Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse.
Evidence from the past few years indicates that this type of pain is not related to inflammation and as such traditional treatments aimed at controlling inflammation such as corticosteroid injections and nonsteroidal anti-inflammatory medications (NSAIDS) may not be the most effective option.
We look at the best things you can start doing now to get your troublesome tendon fit and healthy again.
What is a tendon and what does it do ?
Tendons are more than just the attachment of the muscle to the bone, although this is an important function allowing movement at a joint.
They are highly specialised tissue made of a protein known as collagen that have the ability to store energy and act like a spring to release that energy. The best example of this is watching kangaroos hop !
Why causes tendinopathy ?
This is a difficult question to answer as it differs between individuals depending on their lifestyle factors, activity levels , underlying health conditions as well as the strength and flexibility of the tendon and its surrounding structures.
Reactive tendinopathy is the fancy term for when a tendon becomes painful.
It is usually a reversible process and is a result of a sudden change in demands placed on the tendon.
It typically involves the tendon responding to a rapid increase in loading. For runners this often means a large increase in mileage, a reduction of rest days or a change in training type (e.g. Introducing hill or speed work).
For others it may be the result of increasing walking distance suddenly such as going on holiday and sightseeing. Or starting a new sport or exercise after a period of doing nothing. Returning to pre season training for netball and suddenly jumping and landing again.
It can also be from direct trauma to a tendon.
Tendon dysrepair
is another term you may here regarding tendon pain. It is usually the stage that would follow reactive tendinopathy if the tendon continues to be excessively loaded.
It is similar to the reactive stage but the tendon structure becomes more disorganised and is not as mechanically sound. The good news is that in early stages it is reversible to go back to normal tendon and usually it can become pain free with appropriate measures even if it cant revert back to a normal state.
Degenerative tendinopathy
This stage is more common in the older athlete and represents a response of the tendon to chronic overloading as well as a natural aging process. However despite structural changes to the degenerative tendon it too has the ability to get stronger and less reactive creating less impact and hopefully being pain free.
Tendinopathy Risk factors include:
Sudden increases in activity or adding a new activity:
- Walking 10,000 steps a day from 2000 steps.
- sudden spikes in loading in athletes training program are related to an increase in injury rate.
- Individuals returning to pre season after doing very little conditioning.
- Taking up a sport after a long year break…. Masters athletes.
Underlying health conditions:
- Diabetes the increased blood sugar level affects the tendon by making the collagen too stiff.
- Link with cholesterol levels as a risk factor.
- Hormonal. Oestrogen increases the risk of injury in tendon by affecting collagen quality.
- Rheumatoid conditions.
Tendons are more vulnerable due to anatomical location causing more compression:
So what’s the best treatment for tendonitis or tendinopathy ?
Not all tendinopathies or tendons are created equal so it will differ between individuals, however the following rules are a brilliant framework to get started on:
Rule 1: Do not ignore your pain if you have tendonitis or tendinopathy.
Pain is telling you that you need to change. It’s an indication that the tendon is not fit enough to cope with your current activity .
Rule 2. Is it a tendinopathy or tendonitis ?
Tendonitis was the old term used for a painful tendon. Since research has shown that inflammation is not a big player in this issue it was renamed tendinopathy. The joy of semantics. The main issue is you need a good diagnosis to form a great plan of action, get the best starting point and a progressive plan of action. Otherwise it can be a bit hit and hope.
Rule 3. Don’t let your tendon forget what its job is. Rest for tendonitis / tendinopathy is NOT usually the cure.
Rest or de-loading can be used in an acute or reactive stage, but that doesn’t mean the tendon is “better”.
Tendons are structures that are designed to absorb load and release load therefore they need to have the strength to do this. If we rest the tendon and the muscle attached to it they will get weaker and less resilient resulting more of the same problem.
Rule 4.Often we need to unload the tendon first so you can reload it.
Most tendon issues are due to a lack of tissue fitness. We need to get them stronger to tolerate and absorb force.
In the early stages its a case of taking 1 step back to move 3 steps forwards.
This can be as simple as
- identifying and stopping aggravating postures or activities.
- reducing training volume.
- adapting exercises to suit your symptoms.
- using more appropriate footwear
- taping, ice or NSAIDs
Once the pain has settled then we can really get down to the business of getting a healthy tendon back.
Rule 5.Don’t rely solely on passive therapies for tendonitis or tendinopathy, you must play an active role.
On their own the likes of TENs machines, ultrasound etc are effectively useless. At best they will offer temporary relief of symptoms but won’t improve the strength of the tissue.
Shockwave can be helpful as an adjunct to help reduce pain and “kick start the repair process, but is most effective in conjunction with a strength based exercise protocol.
Rule 6. Ain’t nothing wrong with getting the tendon strong.
The evidence suggests that the best way to strengthen a tendon is to work at 70% 1RM.
It is best to do one or two days on followed by a day of rest when loading the tendon to allow it to recover, adapt and get stronger.
A mix of static, heavy load and eccentric exercises work best, and they need to be made progressively harder and more specific every 4 weeks.
A good example of this is the protocol we use for treating Achilles tendons and plantar fascia.
Rule 7.Do Not worry about tearing or rupturing the tendon.
Pain is poorly correlate with tendon ruptures so it is unlikely you are at risk of rupturing it . In fact most individuals who rupture a tendon do not report having any pain.
Rule 8. With tendinopathy treatment you need to be patient and be persistent.
As a rule of thumb it takes about 3 months to increase the strength of a healthy tendon. Your symptoms will improve well before this in most cases, but you have to work over a long period of time to get it back to its optimal state.
Rule 9: How to feed a tendon for better health.
Did you know that you can nourish the tendon by using a collagen based supplement and vitamin C ?
This strategy has been shown to help increase the strength and function of the tendon. Helping to build a stronger , more resilient structure. If you want to know how to implement this in your rehab and training you can find out more here.
If you have any tendon related problems you can book in here to see one of very experienced clinicians
Dave
