1 The scientific basis for eccentric quasi-isometric resistance training:

2 A narrative review
3

5 Abstract
6 Eccentric quasi-isometric (EQI) resistance training involves holding a submaximal, yielding

7 isometric contraction until fatigue causes muscle lengthening, then maximally resisting

8 through a range of motion. Practitioners contend that EQI contractions are a powerful tool for

9 the development of several physical qualities important to health and sports performance.

10 Additionally, several sports involve regular quasi-isometric contractions for optimal

11 performance. Therefore, the primary objective of this review was to synthesize and critically

12 analyze relevant biological, physiological and biomechanical research and develop a rationale

13 for the value of EQI training. Additionally, this review offers potential practical applications

14 and highlights future areas of research. While there is a paucity of research investigating

15 EQIs, the literature on responses to traditional contraction types is vast. Based on relevant

16 literature, EQIs may provide a practical means of increasing total volume, metabolite build-

17 up and hormonal signalling factors while safely enduring large quantities of mechanical

18 tension with low levels of peak torque. Conversely, EQI contractions likely hold little

19 neuromuscular specificity to high velocity or power movements. Therefore, EQI training

20 appears to be effective for improving musculotendonous morphological and performance

21 variables with low injury risk. Although speculative due to the limited specific literature,

22 available evidence suggests a case for future experimentation.

23

24 Keywords: biology, biomechanics, musculoskeletal, physiology, strength

25

1
26 Introduction

27 Apparently coined by Yuri Verkhoshansky (169), eccentric quasi-isometric (EQI)

28 contractions, also known as yielding, holding, or eccentric isometrics (50, 71, 136), have

29 many variations and proposed applications. However, for this review, EQIs will be defined as

30 “holding a position until isometric failure and maximally resisting the subsequent eccentric

31 phase”. Theoretically, the prolonged quasi-isometric and eccentric component enable a large

32 accumulation of mechanical tension and metabolic stress that would contribute to

33 improvements in work capacity, muscle size and connective tissue health. While traditional

34 high-intensity isometric contractions and eccentric muscle actions are commonly used by

35 practitioners, with well-established value in the modern scientific literature (38, 44, 45, 79,

36 90, 120), EQIs remain relatively unexplored. Therefore, this review aims to synthesize and

37 critically analyze relevant research and subsequently develop a rationale for the value of EQI

38 training and highlight potential areas of future research.

39

40 Defining eccentric quasi-isometric training

41 Prior to the EQI contraction, a submaximal (being hereafter relative to one repetition

42 maximum (1RM)) eccentric contraction where the muscle-tendon unit undergoes an active

43 lengthening is performed. Once the prescribed joint position is met, the trainee shifts to

44 yielding isometric muscle action and attempts to hold the position for as long as possible. The

45 final phase occurs as fatigue accumulates, and an eccentric contraction commences while the

46 trainee attempts to resist muscle lengthening maximally. Some practitioners contend that this

47 second lengthening phase places additional stretch and strain on the musculotendinous

48 system similar to supramaximal eccentric training (112, 142). Practitioners have

49 recommended a wide range of loads, with the goal of holding the quasi-isometric contraction

50 for 5-90 seconds (112, 142). Consistent with traditional resistance training, greater intensities

2
51 and shorter contraction durations are recommended for strength and power athletes while

52 lower loads and longer contractions may be advantageous for oxidative or rehabilitative

53 purposes (112, 142). Anecdotally, increased muscle thickness, improved range of motion

54 (ROM), altered force-angle relationships and improved tendon health, have been reported

55 following EQI training (112, 142). Although quasi-isometric muscle actions have been used

56 to describe sport-specific and stabilizing positions in sailing, speed-skating, cycling, and

57 sprinting gait (24, 99, 150, 152, 166-169), there is no published empirical data on EQIs, and

58 much if the related literature utilizes animal models.

59

60 Methods

61 Literature search methodology

62 An electronic search for relevant literature was conducted utilizing MEDLINE,

63 SPORTDiscus, PubMed and CINAHL databases from inception to May 2019. Key terms

64 were searched for within the article title, abstract, and keywords using conjunctions ‘OR’ and

65 ‘AND’ with truncation ‘*.’ Combinations of the following Boolean phrases comprised the

66 search terms: isometric, static, eccentric, contraction, occlusion, blood flow restriction,

67 hypertrophy, strength, power, endurance, muscle, fiber, cross-sectional area, tendon, fascicle,

68 pennation and neuromuscular. Reference lists and books were also utilized.

69

70 Inclusion and exclusion criteria

71 Studies were included in the review based on the following criteria: 1) full text

72 available in English; and, 2) peer-reviewed journal publications or doctoral dissertations.

73 Studies were excluded if they; 1) were conference papers/posters/presentations.

74

75 Statistical analysis

3
 76 Percent change and Cohen’s d effect sizes (ES) were calculated wherever possible to

77 indicate the magnitude of the practical effect. Effect sizes were interpreted using the

78 following criteria: trivial <0.2, small 0.2-0.49, moderate 0.5-0.79, large >0.8 (47). All

79 reported ES and percentage changes are pre-post within–group, unless otherwise stated.

80

81 Eccentric quasi-isometrics and morphological adaptations

82 Eccentric quasi-isometric training appears to be a valuable tool for targeting specific

83 musculotendinous morphological adaptations such as increased muscle thickness and fascicle

84 length, and tendon stiffness and elasticity. Functional morphology refers to the structure and

85 function of organisms and their specific structural features. Although morphology affects

86 function in all tissues, this review will focus on the musculoskeletal system, which is often

87 broken down into the three-component model of force transmission (Figure 1) (66). The three

88 component model provides insight into the determinants of force production and transmission

89 - the contractile element (CE), series elastic component (SEC) and parallel elastic component

90 (PEC) (69, 70, 104, 126). The PEC, synonymous with the extracellular matrix, includes the

91 elastic tissues surrounding the myofibrils (the endo, peri and epimysium) as well as the

92 sarcolemma and fascia. These tissues are thought to contribute to sensations of pressure, and

93 although yet to be fully quantified, may play a meaningful role in force transmission between

94 joints and body segments (69, 70, 104). The SEC encompasses the spring-like tissues in

95 series with actin and myosin, the tendon and aponeurosis being most obvious. Controversy

96 exists regarding the exact function of the titin myofilament, which appears to play a role in

97 both active and passive force transmission (41, 64, 68). For example, titin was originally

98 thought to be somewhat innate and only contribute to passive tension in a fully stretched

99 sarcomere (68). However, contemporary research has demonstrated that titin is activated by

100 calcium ions and adenosine triphosphate, contributing to active force transmission (41, 64,

4
101 95). Finally, the CE consists of the myofibril, and more specifically, the myofilaments of

102 actin and myosin.

