5 Facts About Tendinopathies.
What is a Tendinopathy?
Tendinopathy is a broad term that encompasses painful conditions occurring in and around tendons in response to overuse. The previous term tendinitis worked on an old paradigm that inflammation was involved in tendon injury however more recent studies show painful tendons are devoid of inflammatory cells. What that means is that dysfunction here doesn’t follow normal inflammatory/histological processes that we may find with muscle or bony injury and has no clear end-point. Instead, the pathology involves complex and ongoing non-inflammatory alterations in the tendon matrix and cells. It is essential to understand this, as it underpins how we choose to treat and assess the injury.
How to know if it is a tendon that you hurt?
Tendons adapt very slowly to new loads, so if you have developed pain associated with a recent increase (or new) activity, it is possible that your tendon rather than your muscles are the structure that is struggling with your new activities! To be sure that your tendon is what is at fault takes close questioning and assessment. Often tendon pain is one that seems to come back over and over again and I’m guessing quite a few of you have experienced this or at least know someone who has!
The different stages of Tendinopathy Injury.
Stage 1 – Normal Tendon
Stage 2 – Reactive Tendinopathy
Generally, follows a period of acute overload (i.e. a burst of unaccustomed physical activity) or a direct blow. More common in the young athlete and produced through increases in training load or commencement in training if previously sedentary.
Stage 3 – Tendon Disrepair (Failed Healing)
Similar to reactive tendinopathy this is an attempt at tendon healing, however This stage appears in chronically overloaded tendons. This has the potential to appear over a range of ages and loading environments
Stage 4 – Degenerative Tendinopathy
More commonly seen in the older patient/athlete, but can also be seen in younger patients with a chronically overloaded tendon. Therefore, there is real potential to see this in a young, elite athlete. However, the more classic presentation is the middle-aged recreation athlete, with focal swelling and pain. They often describe repeated bouts of tendon pain. If allowed to progress this stage can inevitably lead to rupture. Analysis of ruptured tendons have shown these degenerative changes in 97% of cases.
Stage 5 – Rupture Tear
5 Facts About Tendinopathies.
There is a lot we do not know about tendinopathy, but there are some inalienable truths that you should know as a patient.
1) Tendinopathy does not improve with rest – the pain may settle but returning to activity is often painful again because rest does nothing to increase the tolerance of the tendon to load.
2) Tendinopathy can be caused by many different risk factors. The main factor is a sudden change in certain activities – these activities include 1) those that require the tendon to store energy (i.e. walking, running, jumping), and 2) loads that compress the tendon. Some people are predisposed because of biomechanics (e.g. poor muscle capacity or endurance) or systemic factors (e.g. age, menopause, elevated cholesterol, increased susceptibility to pain, etc). Predisposed people may develop tendon pain with even subtle changes in their activity.
3) Exercise is the most evidence based treatment for tendinopathy – tendons need to be loaded progressively so that they can develop greater tolerance to the loads that an individual need to endure in their day-to-day life. In a vast majority of cases (but not all) tendinopathy will not improve without this vital load stimulus.
4) Tendinopathy rarely improves long term with only passive treatments such as massage, therapeutic ultrasound, injections, shock-wave therapy etc. Exercise is often the vital ingredient and passive treatments are adjuncts. Multiple injections in particular should be avoided, as this is often associated with a poorer outcome.
5) Tendinopathy responds very slowly to exercise. You need to have patience, ensure that exercise is correct and progressed appropriately, and try and resist the common temptation to accept ‘short cuts’ like injections and surgery. There are often no short cuts.
Please note that these are general principles and there are instances when adjuncts, including injections and surgery are very appropriate in the management of tendinopathy.