What is Tendinopathy ?November 30, 2017
What is tendinopathy?
Painful tendons plague a large proportion of the population at some time or another and are responsible for a lot of sports related injuries. In the clinic, we commonly treat people with tendon pain including in the shoulders, hips, knees and the Achilles tendon at the back of the ankle. Tendons are flexible but inelastic cords of strong fibrous collagen tissue, which attach muscle onto bone. Tendons, like bones, muscles and ligaments, are in a constant state of building new tissue and breaking down old tissue. This process of building tissue (synthesis) and breaking down tissue is effected by the amount of load placed on a structure. If we put too much load on a tendon and we continue to do it frequently, the process of tissue breakdown can exceed tissue synthesis. With this, the structure of a tendon starts to change, often becoming swollen and painful, making it less efficient in dealing with load, which in turn tends to lead to even more tissue breakdown, creating a cycle that can be hard to stop, without intervention. This process of changes involving the tendon, is called tendinopathy.
Tendinopathy is usually divided into stages which start with a reactive stage. This is usually in response to a rapid increase in load and the tendon is often painful and swollen. At the other end of the spectrum are degenerative tendons, which involve more structural changes in the tendon that may include thickened nodules. Degenerative tendinopathies may present as a grumbly tendon but quite often are not painful and the first sign of it is when the tendon reacts (known as a reactive on degenerative tendinopathy) or a sudden unexpected tear or rupture. Tendinopathy may involve a small component of inflammation, but it is not considered to be a classic inflammatory response.
The treatment varies considerably between these stages. The more persistent degenerative tendon stage generally needs to be loaded with an appropriate loading program straight away. However, early stage reactive tendons may be made worse with the same type of exercises It is therefore very important to identify the correct stage of the tendinopathy to guide rehabilitation.
Managing tendinopathy in the reactive/ early dysrepair phase
If you have tendon pain that has come on recently, especially after a change in training or work load, then it is likely that you have a reactive tendinopathy. Arguably the most important treatment in this stage is load management. This means reducing both tensile (stretch) and compressive load on the tendon. When running for example, as we land and absorb impact our Achilles tendon is stretched, but the end of the tendon is also compressed against the heel bone. To reduce tensile load runners can reduce the distance and or frequency of runs or possibly taking a rest from running for a while. The amount load is reduced is highly variable and must be determined on a case-by-case basis depending on an individual’s tolerance to load. It is important to note that tendinopathy does NOT improve with rest alone. The tendon may need to be offloaded to allow it to settle but then needs to be loaded to increase its tolerance to load in the future.
Other treatments to settle symptoms for reactive tendinopathies include taking anti-inflammatory medication, isometric exercises, using orthosis and icing. Ibuprofen has been shown to down regulate the tenocytes that are upregulated during reactive tendinopathies and have been shown to be effective in alleviating symptoms. Isometric exercises involve a sustained contraction under tension, such as holding a calf raise in the mid-range. They have been shown to have an analgesic effect, helping to relieve pain associated with tendinopathies as well as starting to put load through the tendon. Icing can also be used to reduce pain and is generally applied for 15-20-minute increments. Depending on the tendon effected, it can be beneficial to use an orthosis such as a foot orthotic with heel raise to reduce compressive forces on the Achilles tendon. Do not stretch your tendons (or attaching muscles) as this is likely to add to the tensile and compressive load that is placed on the tendon. Instead massage may be a better way to reduce muscle tightness.
Once your symptoms settle, it is necessary to return to your activities in a gradual way to allow your tendon and body to gradually adapt to the increase in load. Exercise rehabilitation should target any weakness in the tendon and the rest of the body or movement patterns that could have contributed to the occurrence of the tendinopathy. This is where your physiotherapist will be working with you to ensure that your return is graduated and that you are addressing the causes of the tendinopathy in the first place such as any biomechanical and or load issues.
Managing more degenerative, persistent tendinopathies
For those tendons that have been grumbly for a while (usually more than 12 weeks) then it is likely you have a degenerative tendinopathy, especially if you are an older athlete. Tendons can become thickened with nodules that you may be able to feel. Degenerative tendons can still have short term flare ups which are still classified as reactive tendinopathies and the management above should be followed to settle it prior to continuing onto incorporating the steps for degenerative tendinopathy.
Technically once the tendon enters the degenerative stage then the structural changes in the tendon are not completely reversible. Despite this, with proper management symptoms will usually settle but it is generally advisable to keep up a strength and maintenance program to ensure symptoms do not return.
Managing load is still critical during this stage and you may need to reduce your current activities to allow the tendon symptoms to settle and prevent severe degenerative tendinopathies or even tendon rupture.
The most important intervention for degenerative tendinopathies is to commence a graduated loading program to improve the tolerance to load of your tendon and the rest of your body. This should be done in conjunction with your physiotherapist who will help you to identify an appropriate starting point that can challenge your tendon without aggravating it. Generally, exercises in this stage will be somewhat uncomfortable and mild to moderate pain is tolerated. It is necessary to quickly progress to isotonic exercises, meaning exercises through range involving concentric (muscle shortening under load) and eccentric (muscle lengthening under load). Your physiotherapist will also work with you to address whole body strength and conditioning as well as your overall health and wellness.
Exercise and load are the key interventions that lead to long term improvements whereas massage, trigger point release, therapeutic ultrasound, injection, shock-wave therapy and similar interventions are adjuncts that may be used improve symptoms and allow people to commence appropriate exercise rehabilitation. Multiple injections should be avoided as this is often associated with a poorer outcome. Exercises need to be individualised based on a person’s pain and function and need to be progressive and goal oriented. It is also important to appreciate that tendinopathy responds very slowly to exercise. Patience is critical, and exercises should only be progressed in a graduated manner and short cuts such as injections and surgeries should be resisted if possible.
If you suspect you are suffering from a tendinopathy make sure that you are properly assessed and diagnosed by a physiotherapist. For any more details or to book an appointment, please contact Caloundra Sportscare.
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Malliaras P, Barton CJ, Reeves ND, Langberg H: Achilles and Patellar Tendinopathy Loading Programmes. Sports Medicine. 2013:1-20.