103

104 (Figure 1. about here)

105

106 Contractile element

107 Muscle length and joint angle

108 Typically prescribed at long muscle length (LML) and often held through full ROM,

109 EQIs fulfil the scientifically based criteria of mechanical stretch and tension for improving

110 muscular hypertrophy and function. Produced by force generation and stretch, mechanical

111 tension is effective in promoting muscular hypertrophy regardless of contraction type (15, 55,

112 137). In animal models, prolonged mechanical tension has been shown to produce dramatic

113 increases in muscle size. For instance, extreme increases in muscle mass (318%), muscle

114 length (51%), mean fibre thickness (39%) and fibre number (82%) were reported following

115 loaded stretching of avian wings over 28 days (9). Similarly, Tabary et al. (155) reported that

116 cat soleus muscles immobilized in a lengthened position had 20% more serial sarcomeres

117 whereas a shortened soleus group had 40% fewer sarcomeres in series than normal muscle,

118 respectively (155). An increase in muscle hypertrophy of up to 30%, with an increase of up to

119 250% RNA content in four days was observed following electrically induced overload in

120 stretched rabbit tibialis anterior muscles (55). The effect of mechanical tension on skeletal

121 hypertrophy was examined by Ashida et al. (15) utilizing electrically induced contractions in

122 mice. Peak torque and torque-time integrals were highly correlated with increased muscle

123 mass and mTOR regulating p7S6k phosphorylation in isometric contractions and eccentric

124 muscle actions (15). Thus, animal models suggest that loaded stretching may provide a

125 unique stimulus for inducing gene transcription and muscular hypertrophy (55).

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126

127 Recently, loaded stretch training with human subjects has grown in popularity (10, 63,

128 148). For example, following six-weeks of loaded (20-45% of maximal voluntary contraction

129 (MVC)) stretching for five, 3-minute sessions per week, fascicle length (25%), ROM

130 (14.9%), and muscle thickness (5.6%) significantly increased, while the pennation angle of

131 the lateral gastrocnemius significantly decreased (7.1%) (148). However, no change (p =

132 0.94, ES = 0.08) in MVIC or voluntary activation (p < 0.05, ES = 0.13) was present (148),

133 despite several cross-sectional investigations supporting the relationship between muscle

134 architecture and performance (3, 7, 23, 89, 118, 163). Yet, the causal relationship between

135 alterations in muscle architecture and muscular strength has become a hot topic in

136 contemporary literature (36, 117). Additionally, the concept of constant-torque versus

137 constant angle-stretching has been recently examined (10, 63). For example, Herda et al. (63)

138 examined the short-term effects of acute knee flexor stretching at a constant-angle, or under

139 constant-torque where the muscle was initially held at a point of mild discomfort followed by

140 additional muscle-tendon unit lengthening via “muscle creep,” and stretch-induced analgesia

141 occurred. While both groups experienced similar improvements in passive ROM and passive

142 torque, only the constant-torque treatment resulted in decreased muscle-tendon-unit stiffness

143 (p < 0.001) (63). Unfortunately, Herda et al. (63) did not report any performance measures, a

144 trend that is common in stretching research (10). From these results, it appears that, in young

145 males, loaded stretching can provide sufficient stimulus to affect musculotendonous

146 architecture, viscoelastic properties and likely, acute pain thresholds (10, 63, 148). As

147 variants of loaded stretching utilize extended periods at or near end ROM, the results of the

148 aforementioned research lend credence to the hypothesis that EQI training may be a valuable

149 training methodology for improving acute and chronic flexibility and musculotendonous

150 function. However, there is a dearth of stretch research elucidating the ideal stretching

6
151 intensity and the efficacy of loaded stretching to improve muscular or athletic performance

152 (10).

153

154 Although eccentric muscle actions have the highest potential for muscular force

155 production, isometric muscle actions are the only contraction type that has no ROM

156 dependent endpoint. Isometric training is also easily implemented as simply flexing (co-

157 contracting the agonists and antagonists of a limb) can increase muscle size and strength in

158 active men (100, 175); though the value of co-contraction training in a well-trained

159 population has yet to be elucidated. Additionally, isometric contractions enable training at

160 specific joint angles and, therefore, muscle-tendon lengths. While strength improvements are

161 joint-angle specific (97), increases in muscular hypertrophy, which is larger following full

162 ROM and LML training, (106), transfer to all joint angles (5, 87, 115, 116). McMahon et al.

163 (106) compared the effects of dynamic resistance training executed with full or partial ROM.

164 The full ROM group experienced significantly greater improvements in the distal anatomical

165 cross-sectional area (59% vs. 16%), fascicle length (23% vs. 10%) and isometric force at all

166 seven (30-90° of flexion) measured knee joint angles (11-30% vs. -1-6%) (106) when

167 compared to the partial ROM group. Although isometric contractions resulted in less muscle

168 damage and less dramatic muscular-tendinous adaptations compared to maximal eccentrics,

169 maximal voluntary isometric contractions (MVICs) at LML increased markers of acute

170 muscle damage and soreness relative to MVICs at short muscle length (SML) despite lower

171 torque outputs (6). Isometric training at LML produces greater hypertrophy, force production

172 at different joint angles, and dynamic performance benefits compared to training at SML

173 following long-term trials (5, 17, 87, 115, 116, 160). In a recent systematic review into the

174 effects of isometric training variations, Oranchuk et al. (120) determined that isometric

175 training at LML produced greater increases in muscular hypertrophy than volume-equated

7
176 SML training, (0.86-1.69%·week-1, ES·week-1 = 0.03-0.09; and 0.08-0.83%·week-1,

177 ES·week-1 = -0.003-0.07, respectively) (120) likely due to increased mechanical tension

178 throughout all tissues involved in force transmission (Figure 2).

179

180 (Figure 2. about here)

181

182 The larger architectural and functional adaptations following LML training might be

183 due, at least in part, to the greater degree of fascicle stretch, which results in increased muscle

184 damage, and sarcomere compliance (6, 27) demonstrated by acute optimal angle shifts

185 towards longer muscle lengths. Although more dramatic following eccentric muscle actions,

186 these angle shifts have also been observed following concentric contractions at long fascicle

187 lengths (58). For example, Guex et al. (59) examined the effect of three weeks of maximal

188 eccentric knee flexions at either LML or SML on fascicle length and optimal angle. While

189 fascicle length increased in both groups (SML, 4.9%, ES = 0.57: and LML; 9.3%, ES = 0.89),

190 the SML group only experienced a shift in the optimal concentric angle (8.8°), whereas the

191 LML group experienced optimal angle shifts in both concentric contractions and eccentric

192 muscle actions (17.3° and 10.7°, respectively) (59). There is evidence to support the principle

193 that mechanical tension can increase muscle volume, and that isometric training at LML leads

194 to greater hypertrophy and a shift in the optimal angle.

