An Update on How to fix Tendon Injuries?

Written by Britt Caling - APA Titled Sports Physio

Do you have Achilles pain when you first get out of bed in the morning, or when you start to run until you are warmed-up?

Do you have patella tendon pain in your knee when you squat or run?

Are you a mature female with side hip pain in your gluteus medius to do your shopping, or walk around the block?

Are you an endurance triathlete/runner with hamstring pain that limits your run training?

These are some of the common tendon injury presentations we see in clinic. Tendon injuries are frustrating for you as an athlete because they tend to stick around for long periods, often gradually worsen until you suddenly realise they are limiting your training and don’t get better with rest alone. They are just as frustrating for us as Therapists to manage given the long time-frames they may take to improve and the specific exercise intervention that is required to improve your symptoms. This exercise intervention also requires patience from you the athlete, very specific management from the therapist and good compliance to the exercise and training advice given by the therapist.

Here is a snippet of the latest information on tendon injuries?

- We know that there is no such thing as a “tendonitis”. “itis” refers to inflammation within the tendon and research has demonstrated this does NOT occur within the tendon itself. The tendon sheath (or paratenon, however, can be infiltrated by inflammatory cells and is referred to as a “paratendonitis”. Treatment for paratendonitis is also slightly different from treating a true tendon injury.

- There are 4 phases that best describe the state of a tendon:

1. a Normal Tendon

2. when a normal tendon is exposed to excess overload it becomes a Reactive Tendon which is where the tendon cells are working overtime to try and deal with the stresses placed on them.

3. if the tendon continues to be stressed above its capacity to repair, it is in a state of Tendon Dysrepair. Abnormal cells are present within the tendon and these cells attract water- this process starts to separate the tendon fibres. Early in this stage the tendon fibres may still be in normal, parallel alignment but your tendon may be thickened and swollen due to the increased water content and fibre separation. At the end of this stage, tendon fibres start to become disorganised in their orientation and this is partly what makes the tendon weaker and more symptomatic.

4. if the process of overload continues, you will end up with a Degenerative Tendonopathy. This is a tendon that has abnormal tendon cells and disorganised fibre alignment meaning the tendon is unable to cope with normal forces. At this time extra nerves and blood vessels infiltrate the tendon which may be once source of increased pain.

- If a tendon moves from being a reactive tendon to a tendon in disrepair, it can still recover its state back to being a normal tendon structure; but once a degenerative tendon is present the normal tendon structure is NOT recoverable. Luckily, this does not mean that symptoms cannot be reversed, but the time-frame to get symptoms under control for this tendon is much longer and requires very specific adherence to an exercise program that is gradually progressed.

- A reactive tendon phase that occurs on top of a degenerative tendon will often settle in 7-10days if the abnormal stress is removed. Acute reactive tendons due to an acute trauma may take weeks to settle and much care needs to be taken to not aggravate tendons in this state to ensure symptoms settle.

- Care needs to be taken about prescribing (or self-prescribing via Doctor Google) unloading time (ie. rest) for any symptomatic tendons. Too long rest/reduced load will reduce the tendon’s tolerance for load and create further problems/symptoms. What we do know is that tendons adapt to load slowly, but there is a very fine line between good load to stimulate positive tissue changes and overload that will cause further tissue breakdown.

- The trend for improving a tendon’s tolerance for load over the past few years has been to perform eccentric exercises. An eccentric exercise is one where the muscle is lengthening as it contracts (for example, a slow lower from a calf raise position). It now appears the most successful rehabilitation programs for chronic degenerative tendons are far more detailed, and individualised, to you than simply performing 3-6 sets of eccentric calf raises!

o Your therapist should take a thorough history or what you do as an athlete and your goals of returning to activity/competition. From this they need to determine what is “low” tendon load for you, and what is “high” tendon load. For example, a marathon runner that needs strength-endurance in their tissues and doesn’t need their tendons to function in a stop-start manner will have a different amount of “high” load compared to sprint hurdler whose Achilles needs to tolerate body-weight forces landing maximally from a hurdle or an AFL athlete whose Achilles must help decelerate and accelerate their body weight over the course of a game.

o After exposing your tendon to load (ie. exercise), tissue reparative changes are maximal between 48-96hrs (2-3days). Therefore, it now seems important to cycle your rehabilitation around this time-frame, so that your tendon is only exposed to “high” load every (2-) 3 days. This will ensure your tissue is adapting positively to the load, and not being stressed to overload.

o A critical means of exercise in the “low” load days may be to use isometric exercises, followed with slow but heavy concentric-eccentric exercises in the “moderate” load days, and plyometric exercises plus sports training in the “high” load days.

o Your exercise rehabilitation program should not remain the same forever- there should be a specific progression by your therapist until you achieve a full return to activity/competition. Once you return to symptom-free activity or sport, it is also important to maintain the strength tolerance of your tendon-muscle complex, so an on-going heavy load program is recommended at least twice per week.

In summary:

A reactive tendon needs to be calmed down (decrease load)

A degenerative tendon needs stimulation (very specific increased load)

Reactive on degenerative tendons needs to have the reactive component settled first, then the degenerative component rehabilitated correctly

If you are experiencing tendon pain, don’t try to fix it yourself- see your Physio at Gold Coast Physio & Sports Health to help you interpret this information and guide you through the difficult exercise pathway to help you achieve your fitness or sporting goals symptom-free!

Get to know Sports Physio Britt Caling…

Currently Britt provides physiotherapy services to Triathlon Australia’s Elite Program and works extensively with The Australian Institute of Sport Triathlon, Kayaking, and BMX programs, Swimming Australia, The Queensland Academy of Sport, The New South Wales Institute of Sport and has managed Sally Pearson since 2006.