Tendinopathies are an incredibly common type of injury, yet they are often poorly understood by the general public. In this article, we take a look at deeper look at tendinopathies – what they are, where they occur and what can be done about them.
Let’s start at the beginning:
What is a Tendinopathy?
A tendon is the fibrous tissue that connects a muscle to a bone, and a tendinopathy – in basic terms – refers to a pathology within a tendon. One example of a tendon most people know is the Achilles tendon, which connects the calf muscle to the heel bone.
A tendinopathy occurs when a load is repeatedly placed upon/through a tendon, eventually causing damage, pain, dysfunction, and reduced exercise tolerance. Other common names for tendinopathy include ‘tendinitis’, and ‘overuse tendon injury’.
Stages of Tendinopathy
There are 3 main stages of a tendinopathy. These are known as reactive tendinopathy, tendon dysrepair, and degenerative tendinopathy.
Stage 1: Reactive Tendinopathy
Tendinopathy results from acute overload to the tendon (an increase in unaccustomed activity) resulting in an adaptive response causing thickening of the tendon. Large proteins in the tendon are produced more rapidly and combine with water molecules. The aim is to increase surface area by thickening the tendon, resulting in reduced stress and increased tendon stiffness. This stage is non-inflammatory and can be reversed.
The first stage of a tendinopathy can be precipitated in any number of ways. For example, it may occur in an athlete who has dramatically increased his or her training load in a short space of time, or in an individual doing a large amount of unaccustomed activity, such as a long day in the garden.
Stage 2: Tendon Dysrepair
This is the stage where there is an attempt by the tendon to heal itself. However, compared with the reactive tendinopathy (stage 1), there is greater breakdown of the tendon, resulting in disorganisation of the tendon matrix. Tendon dysrepair occurs when there is repeated overload of the tendon for a prolonged period of time. At this stage, there is still a chance of reversibility if managed appropriately; however, recovery becomes more challenging.
Stage 3: Degenerative Tendinopathy
This stage is characterised by areas of cell death within the tendon itself, something generally seen in older people who have had multiple bouts of tendinopathy. This stage is unfortunately irreversible, but there are still treatment options that can help with the management of symptoms and improving functionality.
Common Types of Tendinopathies
Achilles Tendinopathy
Achilles tendinopathy can either occur in the middle of the tendon, or where the tendon attaches onto the heel bone. It most commonly affects athletes involved in lots of running, but can also afflict relatively sedentary people as well. There is often associated swelling around the tendon itself.
Extensor Tendinopathy (Tennis Elbow)
Extensor tendinopathy, more commonly known as tennis elbow, causes pain to the outside of the elbow. This can result in dysfunction due to weakness, and individuals often have trouble with activities involving gripping. It most commonly affects tennis players (hence the moniker) since each time they swing the racquet, large forces are transmitted through the extensor muscles and tendon. Importantly, though, this condition can afflict anyone. It may occur following highly physical activity (e.g., hammering or brick laying) or as a result of relatively innocuous tasks, such as typing.
Degenerative Rotator Cuff Tear
The rotator cuff consists of three muscles at the back of the shoulder and one at the front. Its role is to dynamically support the ball inside the socket, which is the shoulder joint, during movement. A degenerative rotator cuff tear can be considered on the spectrum of tendinopathies as a degenerative tendinopathy (as opposed to acute damage). Studies have shown that in people over the age of 60, 54% have a rotator cuff tear (28% full thickness, 26% partial thickness) on imaging with no symptoms at all. Often, a degenerative rotator cuff tear becomes painful after a large increase in unaccustomed load (heavy lifting, gardening).
Patellar Tendinopathy (Jumper’s Knee)
The patellar tendon connects the quadriceps (thigh) muscles to the shin bone. Patellar tendinopathy is commonly seen in sports that require a lot of jumping, such as basketball and volley ball, hence why it is referred to as ‘jumper’s knee’. Individuals will commonly experience pain in the tendon, just below the knee cap.
Gluteal Tendinopathy
Once referred to as ‘trochanteric bursitis’, gluteal tendinopathy results in pain and weakness in the side of your hip. It results from an overload of the gluteal tendons (most commonly gluteus medius) which connect your gluteal (butt) muscles to your hip. Gluteal tendinopathy more commonly affects women and impacts on activities such as walking, sitting, and sleeping.
Tendinopathy Treatment
Ok, so there are numerous types of tendinopathies and none of them are much fun, so what can we actually do about them?
Load Management
First and foremost, tendinopathies are a load issue, so load management is a key feature of their rehabilitation. ‘Load’ essentially refers to the amount of work a tissue (e.g., a tendon) is required to do. A certain amount of appropriate load is good, as it helps to strengthen and promote healing of the tendon. However, if the tendon continues to be overloaded, the problem will continue to linger on and be aggravated.
It is important you get assessed by a properly trained physiotherapist in order to determine what stage the tendinopathy is at, and how irritable it is. Each stage of tendinopathy responds differently to the amount and type of load being applied, making the assessment vitally important. Your physiotherapist will be able to come up with a progressive loading program based on the stage and irritability of your tendinopathy as guided by their assessment. They will also be able to educate you on the “dos and don’ts” of loading your tendon, so that it settles down quicker. This management strategy will be used across all stages of tendinopathy.
Exercise Rehabilitation
This ties in with load management, because again a certain amount of appropriate load will promote tendon healing and strengthening. Your physiotherapist will devise a home exercise program for you – dependent upon your tendinopathy – and progress it accordingly. It is important that you are doing the correct exercises, as different exercises load your tendons in different ways, so there is potential for aggravation.
Physiotherapists use various targeted exercise techniques to manage tendinopathies. For example, there are certain types of exercises called isometrics (contracting a muscle without any change in muscle length) that have been shown to reduce tendon pain. Eccentric exercises (contracting the muscle while it lengthens) also appear to promote tendon healing.
Manual Therapy
Manual therapies, such as massage, joint mobilisation, and dry needling can be incorporated into the management of your tendinopathy. Whilst they probably won’t change the structure or strength of your tendon, they are useful tools to help manage the pain associated with your tendinopathy. By increasing the flexibility in certain muscles and reducing stiffness in joints, your tendon will also be placed in the best possible environment to function. This should allow you to complete your home exercise and loading program more easily, ultimately resulting in faster strengthening and a quicker recovery.
Taping, Bracing & Positioning
Taping can be used to assist in unloading the tendon, or as a proprioceptive (knowing where we are in space) strategy to limit certain movements. Taping techniques aim to reduce the amount of abusive load going through the tendon, creating an environment conducive to a faster recovery.
Other similar techniques may also be used to achieve this goal. For example, heel raises can be inserted into shoes for Achilles tendinopathy to again reduce the amount of load going through the tendon. These options are not permanent fixes for a tendinopathy, but strategies to reduce the irritability and pain of the tendon to allow for more targeted rehabilitation.
See A Physiotherapist
As always, any musculoskeletal injury should be assessed thoroughly by a physiotherapist, who will then prescribe treatment based on their findings. Every case is unique, so make sure you seek professional and personalised advice. If you have a tendinopathy complaint and want to get expert guidance, book in with one of our clinicians at Peak Physio in Newcastle today.
References
- Cook, J. L., Purdam, C. R. (2009). ‘Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy’. British Journal of Sports Medicine, 43, 409-416
- Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., Cook, J. (2015). ‘Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy’. British Journal of Sports Medicine, 49, 1277-1283
- Sealey, P. Lewis, J. (2016). ‘Rotator cuff tears: is non-surgical management effective?’. Physical Therapy Reviews, 21, 215-221