195

196 Contraction intensity and duration

197 Cumulative tension and total workload are key determinants of hypertrophic

198 adaptation, regardless of contraction type (110). Moore et al. (110) found that changes in

199 torque and muscle thickness were not significantly different between load-matched

200 concentric and eccentric resistance training groups, despite the eccentric group requiring 40%

8
201 fewer contractions to match training load. Morphological adaptations to isometric resistance

202 training are similar between work matched high and low-intensity training (120). While much

203 of the literature recommends high-load over low-load resistance training for strength

204 development (102), many periodization models emphasize muscular hypertrophy and general

205 muscular endurance early in a macro and mesocycles (34, 169). Accordingly, EQI training

206 emphasizing time under tension with the application of practitioner-recommended intensities

207 of 30-80% of 1RM may be a useful training method to alter muscle size.

208

209 Metabolic factors

210 Total time under tension, acute hypoxia and metabolic stress are mechanisms that

211 contribute to morphological adaptations (25, 49, 51, 120, 123, 140, 157, 158). Several studies

212 have reported significant reductions in oxygen availability from submaximal isometric

213 contractions at 30-50% of MVC (4, 150). Additionally, blood flow does not appear to

214 decrease linearly with intensity (107). Isometric contractions at 60% of MVIC result in

215 greater short-term blood flow restriction relative to 30% and 100% MVIC, as the moderate

216 intensity contraction could be sustained for a significantly greater duration than 100% while

217 the tension created by the 30% contraction was not enough to reduce blood flow and

218 metabolite clearance (107). These occlusive effects have several potential effects, including

219 increased metabolite build-up and post-contraction blood flow, both of which stimulate

220 muscular hypertrophy (98). Several studies have examined the impact of blood flow

221 restriction on hormones and hypertrophic markers in humans (49, 123, 157, 158). Fujita et al.

222 (49) examined the metabolic and hormonal effects of blood flow restriction during low-

223 intensity resistance training and found 46% greater mTOR regulated muscle protein

224 synthesis, via significantly greater S6K1 phosphorylation markers compared to the exercise-

225 only group. Gentil et al. (51) also found that both isometric contractions and vascular

9
226 occlusion resulted in greater blood lactate responses which can increase muscle cell

227 myogenesis, satellite cell activation and phosphorylation of mTOR and P70SK (113).

228 Additionally, acute ischemia combined with low-intensity muscular contraction can

229 significantly increase growth hormone, IGF-1 and mechano-growth factor production (42),

230 which are physiological responses to decreased muscle and blood pH (123, 157, 158).

231 Occlusion may also help to bypass the size principle by reducing the amount of oxygen

232 available for the oxidative type-1 motor units, resulting in preferential recruitment of fast-

233 twitch fibres at relatively low intensities (111). Long-term morphological adaptations to

234 blood flow restriction training include increased muscle thickness and function in a variety of

235 training circumstances (98, 159, 172).

236

237 Though sparse, a few studies have examined the effect of blood flow and metabolites

238 during isometric training (37, 140). de Ruiter et al. (37) examined the oxygen consumption

239 characteristics of isometric contractions at several knee angles. Isometric contractions at

240 LML (60° and 90°) consumed significantly greater quantities of blood oxygen compared to

241 SML contractions (30°) at 10%, 30% and 50% of MVC (37). These findings may, in part,

242 explain why long-term isometric training at LML has a greater effect on muscle thickness and

243 strength, compared to SML training at least in “healthy”, or “recreationally active” subjects

244 (5, 17, 87, 97, 115, 116, 120). Schott, McCully and Rutherford (140) compared the metabolic

245 response and adaptations to short (four sets of 10 x three-second contractions) or long (four

246 contractions of 30 seconds) duration isometric contractions at 70% MVC. Although blood

247 flow was not measured, the long-contraction limbs experienced greater changes in

248 metabolites and larger decreases in pH (140). Muscle thickness also significantly increased in

249 the upper (10.1%) and lower (11.1%) portions of the quadriceps in the long-contraction, but

250 not short-contraction limb (140). Although blood flow restriction has many benefits in older

10
251 and injured populations, it does not appear to offer any additional adaptations in healthy well-

252 trained athletes (141). Furthermore, while low intensity single-joint isometric contractions

253 have been found to result in blood flow restriction, the effects of multi-joint isometric and

254 quasi-isometric contractions have yet to be examined.

255

256 Exercise-induced muscle damage

257 Although exercise-induced muscle damage is not needed to promote muscular

258 hypertrophy (137), emerging research suggests that exercise-induced muscle damage may

259 play some role in morphological adaptations (138). When exposed to a novel stimulus, acute

260 myofibril micro-trauma occurs as an abundance of Ca2+ enters and remains in the myofibril

261 (35). Eccentric muscle actions typically result in a greater degree of acute trauma as

262 evidenced by elevated serum creatine kinase, myoglobin, and skeletal troponin-1 levels, and

263 delayed onset muscle soreness (32). These markers typically coincide with a temporary

264 reduction in muscle force and power (32). While detrimental to short-term performance,

265 exercise-induced muscle damage is associated with changes in a variety of chemokines that

266 attract inflammatory cells, which influence muscle hypertrophy remodelling associated with

267 phagocytosis, free radical production, and circulating cytokines and growth factors (80).

268 Additionally, a novel delayed onset muscle soreness inducing stimulus may lead to increased

269 sarcoplasmic reticulum re-uptake of Ca2+ by altering t-tubule structure (35) and increasing the

270 concentrations of proteins such as calsequestrin (20) and dysferlin (77). These proteins

271 function to promote debris clearance and increased concentrations of IGF-1, fibroblast

272 growth factor, nerve growth factor, and interleukin-6, which increase satellite cell

273 proliferation (16, 18) and rates of protein and collagen synthesis (76). Although acute

274 increases in myofibril protein synthesis do not necessarily correlate with long-term

11
275 hypertrophy (108), these increased synthesis rates, theoretically result in thicker, stronger

276 tissues that are less susceptible to future damage (45).

277

278 The repeated bout effect refers to the substantial reduction in muscle damage from

279 subsequent training (105). While most commonly observed following eccentric exercise (45,

280 105), the protective effects have also been found to occur following isometric exercise (2),

281 especially at LML (6, 31). Isometric training at LML results in greater delayed onset muscle

282 soreness and acute performance decrements (6) as well as chronic adaptations, compared to

283 isometrics at SML (5, 87, 115, 116, 120, 160). Likewise, greater exercise-induced muscle

284 damage and delayed onset muscle soreness are reported following maximal effort high-

285 velocity (210°·s-1) isokinetic eccentric muscle actions when compared to an equal volume

286 bout at low-velocity (30°·s-1) (29). As a greater number of high vs. low-velocity eccentric

287 muscle actions are needed to equalize volume, the difference in muscle damage and soreness

288 is likely due to increasing the total number of sarcomere bonds and “popping” sarcomeres,

289 which increase Z-disk streaming and subsequent inflammation (39, 146). Similarly, eight

290 weeks of maximal high-velocity (180°·s-1) eccentric training resulted in greater hypertrophic

291 adaptations when compared to maximal low-velocity (30°·s-1) training (44). Conversely,

292 submaximal (70% 1RM) slow velocity (~3 s) eccentric muscle actions during the barbell

293 bench press have been found to stimulate higher blood lactate and recombinant human

294 growth hormone, by promoting a hypoxic environment (28). While EQIs may lead to

295 substantial levels of local fatigue due to a potential lack of blood flow and high metabolite

296 levels, it is unlikely that the low-velocity eccentric component would produce exercise-

297 induced muscle damage (29).

