Treating and managing ‘tendon’ problems one of the most frustrating group of injuries I encounter, mainly because their recovery often has no time frame, it’s never linear, instead they tend to be a 2 steps forward one step back kind of problem. If it’s frustrating for me, I can only imagine how my patients must feel.
The answer isn’t black & white (it never is in medicine). There are however a few anatomical and physiological factors that can help explain why tendon problems can be stubborn as all hell.
I’ll quickly given you a little anatomical insight as to what a tendon actually is, and no a tendon is not a ligament (I do kind of understand why people get this concept confused). Tendons are thin fibrous bands which connect a muscle to a bone. Their function is to transmit forces, essentially providing stability with no real ‘active’ work. Not all tendons function the same. Some are positional purely assisting with controlling the position of the joint (fingers) while some can actually store energy & work as springs to assist with basic movements of the body such as walking.
Tendon dysfunction is usually a result of overuse due to repetitive stress being placed through one particular area of the body. Common sites include the Achilles, the patella tendon, the rotator cuff, tennis elbow & the hamstring tendon. Problems can be categorized as either
TENDONITIS: inflammation of the tendon OR
TENDINOSIS: inflammation with additional micro tearing and wear & tear of the tendon fibres.
Many clinicians also now use the umbrella term ‘tendinopathy’ which encompasses aspects of both.
Anyone can suffer from tendinopathy if there is great enough forces transmitted through a tendon that may not be conditioned to deal with it. Take me for example when I was 22, no history of knee problems, started doing a lot of stair running & plyometric training (jumping lunges, squats etc) combined with running. Ended up with acute patella tendonitis.
Such cases in ‘younger’ athletes are easier to manage. Tendonitis is acute & generally we are dealing with inflammation which with rest from aggravating activities & appropriate rehab will clear up in a matter of weeks.
Tendinosis is a little different & this is where the frustration sets it. Athletes in the 35-40+ category who do a lot of activity are those we worry about here. At this age (which is by no means old) most tendons will be starting to show signs of wear and tear. Small degenerative fraying of the collagen fibres at a microscopic level which is usually asymptomatic. When you start to place a lot of load through that ‘weakened’ area problems begin to arise. It starts as a dull ache, which gradually gets worse. Often stiffest in the morning upon rising. The area may also be tender & swollen if inflammation is also present. In very acute cases there can be ‘crepitus’ or creaking in the tendon itself.
The longer you push through some of these seemingly minor symptoms the harder it will be to manage.
Why are they stubborn?
Well for one tendons don’t get a great blood supply in comparison to our muscles & organs which are constantly bathed in fresh blood filled with oxygen & other lovely nutrients. This contributes to a slightly slower healing process.
Microscopically tendinosis is due to the disruption of the collagen fibres of the tendon. Normal healthy tendon fibres line up side by side while inflamed injured fibres will bunch together & get a little ‘tangled’. It can take up to 100 days for our body to reestablish strong collagen fibres.
Is there any good news?
Yes. Kind of.
In the acute stages you will need to rest from aggravating activities whether it be running, weights, tennis, surfing. However some activity will actually be favourable to your rehabilitation by promoting remodeling of the tendon fibres, however this will normally need to be cross training of some sort so as to reduce the overall load through the tendon.
There will also be certain exercises depending on the tendon in question that will be required to strengthen the tendon for long term management. Such exercises are usually eccentric & focused on the negative phase of movement, this simply means loading the tendon as its lengthening. This has been show to encourage rebuilding of collagen.
The treatment course is always individualized & you and your physiotherapist should work together to develop a rehabilitation program that controls your symptoms whilst also incorporating appropriate strengthening.
There are also alternatives… such as injections, patches to promote blood flow & more recently the PRP (platelet rich plasma) which involves an injection of a concentrated solution made from your own blood to promote healing. (more to come on this in an upcoming blog). Such options can be discussed with your physio or doctor.
Have a great day!