Tendinopathies
Tendon problems are common and we see them regularly in practice. There is much research available, with new knowledge emerging all the time. The old term was “tendonitis” (implying an inflammation); we later referred to them as a “tendinosis” (implying degeneration).
We now realise that it is a bit more complex, with varying stages of what we now refer to as the “Tendinopathy Continuum”. The first stage is a “reactive tendinopathy”, which can become a “tendon disrepair”, worsen into a “degenerative tendon”, which could even tear (major tear or micro-tears). This process happens when the load placed on the tendon exceeds the capabilities of the tendon. This may be because of doing too much too soon, doing something really heavy, not resting enough between training sessions, unusual load (poor technique or biomechanics), or after the tendon capabilities have decreased, like after rest or illness.
Tendinopathies can be difficult to treat, with multiple management strategies and theories suggested. Tendons do not follow the usual healing process of other soft tissue injuries, so need to be treated differently. At present, the strongest evidence supports the use of exercise as a management strategy, with “loading” the tendon the only intervention that can change the strength and mechanical properties of the tendon.
Initially, the day-to-day load on the tendon needs to be reduced, by decreasing and adapting exercise or daily/work activities (and occasionally by also strapping, bracing or using orthotics). This is an important step and cannot be skipped. The initial exercises are usually isometric (static) and held for long periods, which also assist in decreasing tendon pain. Progressive loading is then suggested, with a large body of research advising eccentric training to increase tendon strength. The use of heavy slow resistance is also gaining support and a combined approach is often used. Importantly, rehabilitation should be progressed gradually, with sufficient time between loading periods. Tendon pain should be monitored and the program adapted appropriately. Individual factors need to be taken into account and often rehabilitation will also include “core” retraining and working on muscle imbalances etc.
Exercise programs need to be followed for at least 12 weeks, and for a lot longer for sportsmen. It is important that sufficient time be spent on active treatment before starting with provocative (sports) loading. Plyometrics and sports-specific rehabilitation is only commenced later in the rehabilitation. As a rule, a return to full symptom-free (sports) loading is only possible after a few months of active treatment, at a minimum. A return to sports is associated with a greater likelihood of recurrence, which we would obviously like to avoid.
The following additional treatment options (although not supported by a large body of research) could be considered in case of insufficient improvement in 3 months of the above treatment: collagen supplements, ultrasound, manual therapy, laser/light therapy), extracorporeal shockwave therapy, injection therapies and dry needling. Non-steroidal anti-inflammatory drugs are not usually recommended and Corticosteroid injections are not advised as they may increase the risk of tendon tears. Surgery should only be considered in those patients who do not recover after at least six months of active treatment.
Ultrasound scans may be useful to determine if there are any other concurrent pathologies, but the good news is, that, no matter how bad your ultrasound looks, it does not tell you how well your tendon will recover!
Making the correct diagnosis is essential to correctly manage the condition. There are different types of tendon pathologies that require slightly different exercise adaptations. There are also many structures very close to tendons that, if they are the cause of pain, will not improve and will likely worsen if treated like a tendon problem. Individual factors need to be addressed and an individualised program designed, monitored and adapted as needed. Your physiotherapist is best suited to assist you through this rehabilitation journey.
Juli-Ann Riley, Riley Physiotherapists
