Tendinopathy is an umbrella term that encompasses a variety of reasons why a tendon is irritated. Research is being carried out on the best approach to treating tendinopathies, with new and improved treatment criteria being published all the time.
What is it?
The most basic explanation is that the tendon (what attaches your muscle to your bone) is not tolerating the load being placed on it. It used to be thought that this caused inflammation, however, we now know this isn’t the case. Instead the tendon swells with odema (clear fluid) and the nice, tidy, uniform collagen fibers in the tendon become ‘irregular’ causing failed attempts at healing.
It can affect a number of areas in the body:
- Patella tendon (under the knee cap)
- Tennis or golfer's elbow
- Thumb (DeQuervain's) especially for new and breastfeeding mums
- Shoulder – rotator cuff tendonitis
- Gluteal muscles
Basically it can affect any tendon in the body, but the above are the most common areas we see them in clinical practice.
What Causes It?
The main risk factors are :
- Sudden change in activity, particularly those that require load to be placed on the tendon (running, jumping, walking).
- Compression on the tendon – think: pressure on your Achilles from shoes or falling on your knee and impacting your patella tendon.
- Predisposition due to systemic factors such as high cholesterol, smoking, age.
- Predisposition due to biomechanics such as poor muscle capacity/contraction or misalignment.
Tendons are tough cookies. They can maintain tension for long periods and require much less oxygen that muscles. However, this also means they are frustratingly slow to heal, which means those with tendinopathy get frustrated at us, why are they STILL not better?!
How do you Solve the Problem?
While we don’t know everything, here are some undeniable truths that every patient needs to keep in mind:
- Rest alone is not the answer. It may settle and reduce the pain in the interim but returning to activity is often painful again. This is because rest does nothing to increase tendon load tolerance.
- Tendinopathy is not considered to have a classic inflammation response. There some of the same biochemical elements, but this response is unique to tendons. That being said, research has found that ibuprofen is helpful in the early stages to assist in tissue repair.
- Those with a predisposition to tendinopathy may find that even a subtle change will cause a flare up, which will then take a long time to heal.
- Reducing the load initially to settle the pain is important. A short-term reduction in the aggravating movement/compression is required.
- Research has found that the best treatment for tendinopathy is exercise. Sorry people, but if you want to get better you will need to actually do the exercises you practitioner gives you. A lot. For more than a week. Tendons need to be loaded slowly and progressively to increase their tolerance to load. In most cases, a tendon will continue to be painful and repetitively flare up if this crucial stage is missed.
- Similarly, tendinopathies rarely heal with passive treatments alone. By this I mean, just getting osteopathic treatments/injections/shockwave therapy/acupuncture will not fix your issue. In fact, multiple injections have been found to disrupt the healing process. Do your exercises people!
- Everyone is different. Everyone moves differently, places different strains on their body, has different predispositions, tolerates pain differently. Therefore, exercise needs to be individualised.
- As per my blog post on imaging: the diagnosis on imaging is not equal to the pain you feel. Some people have tears, tendinopathy, calcifications and are asymptomatic. For this reason, treatment focuses on your improving pain levels and function rather than sending you off for repetitive imaging to check on tissue healing.
- Most importantly, remember – Tendons heal slowly. They respond very slowly to exercise and you need to have patience. It may be tempting to resort to the ‘quick fix’ of an injection or surgery, but in reality, there is no easy way out. Put the time and effort in and you will feel better eventually.
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(J. L. Cook, Rio, Purdam, & Docking, 2016; J. Cook & Purdam, 2012; Coombes, Bisset, & Vicenzino, 2010)
Cook, J. L., Rio, E., Purdam, C. R., & Docking, S. I. (2016). Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British Journal of Sports Medicine, 50(19), 1187–1191. https://doi.org/10.1136/bjsports-2015-095422
Cook, J., & Purdam, C. (2012). Is compressive load a factor in the development of tendinopathy? British Journal of Sports Medicine, 46(3), 163–168. https://doi.org/10.1136/bjsports-2011-090414
Coombes, B. K., Bisset, L., & Vicenzino, B. (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy : a systematic review of randomised controlled trials. The Lancet, 376(9754), 1751–1767. https://doi.org/10.1016/S0140-6736(10)61160-9
Imaging – help or hindrance?