298

299 Series elastic component

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300 Tendon, the primary tissue of the SEC, can undergo morphological and functional

301 adaptations through inactivity, injury, sporting activities and resistance training (14, 86, 101,

302 127). Tendon and other connective tissues comprised of specifically aligned collagen fibres

303 have significant resistance to mechanical strain (101). Optimal performance requires the

304 efficient transfer of force from muscle to bone (101, 114) necessitating transmission via a

305 tendon that is sufficiently stiff to minimize electromechanical delay while avoiding rupture

306 (101). Properly executed dynamic, eccentric and isometric training can improve tendon

307 structure and function (11, 12, 81, 82, 85, 86, 90, 101, 127).

308

309 Joint angle

310 A single study has directly investigated the effect of joint angle on tendon

311 morphology by comparing volume-equated isometric knee flexion training at LML (100°) or

312 SML (50°) (87). While both SML (10%, ES = 0.82) and LML (11%, ES = 1.06) groups

313 improved quadriceps volume, only LML training resulted in significant tendon stiffness

314 improvements (50.9%, ES = 1.22) (87). While the sparse results of the preceding studies

315 expose a gap in existing literature, they tend to support holding prolonged isometric

316 contractions at LML with near maximal loads if tendon structural adaptations are paramount.

317

318 The titin myofilament, although thought to be a secondary structure to a tendon in the

319 SEC has several important functions and is likely partly responsible for the residual force

320 enhancement following an active stretch (46, 65, 124, 143-145, 147). Titin adds stability,

321 stiffness and passive and active force transmission at LMLs (64, 125) and is a likely factor in

322 injury prevention. Several studies have found titin to regulate muscle force and length in

323 mechanically lengthened fibres (95, 125). Baumert et al. (19) examined the relationship

324 between force production, delayed onset muscle soreness and genotyping related to titin

13
325 stiffness (19). Subjects with the allele linked to greater titin stiffness (TRIM63 A-allele) had

326 greater MVICs (35%, ES = 1.42, p = 0.006) and recovered more quickly (ES = 1.14 , p =

327 0.022) compared to the other subjects (TRIM63 G-allele) (19). Titin protein fragments have

328 been found in the urine of healthy young males following bouts of a dynamic calf-raise

329 exercise and were strongly correlated with traditional markers of exercise-induced muscle

330 damage (75). While the eccentric muscle action following a fatiguing isometric with EQIs is

331 unlikely to produce significant muscle damage due to low velocities (29), it is plausible that

332 titin may be activated. Although occurring at a range of joint angles (143), residual force

333 enhancement magnitude is greater at LMLs (147), suggesting that LML training may

334 preferentially utilize titin (65). Thus, it may be prudent to examine the effects of quasi-

335 isometric holds in the lengthened position on markers of breakdown and expression of titin.

336

337 Movement velocity and muscle action

338 The SEC appears to be affected differently by movement velocity. The impact of

339 movement velocity on titin is difficult to determine as many questions remain regarding the

340 myofilaments contributions to phenomena such as residual force enhancement (74, 145).

341 While studies have observed the breakdown of titin following resistance training movements,

342 which tend to be relatively slow when compared to activities such as sprinting or jumping

343 (75), there are conflicting data regarding the velocity of stretch and residual force

344 enhancement. Although the majority of residual force enhancement examinations utilize

345 eccentric angular velocities between 30°.s-1 and 60°.s-1 (46, 124, 144, 147), Lee and Herzog

346 (94) compared stretch angular velocities of 10°.s-1, 20°.s-1 and 60°.s-1. While eccentric force

347 during the stretch increased with velocity, there was no significant difference in proceeding

348 isometric force between the three protocols (94). Though the above research is intriguing as

14
349 the effect of velocity on titin is unknown due to several confounding variables, including

350 different neuromuscular strategies and contributions from the CE and PEC (43, 122).

351

352 The relationship between velocity, residual force enhancement and titin are not yet

353 determined; however, the effect of movement velocity on the tendon holds greater clarity.

354 Acutely, it appears that isometric contractions provide superior analgesic effects compared to

355 dynamic resistance exercise (128, 130, 161). Rio et al. (128), examined patellar tendon pain

356 during a decline squat exercise in six male volleyball players with tendonitis. The pain was

357 evaluated before and after performing either slow isotonic leg extensions for four sets at an

358 8RM load or five sets of 45s isometric knee extensions at 70% of MVIC (128). While both

359 the isometric (-97%, ES = 3.6) and dynamic (-40%, ES = 0.67) groups significantly reduced

360 pain acutely, pain reduction only remained significant at the 45 minutes mark following

361 isometric exercise (128). Loaded between 30% and 80% of 1RM (136, 169), and maintained

362 for similar periods as Rio et al.’s (128-130), the zero to low-velocity EQI contractions may

363 have potential to reduce tendon pain, despite recent controversy (57).

364

365 Long-term changes in tendon morphology seem minimal in healthy, mature human

366 tissue (79, 101). However, injured tendinous tissue can undergo dramatic adaptations (79,

367 136). Tendon adaptation is independent of contraction type, so long as a minimum

368 mechanical load threshold is reached (61, 62, 70), which likely explains why traditional

369 exercises with an eccentric emphasis have been found to be superior to dynamic contractions

370 in tendon rehabilitation (81, 90, 101). However, movement velocity is critical as healthy

371 tendon fibres will “spare” the damaged tissue by transmitting a greater portion of the load

372 when high velocities are utilized (13, 101). Conversely, damaged tendon tissue can undergo

373 sufficient loading during slow contractions (13, 101). For example, Kongsgaard et al. (81)

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374 compared 12 weeks of single-leg decline squats with an eccentric emphasis, bilateral heavy

375 and slow (three second eccentric and concentric phases) resistance training, and

376 corticosteroid injections. While both resistance training groups experienced significant

377 improvements in several measures of performance and architectural and physiological

378 markers, the heavy and slow resistance training group reported greater satisfaction of clinical

379 outcomes (70%) compared to the eccentric (42%) group (81). The researchers theorized that

380 the decreased tendon pain, tendon collagen content and voluntary force production was due to

381 the greater intensity-induced mechanical overload throughout the training period (81). These

382 data demonstrate that tendon adaptation can be achieved via relatively slow movement

383 velocities and that maximal or supramaximal eccentric exercise is not necessarily required.

