Fixing Tendon Pain

Impaired Tendon Stiffness

Tendon stiffness is built up over months and years to match the loads we impose on our bodies. In the athletic realm, tendon stiffness increases via general strengthening and sport-specific training programs that either matches or is greater than the needs of our athletic pursuits.
 
So you have tendon pain? We know that tendons with chronic pathology usually have changes in structure including thickening, increased extracellular fluid (also called ground substance) and degeneration of the collagen matrix.  We also know that tendons with chronic pathology have reduced stiffness, which impairs the tendon’s ability to store and release energy as a healthy tendon would (1).
 
So what factors can assist health care practitioners to determine who is more likely to develop tendon pathology? Also what strategies seem to work the best in improving tendon pain? I’ve extrapolated this blog post from a summary statement I wrote for Family Physicians in the Bow Valley.  Read on and let me know if you have any questions or comments!

Tendons doing what they do: Transmitting force from muscle to bone.

Pathophysiology - Why do we develop tendon pain?

Genetic Predisposition – Collagen diseases (Benign Hypermobility Syndrome, Ehler’s Danlos, Scleroderma) (2).
Comorbidities that may predispose you to a greater risk of tendon pathology – Diabetes, thyroid, menstrual disorders, kidney disease, gallstones, gout (2,3).
Environmental Overload – Change in activity, duration, intensity, footwear, sporting equipment, activity surface (2).
Asymmetries –Biomechanical disadvantage secondary to stiff muscles, joints, poor strength, poor movement patterns/control (2).

Solutions - Reducing pain and helping patients plan for long-term success.

Step #1: Control Pre-Existing Medical Issues (from above).
 
Step #2: Educate
A) “You need to improve the strength of your tendon”.  The best treatment outcomes occur from loading the tendon, improving movement patterns, building a proper training schedule, and reducing fears (4-7).
B)  “This may take a while”.  Resolving irritable tendon pain can take months.  Although it is a generalization, for every one month that your patient has had tendon pain, they can expect one month of strength and rehab work (4).
C) “Some pain is acceptable during and after you exercise”.   Ideally pain does not exceed 3/10 on a visual analogue scale, and symptoms should resolve quickly after exercise.   Patients should perform a self-assessment 1 hour after exercise AND 24 hours later.  If they experience increased levels of discomfort, they have loaded the tendon too much and must reassess their exercise form, and reduce the exercise volume or intensity (5).
D) "Every tendon rehab is different".  Each area of the body requires a different set of priorities and exercises to properly manage the tendon pathology.  Your day-to-day activities, or athletic pursuits affect how you will heal and what is included in your rehab program.  It is best to get a plan that is tailored for you.
 
Step #3: UNLOAD The Tendon
A) Physiotherapy: Reduce asymmetries in body.
B) Reduce irritable activities but continue exercise.
C) Tendon-specific unloading devices, if required.
 
Step #4: Start To RELOAD The Tendon.  Improve the tendon's ability to tolerate loads.
A) Isometrics exercises involving the tendon, 2x/day. Perform 3 repetitions of 30 seconds hold and 30 seconds rest.   Start with low intensity and increase as tolerated. Isometrics have been shown to reduce pain fairly quickly and is the necessary first step of loading the tendon before you can progress the patient to dynamic strengthening exercises (4,8-10).
B) Dynamic strengthening exercises, 3x/week. 3-5 sets of 8 reps. Heavy and very slow (4,8-10).
C) Activity/Sport Specific – Graduated return (4,8-10).
 
Step #5: Consider Modalities And Injections.
A) Extracorporeal Shockwave Therapy is a non-evasive technique that has a large and expanding amount of research to support its use in treating chronic tendinopathies (4,11).
B) Injection therapies: If the aforementioned steps do not help to improve function consider referring the patient to a Sports Medicine Physician to determine any underlying pathology and possible cortisone injection, plasma-rich-protein injection, prolotherapy injection, or barbotage.

Resolve

There is almost always a way to escape tendon pain.  Resolve to finding a health care team that understands tendon rehab, your sport, and fights as hard as you do to find answers. 

References

1) Arya S, Kulig K. Tendinopathy alters mechanical and material properties of the Achilles tendon. Journal of applied physiology. 2009 Nov 5;108(3):670-5.
 
2) Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology. 2006 Feb 20;45(5):508-21.
 
3) Ejnisman B, Andreoli CV, Monteiro GC, de Castro Pocchini A, Cohen C, Tortato S, Franklin MM, Machado AB, Cohen M. Calcifying tendinopathy: a local or a systemic condition?. Revista Brasileira de Ortopedia (English Edition). 2012 Jul 1;47(4):479-82.
 
3) Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):887-98.
 
4) Smith BE, Hendrick P, Smith TO, Bateman M, Moffatt F, Rathleff MS, Selfe J, Logan P. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med. 2017 Dec 1;51(23):1679-87.
 
5) Kubo K, Ikebukuro T, Maki A, Yata H, Tsunoda N. Time course of changes in the human Achilles tendon properties and metabolism during training and detraining in vivo. Eur J Appl Physiol. 2012;112:2679–91.

6) Kubo K, Ikebukuro T, Yata H, Tsunoda N, Kanehisa H. Time course of changes in muscle and tendon properties during strength training and detraining. J Strength Cond Res. 2010;24:322–31.

7) de Boer MD, Maganaris CN, Seynnes OR, Rennie MJ, Narici MV. Time course of muscular, neural and tendinous adaptations to 23 day unilateral lower-limb suspension in young men. J Physiol. 2007;583:1079–91
 
8) Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clinical orthopaedics and related research. 2008. 1;466(7):1539-54.
 
9) Rio E, Kidgell D, Moseley GL, Gaida J, Docking S, Purdam C, Cook J. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med. 2016 Feb 1;50(4):209-15.
 
10) Mani-Babu S, Morrissey D, Waugh C, Screen H, Barton C. The effectiveness of extracorporeal shock wave therapy in lower limb tendinopathy: a systematic review. The American journal of sports medicine. 2015 Mar;43(3):752-61.