Tendinopathies – Treating and Healing Tendon Pain
Tendinopathies can happen at any time during one’s lifetime and are responsible for up to 50% of musculoskeletal conditions.
WHAT IS A TENDON?
- Tendons are the tissues that connects muscle to bone. They are the end section of the muscle.
- The main job of a tendon is to transfer the load generated by the muscle.
- Tendons also act as a shock absorber and energy storage sites.
- Tendons move over bones and limit friction with other tissues.
- Tendons move smoothly through range and prevent joint displacement and injury.
- Tendons can remodel when placed under load.
- Tendons are active tissues and acute volumes of exercise can change the structure of the tendon. Period of inactivity will reduce the amount of collagen in the tendon which in fact reduces the strength of the tendon.
Tendon healing occurs in three phases, inflammation, repair and remodelling. The inflammatory process happens for 3-7 days after injury. At approximately day the collagen production starts. In the following months, this new tissue then matures and the collagen fibres settle in the tendon. The new fibres are stronger and more stable in the final stage of repair.
WHAT IS TENDINOPATHY?
Tendinopathy describes pain and incorrect function of the tendon. Tendinopathy is believed to exist in 3 phases: reactive tendon, tendon dysrepair and degenerative tendon. A reactive tendon usually occur acutely, often in younger athletes when there is an increase in load on the tendon. Tendon disrepair occurs in chronically overloaded tendons where the tendons have begun to change their structure. This change in the tendon structure can be reversed back to its optimal state however. A degenerative tendon is more commonly seen in older people, especially with people who have had multiple injuries to this area over the years. There will usually be parts of the tendon that are healthy and parts that have degenerated.
In the early stages of a tendinopathy, load management and reducing any aggravating activities will help reduce pain and allow for increased load on the tendon. This allows for increased load to slowly be placed on the tendon which strengthens the tendon and allows for higher volumes of load such as running on an achilles tendon injury.
TENDON RISK FACTORS:
Repetitive loads, overuse, underuse and steroid injections are typical risk factor. Other risks include autoimmune conditions, rheumatic conditions, endocrine and metabolic disorders. In the younger population, tendon injuries such as Osgood-Schlatter’s in the knee and Sever’s Disease in the heel are common. In older people, overuse injuries are more prevalent. Males are generally more at risk of tendon injuries except for gluteal tendinopathies where woman are more prone due to the biomechanical structure of a woman’s hips and pelvis. Increased BMI also increases the risk of a tendon injury. Large training loads, especially significant increases in loads increases the risk of injury as well as adding new elements to training such as hill running. Old footwear or a change such as runners to football boots increases the risk as well.
COMMON LOWER LIMB TENDON INJURIES:
Achilles tendinopathy usually has pain and swelling around the Achilles tendon. There are two types of Achilles injuries: one is at the bottom of the heel where the tendon attaches and the other is in the middle of the tendon. Half of all long distance runners will experience Achilles problems at some point in their life. In the early stages of the injury, pain occurs at the beginning and end of a running sessions and is better in the middle portion of the run once the tendon “warms up”. As the injury progresses the pain will no longer ease off during a run.
Patella tendinopathy involves pain at the front of the knee and is very common in jumping or explosive running sports such as basketball, hockey and high jump. It is also very common in runners. Patella tendinopathy occurs when there is increased load on the knee and the knee extensors. The pain is at the front of the knee just below the patella (kneecap). The pain gets better once warmed up but often is aggravated the following day. The pain can be sharp especially with jumping and can also be aggravated by stairs, squats or sitting. Often muscle weakness is found in the affected leg in the ankle, foot, hip and knee.
Gluteal tendinopathy involves pain at the lateral hip and sometimes into the thigh. Females are more commonly affected. Pain usually comes on slowly without incident and progressively worsens and can be associated with an increase in activity. Sometimes the pain can worsen at night
PROXIMAL HAMSTRING TENDINOPATHY
Proximal hamstring tendinopathy causes pain at the ischial tuberosity which is just below the gluteal muscles. It typically occurs in long distance runners or change of direction athletes such as soccer or hockey players but can also occur in people who increase their load or add new running features such a sprinting to their program. Pain occurs with squats, lunges, sitting and hip flexion movements of bringing the knee to the chest.
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS):
NSAIDS reduce inflammation and can provide some relief from pain although they are unlikely to provide long term improvement. They can be useful in reducing symptoms which allows a rehab plan to be more effective. However, the use of NSAIDS in the first 3 days after an acute tendon injury is contra-indicated as this is can cause a reduction in the inflammatory processes and cellular metabolism and will delay the healing process.
Corticosteroid injections can help reduce inflammation, however in some tendinopathies there is very little inflammation and therefore this may not be warranted. Intratendinous injections can also weaken the tendon and increase the likelihood of a rupture.
Usually reducing the aggravating activity such as running or jumping is the starting point for tendon rehabilitation. However, re-introduction of the load should be performed fairly quickly to reacclimatise the tendon to the activity.
Shockwave therapy is a common, non-invasive technique aimed at reducing pain and is used in conjunction with other treatments. It has minimal long term effect when used in a one off session but when performed 3+ times it can aid the recovery from injury.
PLATELET RICH PLASMA (PRP):
Platelets help in the healing process and thus PRP is a possible option for treating tendinopathies as it helps promote the healing process of the tendon. PRP involves removing your blood, spinning the blood in a machine which increases the number of platelets in the cells and then re-injecting it back to you.
Tendons have the capacity to remodel themselves with appropriate load and strengthening and thus exercise programs are crucial in tendinopathy rehab. Complete rest during tendon injuries often lead to a further decrease in load tolerance and lead to a longer recovery time and an increased risk of re-injury.
TYPES OF EXERCISES
Isometric exercises have been used to improve tendon pain in many injuries and are often a key component of a rehab plan.
Eccentric loading of the tendon occurs by slowly lengthening the muscle but is used selectively for some tendon injuries.
HEAVY SLOW RESISTANCE TRAINING
This type of rehab involves low repetitions and heavy weights in the exercises. It is also an effective means of improving tendon injuries and can help remodel tendon pathologies.
Often isometric exercises are most effective in the early treatment process to help settle the pain, while eccentric and heavy slow resistance training are important in the long term recovery of the tendon to correct strength deficits. At the point of return to sport, there should be minimal pain both during the activity and in the 24 hours post playing. An increase in pain indicates the return to sport was too soon and further rehab is required before returning to sport. Compression of a tendon against bone can cause problem and as such stretching a tendon should be performed very carefully in conjunction with your physio.
Using ice results in a reduction in muscle spasm, tissue temperature, pain and swelling in acute injuries. It also reduces cellular metabolism, inflammation, tissue extensibility and joint proprioception from the skin level to 2cm below. The evidence is unclear as to whether ice or heat can help the healing process of long term tendon injuries however.