corticospinal excitability and inhibition, that is, the signals from the motor cortex that excite or inhibit a muscle.

File:UMN vs LMN.png

Adapted from: https://commons.wikimedia.org/wiki/File:UMN_vs_LMN.png

For example, a study showed that patients with patellar tendinopathy exhibited abnormal excitability of the quadriceps (1). Normal excitability looks like smoothly ramping up the signal from the motor cortex down to the muscle. However, abnormal excitability looks like little to no signal and then suddenly a sharp spike in the signal to activate a muscle. Think of a driver who shifts from 2nd to 4th gear abruptly, causing the car to jerk forward, versus an experienced driver who smoothly shifts through gears to build up speed.

Curiously, these patients also exhibited increased inhibition of the quadriceps. This means that their brain is limiting the signals from the motor cortex down to the muscle. The net effect has been described by Dr. Ebonie Rio as a driver who has their foot on the gas and brake at the same time (1). This dysfunctional signaling makes it difficult for the muscle to properly respond to the loads placed on it.  

So in rehab, we need to normalize this corticospinal excitability and inhibition to restore patients to full function and reduce the risk of recurrence.  

How Do We Change Motor Control?

To target the motor control deficits seen in tendinopathy, we can use externally paced strength training. Self-paced exercises have less of an effect on cortical motor control, so just doing more reps with heavier loads will not create the desired changes in motor control. External pacing, on the other hand, has a powerful effect on changing motor control (2).

Enter Tendon Neuroplastic Training (TNT), where we use an external cue, like a metronome, to control the pace of an exercise. For example, rather than performing a heel raise where the patient counts “3 seconds up, 4 seconds down”, in TNT, the patient coordinates their heel raise to a metronome set at 60 beats per minute (bpm), to ensure they are truly working at the desired speed. Once patients try it, many are surprised by how inconsistent their self-paced speed is compared to when they follow the metronome beat.

In addition to improving motor control, TNT keeps patients much more engaged with exercises. How often does a patient perform an exercise and then start gazing around the clinic? Or even forget what rep they are on? The external auditory cue of the metronome creates more engagement in the exercise and keeps patients on task.

How to Implement TNT in the Clinic?

The original protocol described in research by Dr. Ebonie Rio was used for patellar tendinopathy and included an isometric and isotonic knee extension as shown in the table below (1):

5 sets of 45 seconds4 sets of 8 reps
Patient counts duration of hold with 60 bpm metronomePatients performs 3 second concentric and 4 second eccentric to a 60 bpm metronome

Of course, this protocol should be modified based on the person in front of you and their stage of rehab.

For example, for posterior tibialis tendinopathy, we could use a heel raise while squeezing a tennis ball, performing a 3 second concentric and 4 second eccentric phase. In the clinic, I set the metronome to 60 bpm and count the first few reps with the patient, saying “1-2-top” (meaning that they should be at the highest position of the heel raise on the 3rd beat) and then “1-2-3-bottom” (meaning that they should be at the lowest position of the heel raise on the 4th beat). Once the patient understands the pacing, they would complete the prescribed number of reps. Below is an example of how this would look in practice:

As the patient progresses we can use the metronome to quantify and progress the speed of exercise, since rate of loading is a crucial factor in tendon rehab. For example, performing slow, heavy heel raises is great. However, during the gait cycle, the average stance time is just 0.6 seconds, meaning that lower limb tendons must handle fast rates of loading (3). Instead of just saying “do the heel raise faster” we can gradually increase the rate of the metronome beat to approximate the goal activity. Then if appropriate, we can progress to plyometric exercise.


Tendon Neuroplastic Training (TNT) addresses the motor control deficits that come with tendinopathy in a novel way. All you need to get started is a metronome so that patients have an external cue to pace the speed of an exercise. I personally have integrated TNT seamlessly into clinical practice and look forward to seeing more research into its application in a variety of tendinopathies. Its main benefits are that it:

-Improves motor control from the brain down to the muscle

-Can easily be implemented into exercises we already perform in rehab

-Keeps patients highly engaged during exercises

-Lets us quantify and progress the rate of loading of a tendon


  1. Rio, E., Kidgell, D., Moseley, G. L., Gaida, J., Docking, S., Purdam, C., & Cook, J. (2016). Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. British journal of sports medicine50(4), 209–215. https://doi.org/10.1136/bjsports-2015-095215
  2. Leung, M., Rantalainen, T., Teo, W. P., & Kidgell, D. (2017). The corticospinal responses of metronome-paced, but not self-paced strength training are similar to motor skill training. European Journal of Applied Physiology117(12), 2479-2492. https://doi.org/10.1007/s00421-017-3736-4
  3. Murray, M. P., Drought, A. B., & Kory, R. C. (1964). Walking Patterns of Normal Men. The Journal of bone and joint surgery. American volume46, 335–360.

Improve Recovery and Performance through “Via Negativa”

Weight loss supplements. Muscle building supplements. Home massage tools. There is a tendency in fitness and rehab to want to keep adding more and more interventions to improve recovery and performance. Unfortunately, many of these things, have marginal to zero real benefit (beyond possibly feeling good in the moment). And we often fail to consider how powerful subtraction can be. This removal of barriers is summed up in the term “via negativa”, popularized by Nassim Taleb in his book Antifragile. The idea is that removal can be a powerful strategy that often is cheaper and simpler than adding more. For example, if a pebble in your shoe is causing you a tad of pain, what’s the best solution? You could buy specialized padded socks. Or insert a fancy pebble-shielding shoe insert. Or purchase special shoes that offload the spot where the pebble is. Or you could just remove the pebble.

In the fitness and rehab world, examples abound of adding interventions of marginal benefit, rather than removing barriers to performance and recovery. Consider foam rolling, often recommend as a recovery strategy. While it feels great, foam rolling only has a minor effect on decreasing muscle soreness. On the other hand, improving sleep quality (and quantity when possible) is foundational to recovery.

Some people claim that things like foam rolling are cheap and have no real cost. I would say practices like foam rolling DO have a cost. The reality is that time, energy, and attention are limited. Your time and energy spent foam rolling could be better spent on other more important activities. Further, doing marginally beneficial things, like foam rolling, can distract us from more important practices. For example, if someone foam rolls for 10 minutes but regularly stares into a bright, blue light emitting screen before bed, how great will their recovery be? What if those 10 minutes were instead invested in powering down the phone and starting a relaxing bedtime ritual like having a cup of chamomile tea?

Now to clarify I am not against practices like foam rolling, per se. The issue arises when people start adding in these practices over more fundamental tactics, like managing sleep quality.

So to sum up, before ADDING more, consider asking what can I SUBTRACT to improve recovery and performance?

*There are some supplements (like creatine for strength and building muscle) which are effective. However, the list of truly effective supplements is quite small and they should be just that-supplements. They are not foundational for recovery and performance.