384 As EQI contractions are slow and submaximal, they may be a viable tool for treating diseased

385 tendonous tissues.

386

387 Contraction intensity and duration

388 Contraction intensity, duration and type have different effects on tendon properties.

389 Kubo et al. (84) compared the effects of 12 weeks of isometric and plyometric training on

390 muscle and tendon stiffness. Active muscle stiffness at 30%, 50% and 70% of MVIC only

391 increased significantly following plyometric training (38.1-69.6%, ES = 1.35-2.57 vs. 12.4-

392 23.6%, ES = 0.46-0.75) whereas ballistic and ramp tendon stiffness increased exclusively

393 following isometric training (23.7-42.1%, ES = 0.92-1.21) (84). Likewise, Burgess and

394 colleagues (26) compared the effects of isometric and plyometric training on the plantar

395 flexors. While no statistically significant difference between groups were present (p < 0.05),

396 the isometric group experienced very large increases (61.6%, ES = 4.91) in tendon stiffness

397 when compared to the plyometric group (29.4%, ES = 1.44) (26). Interestingly, no significant

398 differences between the isometric and plyometric groups were apparent for concentric-only

16
399 jump height (64.3%, ES = 2.87 vs. 58.6%, ES = 2.85), or rate of force development (28.1%,

400 ES = 1.89 vs. 14.6%, ES = 1.38); however, no measures of stretch-shortening cycle function

401 were included (26). These findings demonstrate that while isometric contractions are

402 effective in improving tendon stiffness (thereby reducing electromechanical delay) and

403 improving tendon health (14, 128), improvements in stretch-shortening cycle performance

404 likely require specific training to increase ultrasonically assessed elasticity (86-88),

405 suggesting that isometric contractions are an effective addition to traditional resistance

406 training.

407

408 In regards to contraction intensity, Kongsgaard et al. (82) examined the effect of a 12-

409 week, work-equated dynamic isotonic leg extension training program using either “heavy”

410 (70% 1RM) or light loads. The “heavy” group experienced thickening of the distal (4%, p <

411 0.05) and proximal (6%, p < 0.05) patella tendon, whereas the light group only saw

412 significant proximal hypertrophy (7%, p < 0.05) (82). Additionally, tendon stiffness

413 significantly improved following “heavy” resistance training (14.6%, ES = 1.37), whereas the

414 light load group experienced a non-significant decrease (-9.18%, ES = 0.83) (82). Similarly,

415 Arampatizis et al. (11, 12) compared 14-week training programs consisting of volume

416 equated isometric plantar flexion at low (~55% MVIC) or high (~90% MVIC) intensities.

417 Only the high intensity training groups improved Achilles tendon cross-sectional area and

418 stiffness (17.1-36%, ES = 0.82-1.57, p < 0.05. vs. -5.2-7.9%, ES = 0.26-0.37, p > 0.05) (11,

419 12). Furthermore, tendon elasticity only increased following low intensity training (14-

420 16.1%, ES = 0.56-0.84, p > 0.05. vs. -1.4-3.9%, ES = 0.06-0.20, p > 0.05) intensity training

421 (11, 12). Though the aforementioned studies investigated different tendons, and utilized

422 different training intensities, both point to the superiority of high over low-intensity

423 contractions when an improvement in tendon stiffness is desired. While unlikely to directly

17
424 improve plyometric performance, high-intensity isometric training may be a valuable tool in

425 improving tendon thickness and stiffness which may decrease injury rates, and improve

426 performance when included as a supplement to traditional resistance training (26, 84, 86, 88).

427

428 Parallel elastic component

429 The effect of resistance training on the PEC and extracellular matrix is lacking, due

430 to the methodological challenge of separating connective tissue from intrafibrillar elements to

431 evaluate their relative contributions to force transmission (131). Subjective measures such as

432 pain and ROM are limited in utility, as they contain confounding variables and often manifest

433 gradually (131). However, we do know that the PEC is comprised primarily of collagen fibres

434 (126) and that adding collagen around the myofibrils leads to an increase in stiffness and

435 transmission of force to the passive structures of the extracellular matrix (52). Thus, it is

436 postulated that the increase in extracellular matrix stiffness is a contributing factor to more

437 energy efficient eccentric muscle actions (149).

438

439 Several studies have examined resistance training and collagen formation in healthy

440 humans (73, 79, 81, 82, 90, 101). In-situ investigations by Mass et al. (103) and Gomez et al.

441 (56) have reported that damaged tendons and ligaments healing under tension had higher

442 collagen contents compared to passively healing controls. It is understood that damaged

443 tendons experience more efficient healing when factors including transforming growth-factor

444 ß1, platelet-derived growth factor, and IGF-1 are elevated (96). Therefore, resistance training,

445 which places a tissue under tension, increases hormonal and molecular signalling factors,

446 providing optimal extracellular matrix maintenance in the elderly (149). Additionally,

447 resistance training can cause exercise-induced muscle damage and increase local

448 inflammation (32, 149). Muscle damage following unaccustomed loading has been observed

18
449 to acutely increase collagen synthesis and extracellular matrix remodelling (72, 156), while

450 chronic resistance training has resulted in increased intramuscular collagen (73).

451 Interestingly, eccentric and concentric contractions appear equally proficient for increasing

452 collagen synthesis when total work is equated (109). However, eccentric muscle actions

453 enable greater force production or greater work performed at the same load (39) and therefore

454 lead to greater adaptation when total sets and repetitions are equal (67).

455

456 In summary, EQI training appears to offer a time and energy efficient means of

457 triggering morphological adaptations in all primary components of force transmission.

458 Therefore, EQI training should be implemented when increasing muscle size and improving

459 tendon, and other connective tissue health is of utmost importance.

460

461 Eccentric quasi-isometric contractions and neurological qualities

462 Eccentric quasi-isometric training could be expected to improve muscle function at

463 low, but not high velocities. Although a few acute studies are examining and describing EQI

464 exercise on musculotendinous (24, 99, 150, 152) and neuromuscular adaptations (4, 166), the

465 lack of any long-term investigations makes any definitive conclusions problematic. However,

466 there is a significant amount of research examining fatiguing contractions (107, 135),

467 yielding isometrics (4, 50, 71, 132-134, 136), slow tempo resistance training (159, 170-172,

468 174) and joint angle (37, 115, 116, 135, 154) that allow conjecture and identify areas for

469 future research.

