Tendons are responsible for attaching muscles to bones and when they develop pain, they can be really debilitating. This post will discuss what happens, why it happens and some of the things you can do about it.
Tendons are tricky things to manage when they go wrong, and so their management is something which needs careful planning. More important than treatment planning is learning to not irritate your tendon.
Tendon pathology occurs due to an overload of the tendon. This also means that when the tendon is grumbly, it can then be overloaded very easily.
This can occur a variety of ways but the essential point is that every tissue in the body has capacity and if you exceed that capacity, it might "break". Let me expand on that… bones are “tissue”, skin is “tissue” and muscles are “tissue”.
If you imagine doing weight lifting with Arnold Schwarzenegger then you can probably assume that you wouldn’t be able to lift the same weights as him, and you can definitely assume that you’ll hurt a lot afterwards… Meanwhile he’ll be grinning and he’ll probably be back… this is because he is well conditioned to that kind of exercise, whereas your body lacks that capcaity. Whereas when you take it that one step further and do the same workout that exceeds capacity over several days, you then find yourself getting into a lot more trouble and your tendons become grumbly.
The reason that we hurt is due to the fact that we have exceeded the tissues capacity and so the body has to repair. When we exceed tissue capacity, the tissue repairs itself and also makes itself a little stronger… so if you create damage to a muscle with micro tears like you would at the gym then you get bigger and stronger muscles. If you stress your bones frequently by running then they get stronger. Likewise if you don’t stress muscles regularly then you get weaker and if you don’t stress bones frequently then they become more brittle (this is why exercise is so helpful as we get older, especially for females nearing and after menopause as bone stock decreases).
So with tendons, what happens is that the capacity is exceeded and then they try to heal and then they get overloaded again, and they try to heal again and so on. Then you end up in pain and then life sucks as you have a tendon
What kind of tendon problems are there?
Tenosynovitis
This is where the external covering if the tendon has become inflamed and as the tendon moves through it, the tendon becomes sore to use as the lubricant has become inflamed
Tendonitis
This is due to an acute injury of the tendon and normally refers to a tendon pathology of less than 3 months duration. The ‘-itis’ means that there is fresh inflammation in the area and this is the ideal time to start with an exercise program to stimulate healing of the tendon.
Tendinopathy
The ‘-opathy’ ending indicates that there is now a chronic inflammatory process occurring and this usually occurs when the tendonitis has been ongoing for more than three months and results in a degeneration of the tendon rather than inflammation. Whilst chronic tendinopathies are somewhat trickier to manage, there is hope. The healing process can still be stimulated with just exercises alone, however more advanced methods can sometimes be used to speed up the healing process.
Tendon rupture
Fortunately tendon ruptures are relatively rare. They are typically the result of a rapid extension of the tendon causing it to partially or totally tear. It is easy to tell when the tendon has torn however and the management may need to be undertaken within a multi-disciplinary team.
What treatments exist for tendon problems?
A variety of treatments exist and will depend on which tendon is involved, the level and duration of the pathology and the amount of function you currently have. The challenge when treating tendons in the lower limb is that it is very hard to rest them and so other strategies often need to be used.
RICE
Well, we’ve all heard the old term RICE which is an acronym for Rest, Ice, Compression and Elevation. The science has moved away from that now and progressed over the last few years, however in the early stages of a tendon injury, this is not a bad plan. That being said, ice may not be your friend when trying to heal any injury.
Orthotics
When one has a tendon problem, the key is to try to exercise caution when using the affected tendon. It is very hard to rest a tendon in the lower limb, and rest is far from being a friend when it comes to tendon problems. The idea of an orthotic is to redistribute pressure and improve function of the foot as well as to take the load away from the tendon by doing some of its job. When the tendon is allowed to not be regularly overloaded, it stands a better chance of healing.
Exercises
Tendons are quite slow to respond to increases in load which is why they become tendinopathic. This being said, they require load to heal and depending on how painful they are, will require different exercises. Tendon loading programs need to be specific to the tendon as well as to the level of activity that you are used to. Exercise bands are excellent for targeting a tendon, however they do not put the tendon under anywhere near as much load as you do when you’re walking, and therefore bodyweight exercises are preferred.
Load modification (activity pacing)
Tendons follow a very typical pattern when they are irritable and the best way to tell if you have overloaded your tendon is if it gives you more trouble than usual the next day. By optimally modifying loads through reduction in activity but maintaining activities where possible, it is possible to bring yourself back to being as close to as active as you usually are.
Extra-corporeal shockwave therapy This is an excellent treatment modality that is incredibly popular in the sports medicine world. Extra-corporeal shockwave therapy works by stimulating the inflammatory process to encourage healing. At the same time as stimulating healing, it also overloads the pain sensors briefly and in a controlled fashion which causes them to “turn off” reducing your discomfort for the hours and even days following treatment
Steroid injections Although steroid injections may be a highly controversial treatment modality when managing tendon problems, they can be highly effective when used to settle down an acutely inflamed tendon (or structures associated with it. The reason for the controversy is that steroids have been associated with tendon rupture, and therefore caution must be used when treated with a steroid and carefully following instructions for after a steroid injection is essential. One might argue that the issue lies with the reduction of pain perception combined with the tendon being degenerated.
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