Tendinopathy is a common overuse injury that we see very regularly and the diagnosis of the injury is fairly straight forward. Patients usually have pain during exercise and sometimes a little after too. Tendinopathy is common in runners and sports people but can also be found in patients who have recently taken up a repetitive activity such as gardening. We can normally pinpoint what tendon and muscle is causing the pain with specific loading tests.
Tendinitis -vs- Tendinopathy In the 1980’s Tendinopathy used to be referred to, and diagnosed as, tendinitis. The reason for the name change is that inflammation and inflammatory cells were thought to be the main causes of the pain in those with dysfunctional tendons however, a resounding amount of studies in the 90’s showed that this was not the case. A word ending with “itis” means there is a form of inflammation, so for this reasoning, the name had to be changed. Many still see Tendinopathy as though it were strictly an inflammatory condition which is why I wanted to share some good information with you. You can even see the difference between the two types on this picture. One looks inflamed and burning hot, even just to to touch (tendinitis, left) and the other (tendinopathy, right) seems only slightly enlarged or 'thickened' and as you'd imagine, not sore all the time.
How Tendinopathy occurs and its different stages:
Stage 1: Reactive Tendinopathy
When the tendon is overloaded and becomes challenged (usually from sport or activity), the tendons cells become slightly irritated and begin to produce special healing proteins known and proteoglycans. This makes the affected tendon or specific part of that tendon feel thicker. As you can imagine if the tendon is becoming overworked, to become thicker is a healthy protective response that just needs to be managed correctly. To try and run or perform normal exercise could result in the progression of the tendinopathy into the next stage.
Stage 2: Tendon Dysrepair
When the tendon pathology worsens and the thickening and production of proteins increase further. In this case the cells and tendon matrix (embedded cells and structures) becomes disrupted. This can allow for some vessels and nerves to grow slightly more into the structure. This usually occurs when the tendon has been overused for more than just a few days and is indicative of chronic tendinopathy.
Stage 3: Degenerative Tendinopathy
This is a stage where usually those who need operations or an intensive intervention are at. Cells within the matrix begin to die with a lot of extra vessel and nerve tissue growing around the area and a lot less collagen (an important protein tissue). This type of Tendinopathy can also occur in the elderly who may have tendon overuse from daily tasks.
Stage 1: Reactive Tendinopathy
When the tendon is overloaded and becomes challenged (usually from sport or activity), the tendons cells become slightly irritated and begin to produce special healing proteins known and proteoglycans. This makes the affected tendon or specific part of that tendon feel thicker. As you can imagine if the tendon is becoming overworked, to become thicker is a healthy protective response that just needs to be managed correctly. To try and run or perform normal exercise could result in the progression of the tendinopathy into the next stage.
Stage 2: Tendon Dysrepair
When the tendon pathology worsens and the thickening and production of proteins increase further. In this case the cells and tendon matrix (embedded cells and structures) becomes disrupted. This can allow for some vessels and nerves to grow slightly more into the structure. This usually occurs when the tendon has been overused for more than just a few days and is indicative of chronic tendinopathy.
Stage 3: Degenerative Tendinopathy
This is a stage where usually those who need operations or an intensive intervention are at. Cells within the matrix begin to die with a lot of extra vessel and nerve tissue growing around the area and a lot less collagen (an important protein tissue). This type of Tendinopathy can also occur in the elderly who may have tendon overuse from daily tasks.
Management of Tendinopathy:
Strengthening
Strengthening programmes for tendinopathy have recently shown to be effective. These programmes should include eccentric exercises (where the tendon is lengthening under a stress or load). An example of this kind of exercise would be calf raises on a step, lowering the heels below the step under your body weight. As you can imagine, this type of exercise will help train the tendon gradually in preparation for the greater stress loads that will placed upon it when returning back to sport or functional status.
Load Management
Load management is crucial for improving tendinopathy and there is a lot of different ways you can manage the stress load you place on the tendon. One of the most important questions people ask is "should I load it?" and when it comes to overuse, the answer is actually always yes. If you have an annoyed tendon and are a hill-walker, keep walking but walk less and avoid inclines. If you are a runnner, run less distance, intesnity and have a softer terain. As you are continuing to load a tendinopathy, please ensure it does not hurt during that load and stop the second it does. Continously track your load and increase only very gradually. The old "wait and see" or "rest a week then run again" models are completely off the ball.