470

471 Contraction intent

472 Contraction intent is an important factor to consider when evaluating the effect of

473 resistance training (33). Although the intent of the trainee during EQIs is to maintain a

19
474 movement velocity of zero, once isometric failure occurs at low velocity, lengthening follows

475 despite maximal effort due to accumulated fatigue (112, 142). Though a variety of isometric

476 training and exercise methods have been described (50, 71, 136), the vast majority of

477 experiments have utilized maximal contractions against an immovable object. While maximal

478 isometrics serve as a valuable and highly reliable means of evaluating neuromuscular

479 function (40, 119), results from these studies are difficult to apply to EQI exercise. Recently,

480 researchers have demonstrated that “yielding” (resisting an external force) isometrics, with

481 the intent of preventing eccentric muscle action, create different fatigue and neuromuscular

482 characteristics compared to “pushing” (exerting force against an immovable object)

483 isometrics (50, 71, 132-134, 136). Hunter et al. (71) compared time to task failure and

484 neuromuscular function when maintaining a constant force (pushing) of 15% of MVIC, or by

485 supporting an equivalent inertial load while maintaining a constant joint angle (holding).

486 Pushing resulted in significantly greater time to failure (1402 ± 728 s) than holding (702 ±

487 582 s) (71). Similarly, Schaefer et al. (136) examined pushing and holding isometric actions

488 at 80% of MVIC and found that subjects could maintain the target force for twice as long

489 when pushing (41 ± 24 s vs. 19 ± 8 s). Hunter et al. (71), Schaefer et al. (136) and other

490 investigators (50, 132-134) have also demonstrated that agonist activation at failure is greater

491 when pushing, while co-activation of antagonist and synergist muscles are greater when

492 holding (50, 132-134, 136). While the increased co-activation during position tasks are a

493 likely cause of the decreased endurance time (50, 71, 133, 136), it is plausible that position

494 task training may lead to superior joint stabilization and thus carry value in rehabilitative

495 settings (132). Additionally, several activities and sporting actions involve bracing to avoid

496 dynamic muscle action (93, 167). Therefore, while pushing isometrics likely allow for greater

497 morphological adaptations, due to larger forces and time under tension, training with the

498 intent to maintain specific positions instead of exerting force against an immovable object

20
499 may provide improved carry over to specific tasks that involve maintaining specific joint

500 angles or postures due to the similarity of neural characteristics (93, 168).

501

502 Ballistic and ramp contractions are additional means of distinguishing movement

503 intent (120). When comparing the result of several isometric training studies directly

504 comparing contraction intents, Oranchuk et al. (120) determined that training with ballistic

505 intent resulted in constantly greater improvements in muscular activation (3/4 studies) (1.04-

506 10.5%·week-1, ES = 0.02-0.31 vs. 1.64-5.53%·week-1, ES·week-1 = 0.03-0.20) and rapid (0-

507 150 ms) force production (3/3 studies) (1.2-13.4%·week-1, ES·week-1 = 0.05-0.61 vs. 1.01-

508 8.13%·week-1, ES·week-1 = 0.06-0.22). Furthermore, Behm and Sale (21) compared the

509 effects of isometric contractions performed with ballistic intent, and high angular velocity

510 (240°.s-1) concentric contractions. Both concentric and isometric training lead to similar (all p

511 < 0.01) improvements in peak isometric force, rate of force development and relaxation and

512 peak torque at 14.9°.s-1, 29.8°.s-1, 59.6°.s-1, 88.8°.s-1, 173°.s-1 and 240°.s-1 (21). These results

513 highlight the importance of contraction intent, and not necessarily movement velocity, on

514 neurological qualities and performance alterations. Although comparing the above results

515 with EQI training is difficult, given that EQIs are non-ballistic, it is reasonable to suggest that

516 they would be unlikely to improve explosive neuromuscular performance. Thus, a

517 progressive resistance training program to improve explosive performance would avoid

518 incorporating EQIs in late training cycles; they may be best positioned early in a periodized

519 plan, likely as an adjunct to traditional resistance training.

520

521 Contraction intensity

522 While research on isometric contraction intensity is emerging, the only long-term

523 training investigations examining neurological adaptations utilize traditional, pushing

21
524 isometrics. Investigations directly comparing isometric training intensity have determined

525 that little difference in morphological or performance adaptations exist if the total volume is

526 equated (120). While little evidence exists regarding different isometric contraction

527 intensities on neurological adaptations, the wealth of data on dynamic contractions may

528 provide insight. High load dynamic training has been found to increase coordination (162)

529 and reduce neuromuscular inhibition (1), which is valuable when optimal performance is

530 desired (33). Additionally, a significant portion of the existing literature has determined that

531 high-intensity dynamic resistance training is superior for improving neuromuscular function

532 and sports performance when compared to lower intensity methods (33).

533

534 Joint angle

535 Motor-unit activation and muscle inhibition are strongly affected by the joint angle

536 (114, 135, 154). The strain sensing organelles of the Golgi tendon organ and muscle spindles

537 undergo different levels of stimulation at varying muscle-tendon lengths (114, 135). For

538 example, Suter and Herzog (154) examined muscle inhibition and joint angle by comparing

539 voluntary force and force produced by superimposed femoral nerve stimulation at 15°, 30°,

540 45°, 60° and 90° of knee flexion. While muscle inhibition was present at all assessed joint

541 angles, the largest superimposed twitches were present at LMLs (154). Greater muscular

542 stretch, patellofemoral pressure and ligament strain at knee angles between 45° and 60° of

543 flexion are theorized to underpin the greater degree of muscle inhibition (154); however,

544 these observations are not necessarily applicable for all joints or movements to differing

545 tendon structural properties, fascicle lengths and co-contraction dynamics (8, 22, 60, 78, 92,

546 173). Although muscle inhibition is necessary for extreme situations, improving muscular

547 activity is important when returning to activity or when optimizing performance (33, 114).

548

22
549 Advantages of LML isometric training for improving muscle size and force

550 production throughout a full ROM exist (5, 17, 87, 115, 116, 120, 160). Interestingly, studies

551 investigating the effect of restricted ROM resistance training have determined that limiting

552 dynamic contractions to LML does not result in meaningful changes in the length-tension

553 relationship (164, 165). While EQI contractions utilize a full ROM, they are inherently low

554 velocity. Therefore, EQI training should be implemented early in a yearly training plan to

555 improve morphology and improve position-specific functions.

556

557 Applications to performance and rehabilitation

558 Performance

559 Performance in sport is dependent on a variety of physical qualities. As such, training

560 methodologies have differing utility and value depending on the type of sport, proximity to

561 competition, individual training age and a multitude of additional factors. With few

562 exceptions (93, 168, 169), quasi-isometric and EQI contractions have not been widely

563 utilized in training plans. However, although no direct investigations on EQI contraction or

564 training exist, relevant research, (e.g. isometric, eccentric, time under tension, blood flow

565 restriction) suggest that EQIs may have a place in intelligently designed programs. The

566 theoretical potential of EQIs in relation to dynamic (eccentric and concentric), eccentric only

567 and isometric resistance training are summarized in Table 1 (based on (153)).

