By Ryan Dorahy Sydney CBD Physiotherapist
We now know that a grade progressive exercise approach is beneficial when starting to undertake new exercise regimens for tendon health. Increasing your training load too rapidly can cause tendons to overload and become pathologic. Tendinopathies (tendon overload) can lead to overall failure and rupture of the tendon itself if not managed properly. Today we will provide you with some ways to identify your tendinopathy, give you some ideas of strategies to help reduce the pain in your tendon and give you an idea on when to seek help for issues regarding tendons. Read on!
Tendons connect muscle to the bone throughout your body. The main role of the tendon is to transmit forces from the muscle to the bone and generate movement. The makeup of a tendon itself is a collagen matrix. These collagen fibres at rest are organised in a crimped patter, with many individual myofibres making up each crimp.
When the tendon is put under strain, normal tendon function will allow the tendon fibres to form very strong parallel and linear patterns to help with energy storage and release for movement. Once the strain is removed, the tendon bundles revert back to their original form. To give you an idea of the strength of some tendons, an avulsion fracture is when the tendon has pulled off a piece of bone from the insertion of your tendon creating a fracture!
How does your Tendon become damaged?
Creating an irritated or damaged tendon begins with a stimulus of overload, whereby the tendon complex fails to deal with the increase of load. This creates changes to your tendon where the tendon will stiffen and thicken over a short period of time. We call this a reactive tendinopathy. At this stage, the tendon still has the ability to revert back to its normal form.
If not managed appropriately, the progression from a reactive tendinopathy occurs. Over a period of time, constant overload through the tendon creates a change to the tendon matrix, where their components do not slip back into normal alignment and can become disorganised, tangled and weakened. This phase is called the tendon disrepair phase.
The final stage is called a degenerative tendinopathy. Once in this phase, the damaged part of the tendon cannot regenerate itself and irreversible damage occurs. If the degenerative portion of the tendon becomes large enough, eventual partial tears and ruptures may occur. Degenerative tendinopathies are generally found in the older population but may also been seen in the younger athletic people with continual overload in training. Check out the tendon continuum illustration below to get an idea of how this process works.
How do I know I have Tendinopathy?
Some signs and symptoms to look out for:
- Increasing pain at the site of the affected tendon: Usually after an increase in your usual physical activity.
- Load related pain: Pain may be present at the beginning of an activity and then disappear during activity itself, only to reappear when cooling down if the activity is prolonged.
- You can localise clearly: Most people will be able to point exactly to where the tendon pain is located
- The pain is described as ‘‘severe’’ or ‘‘sharp’’ during the early stages and sometimes as a ‘‘dull ache’’ once it has been present for some weeks.
- Age: For example, patella tendinopathies are usually more commonly seen in adolescent athletes, whereas an Achilles tendinopathy is more commonly seen throughout adulthood
- Previous injuries to the localised area or at areas above and below the symptomatic region.
- Family history
- Sedentary lifestyle
What can you do to improve your pain?
Some helpful things that you can do right away are to moderate your exercise, look at external factors that may be impacting on your pain and then start a structured exercise program.
1. Moderating your exercise program
By completely ceasing all activity all and resting you are doing more harm to your tendon than good. For tendon health, there needs to be constant stimulus in order to maintain good strength. With tendinopathies, there is usually a stimulus for your tendon pain. Whether it is running for Achilles tendinopathies, squatting for patella tendinopathies or throwing for a supraspinatus tendinopathy of the shoulder, the ideal treatment is to moderate these activities. Some examples of moderating these exercises may be walking instead of running, completing posterior chain exercise only or trying below shoulder height pulling based resistance exercises to improve these pain levels.
2. The right type of exercise:
It has been demonstrated that initial isometric (without movement) based strengthening of a tendinopathy significantly reduces pain, decreases cortical inhibition (the brains handbrake) and increases your muscular strength in the tendon affected muscle by 19% (Rio et al., 2015). As a rule of thumb, aim for 5 sets of 45 seconds with 2minutes rest in between exercises.
Two important points to make clear. The isometric exercise needs to be heavy enough that you find it quite hard. This may be a bodyweight double leg calf raise hold for one person, and may be single leg weighted calf raise hold on a smith machine for another. It is also important to ensure it is not too hard that you are shaking as this means your exercise is no longer isometric in nature. Check out the video (below) to see some different varieties of isometric exercises for different tendinopathies.
Depending on the nature of your tendon problem, a physiotherapist, osteopath or podiatrist is the best health professional to provide you with a structured program.
What can your Physiotherapist, Osteopath or Podiatrist do?
A physiotherapist or osteopath may look at the overall function of your body from the level of your tendinopathy but also in the muscle, joints and bone above and below the issue. They can help reduce pain and through manual therapy such as massage and joint mobilisation. They will also give a structured exercise program to help you improve functional tasks and return to normal function.
A podiatrist may also look at functional deficits through a biomechanical analysis. However, they will also look at intrinsic foot structure and function and how that impacts on your tendinopathy. They will generally be involved in lower limb tendinopathies.
Return to normal function
Generally, as with other injuries, the return to normal function will vary from person to person. However, when implementing allied health professionals, moderating your normal exercise regime and following a structured strength and motor control based training program, improvements in tendon function become much faster. From personal experience, it generally takes 2-6 weeks to reduce pain levels depending on the severity of the tendinopathy and the compliance to the amended exercise program. From here it usually takes a further 6 weeks to restore full function. The below photo by Dr. Jill Cook illustrates the process of rehabilitation and return to normal function.