Tendons are very important for running and jumping. This blog will look at why we should refer to tendon problems as tendinopathy, not tendonitis!

What Difference Does it Make if We Call it Tendonitis or Tendinopathy?

Have you ever been diagnosed with tendonitis, or is it something you are currently struggling with? Tendons are  incredibly important structures which store and release energy, allowing for powerful dynamic movement. When a tendon is not functioning well it can limit us greatly, in both athletics and in daily life. Historically, tendinopathy was called “tendonitis”, and had a reputation as a condition that may never get completely better, that is was something you would just have to manage or struggle with, or that healing will be difficult. But, over the past 10-20 years our understanding has improved tremendously,  and we now know that this does not have to be the case! Sadly, however, it is still being treated the same by many clinicians. So how has our understanding of this common condition changed?

• Let’s use the modern name – Tendinopathy. Why worry about names; surely this is just semantics? The suffix -itis means inflammation, and was used as we previously thought this was a classic inflammatory condition. However, we now know this is not the case! There are some inflammatory cells, but that this is not the primary problem.

• Tendinopathy is instead a degenerative process of a specific portion of the tendon resulting from excessive loading:
  • If loading becomes too great, the affected portion of the tendon becomes reactive. It tries to respond to the load by growing in size; but it does this by adding disorganized cells. Therefore, a tendon that is painful and seems larger is likely reactive, instead of inflamed as we previously thought. This reactive portion of the tendon can still transmit force and can be normalized if load is relatively reduced!

  • If load is not relatively reduced, the specific portion of the tendon starts to move into disrepair and eventually will become degenerative. This means the cellular make-up of that portion will have become so disorganized that it can no longer fulfill its mechanical function. This is thought to then place a greater demand on the remaining normal portion of the tendon, which increases the risk that portions of it could then become reactive.
    • Once a degenerative portion of tendon has lost its structure, it is unable to transmit force, and cannot return to being reactive or even normal if loading is reduced.

    • This leads us to have a cross section of the tendon where there is normal tendon and a “hole” of degenerative tendon. In this so-called “donut hole” analogy we then need to focus treatment on the remaining donut (the healthy tendon) to help it become more mechanically capable of taking load.

  • To understand this in more depth have a look at our video on the tendinopathy continuum

If we treat it as an –itis and use various treatments to reduce inflammation we may get some short to mid-term relief, so I am certainly not saying that those treatments are without any merit. However, if these more passive, clinician-performed interventions (injections, medication, ultrasound, massage) are the mainstay of treatment, we are missing the big piece of the problem. Using these treatments we may resolve pain and in some cases feel we have fixed the problem, but as we often see (and I have blogged about before), the short-term fix often fails to correct the underlying root cause, and we get recurrence or even progression of the degenerative process. And now we know that once a tendinopathy has progressed to the point of degeneration, that part of the tendon cannot recover and probability of issues in the remaining healthy tendon tissue may increase.

Load is king

When we consider tendinopathy we need to remember that load is king, and as such there are are 3 things we should consider in the management of tendinopathy:

1. We want to have a thorough understanding of sporting activity, as well as training and competitive loads:
   • Does the biomechanics of the sport lead to compressive or tensile (stretching) loading on the tendon?

   • Has pain occurred in response to sudden activity, or has there has been a consistent but gradual overloading?
     • We can consider this using tools such as the Acute Chronic Workload Ratio that we have previously blogged about.

     • We know that tendinopathy will respond to relative rest; so knowing the recent loading can help us understand how much activity is appropriate to allow healing.

   • We can advise on other aspects of training that might be problematic. For example,  tendinopathy should not be stretched as it increases compressive load, so instead massage, or gentle rolling of the muscle may be more appropriate.

   • Knowing the sport and various training methods will provide a better understanding of how to structure the training so that the tendon is loaded in a progressive way.

2. We want to understand how long this has been going on and how it has been treated:
   
   • If it has been going on for a while, or is intermittent/cyclical, and the treatments have been passive in nature, we know that a key component is missing.

   • Educating on how the tendon transmits load and what occurs with overloading is very important. This education and failed recovery using passive treatments should help a patient to see that they need to address loading.