568

569 (Table 1. about here)

570

571 Muscular endurance

572 A systematic increase in the exposure to the total volume that a muscle or muscle-

573 group undergoes is a common means of improving muscular endurance (83, 169). Training

23
574 with EQIs may have the potential to provide a unique stimulus for promoting muscular

575 endurance, as a primary aim is to increase the amount of time that the prescribed position is

576 maintained. Additionally, while a high volume of submaximal dynamic contractions is

577 commonly employed to improve muscular endurance, the constant muscular tension present

578 in isometric and quasi-isometric contractions can alter blood flow and muscle oxygenation (4,

579 150). Although far from conclusive, this mild, and temporary alteration in oxygenation may

580 lead to alterations in aerobic and anaerobic enzymes and significant, yet temporary increases

581 in several anabolic signalling factors (111, 158). Furthermore, muscular endurance training

582 may lead to adaptations to the t-tubule structure and increase Ca2+ re-uptake (35), therefore

583 offering a protective effect from delayed onset muscle soreness and short-term performance

584 decrements that may occur from future high-load training (30, 31).

585

586 Eccentric quasi-isometric training may also offer a novel sport-specific training

587 stimulus to athletes that undergo regular, sustained quasi-isometric contractions. While actual

588 sports participation offers the greatest level of sport-specific adaptation, utilizing quasi-

589 isometric or EQI contractions in a controlled environment such, as a weight-room, offers the

590 ability to apply focused overload. For example, a speed skater wishing to increase lower-

591 body muscular endurance in a skating specific ROM, via morphological adaptations, may

592 wish to experiment with quasi-isometric or EQI training by utilizing a leg-press (Figure 3).

593

594 (Figure 3. about here)

595

596 Hypertrophy

597 Muscle mass is highly related to strength (53) and is, therefore, an important factor in

598 sports performance. While heavy loading, including supra-maximal eccentric training, offers

24
599 a strong stimulus, total work and training volume are the most important determinants of

600 hypertrophic adaptation (91, 110, 137, 139). While moderate resistance training allows for a

601 time-efficient means of accumulating volume, EQIs may be superior in specific

602 circumstances. Depending on the intensity, initial joint angle and other factors, EQI

603 contractions can expose a muscle group to substantial total load in a relatively short period.

604 Eccentric quasi-isometric contractions also offer a likely advantage over dynamic training

605 when it comes to accumulating volume as shortening contractions are less energetically and

606 mechanically efficient (110). While a non-linear, inverse relationship exists between intensity

607 and time under tension (83, 169), exclusion of the less efficient concentric phase allows for

608 higher intensities for throughout a set duration, or more work at the same intensities (38,

609 110). Therefore, a single EQI contraction would likely impart greater time under tension than

610 a similarly loaded set of dynamic contractions when both are taken to failure. Likewise,

611 similar set durations could be met with a greater external load applied to an EQI contraction

612 compared to a dynamic alternative. Additionally, EQIs are likely to reduce muscle

613 oxygenation and metabolite clearance (4, 150) which may lead to preferential recruitment of

614 type-II muscle fibres with increased capacity to increase cross-sectional area and force

615 production, and signal anabolic hormones known to contribute to the hypertrophic response

616 (98, 140, 158).

617

618 Strength and power

619 A variety of morphological and neurological factors including muscle size, muscle

620 fiber type and motor-unit recruitment characteristics determine strength and power (7, 33, 34,

621 38, 43, 48, 93, 114, 153, 163, 172, 175). While EQI contractions may be a viable tool for

622 improving total hypertrophy, an abundance of evidence supports the use of high-velocity

623 contractions and maximal to supra-maximal loads for preferentially targeting type-II muscle

25
624 fibers (48, 121). From a neurological perspective, the ability to express maximal force and

625 power is contingent on several factors. While isometric and eccentric resistance training can

626 lead to the neurological and neuromuscular adaptations of rate-coding, agonist, antagonist

627 and synergist activation and co-activation, the adaptations above are highly specific (1). As

628 EQI contractions are inherently submaximal and intentionally low-velocity, it is likely that

629 direct carry over to high threshold activities would be minimal. However, the slow, relatively

630 high accumulated loading synonymous with EQI contractions, may potentially lead to

631 improved rates of collagen synthesis and stiffness of the SEC and PEC (81, 90, 101). There is

632 reason to believe that these morphological adaptations may improve force transmission by

633 decreasing the electromechanical delay, therefore improving the rate of force development

634 and stretch-shortening cycle function (52, 101). Quasi-isometric and EQI contractions are

635 postulated to build position-specific strength and potentially reduce injury risk (167, 168).

636 Verkhoshansky and Siff (169), described weightlifters utilizing EQI training to strengthen

637 key positions in their weightlifting pulls. For example, a weightlifter who struggles to

638 maintain an ideal position throughout the “first pull” (151) may wish to experiment with EQI

639 contractions (Figure 4).

640

641 (Figure 4. about here)

642

643 Rehabilitation

644 Injuries to any of the three components of force transmission require mechanical

645 overload at some point in the rehabilitation process (101). Isometric and quasi-isometric

646 exercises are already commonplace in the initial phases of muscular and tendon rehabilitation

647 protocols as they enable tight control over ROM and intensity (54, 83, 128-130, 161).

648 Sustained submaximal isometric contractions avoid large peak forces and acutely reduce

26
649 tendon pain, potentially allowing for periods of pain-free dynamic exercise (129, 130, 161).

650 Furthermore, while progressive mechanical tension is crucial (79, 81), slow movement

651 velocities should be prescribed to stimulate damaged fibers (13). Therefore, the combined

652 static and lengthening phases of EQI contractions may provide an analgesic effect while

653 stimulating connective tissue reformation. In the case of serious injuries, such as bone

654 fractures or severe connective tissue strains, patients may undergo a period of full or partial

655 immobilization. These periods of immobilization often result in significant muscle atrophy

656 and fascicle shortening (155). Eccentric quasi-isometric exercise may offer a submaximal

657 means of improving tendon morphology, work capacity, muscle thickness, and

658 neuromuscular function while returning fascicles to a normal length (101). Eccentric quasi-

659 isometric contractions can be performed with a wide range of loads and can be easily

660 implemented through a specific ROM. For example, a patient may experiment with EQI

661 contractions by performing an EQI elbow flexion, with the torso inclined, until the elbow

662 reaches the end ROM (Figure 4). At this point, a second EQI with a focus on the shoulder

663 flexors can be initiated to impart further mechanical loading, metabolic stress to the target

664 tissues (Figure 5). While currently highly speculative, a hypothetical training plan including

665 EQIs for an athlete recovering from patellar tendonitis is provided in table 2.

666

667 (Figure 5. about here)

668 (Table 2. about here)

669

670 Limitations

671 Due to the lack of any long-term investigations regarding EQI or quasi-isometric

672 resistance training, limitations are abundant in this review. Like many methods of resistance

673 training, EQIs can be applied with an endless combination of variables including intensity,

27
674 contraction duration, repetitions, sets, rest periods, frequencies and exercise selection. Any

675 adjustment to the aforementioned parameters will alter the resemblance of EQI to traditional

676 methods. Similarly, much is left to be determined regarding established training methods

677 such as isometrics. For example, while the characteristics of “pushing” and “holding”

678 isometric contractions differ (50, 71, 132-134, 136), there is a paucity of research examining

679 long-term consequences to such altered loading parameters. Researchers and practitioners

680 need to progress the knowledge and understanding of the acute and short-term

681 neuromuscular, biomechanical and metabolic effects of quasi-isometric and EQI contractions

682 (50, 71, 132-134, 136). Furthermore, long-term investigations are needed to compare the

683 potential structural and functional adaptations to established training methods.

