Tendinopathy: the injury with the ever-changing name

For a long time we knew tendon pain as tendinitis and then it was tendinosis. Now we call it tendinopathy. It changed predominantly due to the lack of overt inflammation at the site of injury. Tendinopathy is an umbrella term that doesn't distinguish the location; i.e. tendon vs paratendon. There is still much to learn about tendinopathy, but our knowledge has increased in recent years and management has improved significantly.

Tendons are thick rope-like tissues that connect muscle to bone. They are important in transferring and absorbing forces, as well as creating movement. They are often injured due to progressive, repetitive overload. The overload can be tensile or working load, but can also be excessive compressive load.

Tendons hate compression. They can be compressed against bony structures such as their insertion points, or they can be internally compressed due to being stretched. Tendons often travel over a bony prominence to insert. In the good, healthy tendon this is a mechanical advantage to the tendon, but with excessive repetitive compression perhaps due to biomechanics, or a sudden change of activity this can be too much.

Tendinopathy has four phases, from normal tendon to degenerative tendon. The phases are fluid and a tendon can move easily between them. Excessive loading or unloading can cause your tendon to move towards degeneration. Optimised loading allows the tendon to move back towards normal. This is appropriate modified loading allowing for adaptation of the tissues.

REACTIVE TENDINOPATHY

This stage is a non-inflammatory stage where there is a thickening and stiffening of the tendon. It is often due to an increase in stress or direct impact to the tendon. The tendon at this stage can revert back to normal tendon with load management.

TENDON DYSREPAIR

This stage is associated with chronic overuse and has greater tissue breakdown. This stage often occurs due to poor management of the reactive tendon and offloading rather than optimising load.

DEGENERATIVE TENDINOPATHY

This is the final stage and there are irreversible changes at this stage. There can be cell death at this stage, however it is not all bad. The good tendon tissue that is still there surrounding the affected area can be strengthened to take over and improve the function of the tendon towards normal.

The tendinopathy continuum is an important step in our tendon knowledge base. The most important part is understanding that loading the tendon appropriately is the way back towards a normal tendon.

What draws you to the physiotherapist when you have a tendon problem is usually pain. Sometimes the pain is in the morning, or before activity and in some cases all the time. Addressing the pain is very important in improving the function of the tendon and the function of the person. Isometric contractions have been found to be the tendon 'panadol' and induce immediate pain relief. An isometric contraction is where you hold the contraction rather than move through range. They not only help the tendon, but they help the muscle and the brain.

Isometrics are a great start for a tendon rehabilitation program, but it needs to progress beyond this to ensure a safe return to sport or activity. Rehabilitation needs to be individual and progressive. After isometrics the tendon needs to get strong through range with a strength program. This might start isolated and then move towards function. Prior to return to sport the tendon needs to learn how to be a spring again with energy release exercises. There is no recipe or timeline and each person is individual. Progression will follow the tendon's response to the load. This can be monitored by pain.

It is important to listen to your tendon. Pain will return with tendon overload. The trouble with tendon pain however, is that it is often latent pain. It is often not painful until the next day. Understanding how your tendon responds will help guide you through your progressive program. A physiotherapist is the best person to help guide this program. They are also able to assess the potential cause and what might be impacting your recovery.

Seek help. Listen to your tendon. Complete your rehab!

We are here to help at The Movement Workshop! Our Physiotherapists used a variety of hands-on and exercise techniques specific to your injury and personal goals to help facilitate a pain-free return to activity.