   • It is natural to look for a quick fix, but the patient needs to understand that this type of exercise-based intervention will take time to produce results. As one of the leading researchers, Pete Malliaras, says, “there are no short cuts”

3. We want to consider if there are medical reasons that predispose tendinopathy:
   •  Age, diabetes, menopause, etc., can affect the mechanical ability of a tendon to accept loading. If, for example, a patient has uncontrolled sugar levels, this could be contributing to their tendinopathy and they should be referred on for review by an endocrinologist.

How should tendinopathy be treated?

There are three phases to treat tendinopathy. However, we should note that not all tendons are created equally. In this section I discuss some generally-applicable points, but at the end of the article are links to blogs (as we write them!) discussing specifics of tendinopathy in different parts of the body.

1. Reduce pain
   • Athletes should institute a relative reduction of loading/activity, keeping pain in a 0-3/10 range with less than 24hr flare-up.
     • This might mean that a runner who normally does hills, sprints, changes training to flat, slower paced runs, or even intervals so that it is non-provocative.
     • More often than not it may mean a temporary change in type of physical activity, such as switching from soccer or running to cycling or swimming for cardiovascular exercise. Or running in a pool with a weighted belt.
     • It may mean taking the elevator at work rather than the stairs.
   • We need to focus on active, patient-controlled methods as they are more empowering. The best option here is isometric exercise. Isometric exercise is one where the muscle contracts, but no movement occurs (such as holding a heel raise).
     • 45 second mid range holds, 5 repetitions, 2-3 times a day, 2 minutes between each repetition, are supported by the evidence.
     • Use of a metronome to count the beat of seconds has been indicated to have a positive effect on pain processing/perception in the brain.
     • In a competitive athlete, these isometrics can be used to relieve tendon pain during a game/event.
   • Passive treatments (e.g. rolling, massage, needling etc) can be used, but should be emphasized as an adjunct and temporary relief. Along with the above, they can help the athlete reach the point where the tendon can accept more load.
2. Isotonic loading
   • Once pain is staying in a 0-3/10 range with no flare up greater than 24 hrs, treatment can progress to isotonic exercise. We should continue to aim to keep pain as such.
   • Isotonic loading will help restore strength to the muscle. Isotonic means that the loading is constant throughout the movement. Examples include body-weight exercises like calf raises, push-ups, or the load on a leg press.
   • The range of the isotonic exercise can be controlled so not provoke compression and flare-up.
3. Energy Storage loading exercises
   • Once isotonic exercise has progressed sufficiently, the next step is “energy storage” loading exercises. Exactly when it is time to move on to this step will vary with injury; as a PT I will be looking to make sure your pain levels are staying low, and that you have built up enough strength to safely progress to this type of exercise.
   • These exercises take the tendon through a cycle of loading, storing, and releasing energy. This is the major function that a degenerative portion of a tendon cannot complete (but the remaining tendon can!).
   • Examples of this includes jump landings, hopping, bounding.
   • This is the highest-risk part of the treatment program, but it is also the part that gets finally helps you truly recover from the tendinopathy! We want to move into this stage very carefully, making sure not to flare up the pain or cause re-injury.
4. Return to sports
   • Finally! This is what we’ve been working hard for. Again, we want to move back into normal sports activities with caution, using energy storage exercises that replicate the chosen sporting activity.
   • I like to stay in touch with my patients (usually via e-mail or text) as they move back into their sports and increase their activity levels; pain flare-ups are what we want to avoid, and I’m happy to answer questions and help them stay on track with getting back to their sport in a safe manner.

The videos below give some examples of the exercises used in the first three stages in an achilles tendinopathy:

Conclusion

If you have been dealing with tendinopathy for an extended period of time I hope this gives you a new understanding and restores hope in how it can be treated. If you have not taken this type of exercise/load based approach I would highly advise you to seek it out! This path takes patience, but if done correctly can be very rewarding with long-lasting relief and total healing.

Stay tuned for posts on specific types of tendinopathy. Like our facebook page or signup for our newsletter so you don’t miss them!

References:

• Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409-16.
• Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?. Br J Sports Med. 2016;

Photo credit: Steven Pisano via Foter.com / CC BY