684

685 Practical applications

686 It is common for “novel” training methods to precede evidence-based practice. While

687 there are limited data on long-term adaptations, short-term investigations, anecdotal evidence

688 and relevant scientific knowledge make a strong case for the investigation of EQI loading and

689 training. Based on the existing literature, the value of EQIs appears to relate most strongly to

690 triggering morphological rather that neuromuscular adaptations and are likely best applied

691 early in a periodized training plan, distal to high threshold neuromuscular work. Quasi-

692 isometric and EQI training may also hold value in pre and rehabilitation contexts to modify

693 muscle-tendon structures, provide analgesic effects, and closely match functional movements

694 from a neurological perspective. Finally, EQIs appear to have the potential to provide an

695 efficient means of increasing total load and volumes in specific positions.

696

697 Examination of EQI muscle actions and training are required due to the complete lack

698 of direct empirical evidence investigating this area. As such, several foci for potential

28
699 research exist. From an acute standpoint, EQI contractions may involve unique

700 neuromuscular activation and muscular contraction dynamics that would be worthy of

701 investigation. Researchers may also wish to compare the short-term effects of EQI exercise

702 with volume equated modalities such as dynamic or isokinetic contractions on neuromuscular

703 fatigue, delayed onset muscle soreness or the repeated bout effect. Furthermore, long-term

704 training studies are required to determine optimal loading parameters and exercise selection,

705 as well as whether adaptation is population specific.

706

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1196

1197

1198

1199

1200

1201

1202

1203

1204

1205

1206

1207

1208

1209

39
1210 Figure 1. The three-component model of force transmission

1211

1212 Figure 2. The three-component model of force transmission in muscle contracting at short

1213 and long muscle lengths

1214

1215 Figure 3. Initial quasi-isometric hold and final position following a maximal eccentric

1216 contraction in the single-leg leg-press

1217

1218 Figure 4. Initial quasi-isometric hold and final position following a maximal eccentric

1219 contraction in the snatch pull

1220

1221 Figure 5. Eccentric quasi-isometric incline biceps curl

1222

1223

1224

1225

1226

1227

1228

40
1229 Table 1. The theoretical potential of dynamic, eccentric, isometric and eccentric quasi-isometric resistance training to benefit musculotendinous morphology and performance

Training outcome Training method Contractile element Series elastic component Parallel elastic component

Dynamic ++++ + +

Eccentric +++++ ++ ++
Morphology
Isometric ++ ++ +

EQI ++++ ++ ++
Dynamic ++++ + +

Eccentric ++ +++ ++
Endurance
Isometric +++ ++ +

EQI +++++ ++ ++
Dynamic +++ + +

Eccentric +++++ +++ ++

Strength
Isometric ++++ ++ +

EQI +++ ++ ++
Dynamic +++++ + +

Eccentric ++++ ++ ++
Power
Isometric ++ ++ +

EQI + + ++
1230 Ranked on a scale from + (low potential) to +++++ (high potential). Adapted from Suchomel et al., 2018. EQI = eccentric quasi-isometric.

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1232 Table 2. Hypothetical resistance training program for an athlete recovering from patellar tendonitis
Phase 1: Pain and load management
Day 1 Day 2
Exercise Sets x Reps Intensity Tempo ROM Exercise Sets x Reps Intensity Tempo ROM
Isometric Wall-squat 4 x 30-60s BW N/A 30-60º Isometric knee extension 4 x 30-60s 70% MVIC N/A 30-60º
Mini-band hip-thrust 3 x 15-20 BW 2-1-2-1 Full 1-leg DB Romanian deadlift 3 x 10-12 Moderate 3-0-1-0 Full
Clam shells 3 x 10-15 Band 2-1-2-1 Full Mini-band side shuffle 3 x 10-15 Band 1-0-1-0 0-30º
EQI knee extension 2 x 60-90s 50-60% 1RM N/A Pain free EQI knee extension 2 x 60-90s 50-60% 1RM N/A Pain free

Phase 2: Morphological restoration

Day 1 Day 2
Exercise Sets x Reps Intensity Tempo ROM Exercise Sets x Reps Intensity Tempo ROM
1-leg hip-thrust 3 x 10-20 BW 2-0-2-1 Full 1-leg back extension 3 x 10-20 BW 2-0-1-1 Full
Hamstring curls 3 x 8-12 Heavy 3-0-2-0 Full ECC emphasis 1-leg decline squat 3 x 10-15 BW 4-0-1-0 0-75º
Knee extensions 3 x 8-12 70-80% 1RM 2-0-2-1 Full 1-leg press 3 x 15-20 60-70% 1RM 2-0-1-1 Full
EQI knee extension 3 x 30-60s 70-80% 1RM N/A 15-90º EQI 1-leg press 2 x 30-60s 70-80% 1RM N/A 45-90º

Phase 3: Strength and functional improvement

Day 1 Day 2
Exercise Sets x Reps Intensity Tempo ROM Exercise Sets x Reps Intensity Tempo ROM
Mini-band march 2 x 20 Band 1-0-1-0 Full BB hip-thrust 3 x 8-10 Heavy 2-1-2-1 Full
BB back squat 4 x 6-8 Heavy 3-1-3-1 Full BB front squat 4 x 5-6 Heavy 3-1-3-1 Full
Glute-ham raise 4 x 6-8 BW 3-0-1-0 Full BB Romanian deadlift 4 x 8-10 Heavy 2-0-1-1 Full
EQI skater squat 3 x 15-30s Moderate N/A 75º-floor EQI DB Bulgarian split squat 3 x 15-30s Moderate N/A 45º-floor

Each phase = 2-3 weeks. Tempo = eccentric-pause-concentric-pause. Reps = repetitions. ROM = range of motion. BW = body-weight. N/A = not applicable. MVIC = maximal voluntary
isometric contraction. EQI = eccentric quasi-isometric. s = seconds. 1RM = one repetition maximum. DB = dumbbell. ECC = eccentric. BB = barbell.
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