Treatment in the clinic
Therapeutic Ultrasound can be helpful when the tendon has entered the proliferative phase (where it is is painful and has become stressed). Studies have shown an increase in fibroblasts, enothelial cells and myofibroblasts (important healing chemicals). Massage and deep friction massage have also shown to be beneficial in a small amount of studies. Do not rely to heavily on passive treatment, be sure to focus on load management and the other areas just as much or more.
Consider biomechanics
If you run, turn, jump, land or generally move in a way that could be overloading a tendon even more, then modifying these movements is likely going to reduce or resolve the tendinopathy. It may take a long time to get improvements in biomechanics, but you are far less likely to get a re-ocurrence if it has been taken into consideration. Small studies have shown there is a definite difference in biomechaniscs between those who have tendinopathy and those who do not.
Strengthening
Strengthening programmes for tendinopathy have recently shown to be effective. These programmes should include eccentric exercises (where the tendon is lengthening under a stress or load). An example of this kind of exercise would be calf raises on a step, lowering the heels below the step under your body weight. As you can imagine, this type of exercise will help train the tendon gradually in preparation for the greater stress loads that will placed upon it when returning back to sport or functional status.
Load Management
Load management is crucial for improving tendinopathy and there is a lot of different ways you can manage the stress load you place on the tendon. One of the most important questions people ask is "should I load it?" and when it comes to overuse, the answer is actually always yes. If you have an annoyed tendon and are a hill-walker, keep walking but walk less and avoid inclines. If you are a runnner, run less distance, intesnity and have a softer terain. As you are continuing to load a tendinopathy, please ensure it does not hurt during that load and stop the second it does. Continously track your load and increase only very gradually. The old "wait and see" or "rest a week then run again" models are completely off the ball.
Treatment in the clinic
Therapeutic Ultrasound can be helpful when the tendon has entered the proliferative phase (where it is is painful and has become stressed). Studies have shown an increase in fibroblasts, enothelial cells and myofibroblasts (important healing chemicals). Massage and deep friction massage have also shown to be beneficial in a small amount of studies. Do not rely to heavily on passive treatment, be sure to focus on load management and the other areas just as much or more.
Consider biomechanics
If you run, turn, jump, land or generally move in a way that could be overloading a tendon even more, then modifying these movements is likely going to reduce or resolve the tendinopathy. It may take a long time to get improvements in biomechanics, but you are far less likely to get a re-ocurrence if it has been taken into consideration. Small studies have shown there is a definite difference in biomechaniscs between those who have tendinopathy and those who do not.
Conclusion
Many people are still being told they have tendinitis when in fact they have tendinopathy. A tendon with tendinopathy can feel super painful during exercise and then barely hurt at all a few days after, even to touch or squeeze. Load management is crucial to improving tendinopathy. It is important to spend some time thinking about your own case and tracking how you are managing it. It is up to you whether you require a specialists opinion for advice specific to your condition or if the advice here is enough however, if you are ever in doubt just fire us an email, we'd be happy to help.
Many people are still being told they have tendinitis when in fact they have tendinopathy. A tendon with tendinopathy can feel super painful during exercise and then barely hurt at all a few days after, even to touch or squeeze. Load management is crucial to improving tendinopathy. It is important to spend some time thinking about your own case and tracking how you are managing it. It is up to you whether you require a specialists opinion for advice specific to your condition or if the advice here is enough however, if you are ever in doubt just fire us an email, we'd be happy to help.
References
• Andres, B.M. and Murrell, G.A.C. (2008) ‘Treatment of Tendinopathy: What works, what does not, and what is on the horizon’, 466(7).
• Brosseau L, Casimiro L, Milne S, Robinson V, Shea B, Tugwell P, Wells G. Deep transverse friction massage for treating tendinitis. Cochrane Database Syst Rev. 2002:CD003528.
• Cook, J.L. and Purdam, C.R. (2008) ‘Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy’, British Journal of Sports Medicine, 43(6), pp. 409–416. doi: 10.1136/bjsm.2008.051193.
• Mortimer, A. J. and M. Dyson (1988). "The effect of therapeutic ultrasound on calcium uptake in fibroblasts." Ultrasound in Med & Biol 14(6): 499-506.
• Munteanu, S.E. and Barton, C.J. (2011) ‘Lower limb biomechanics during running in individuals with achilles tendinopathy: A systematic review’, 4.
• Ramirez, A. et al. (1997). "The effect of ultrasound on collagen synthesis and fibroblast proliferation in vitro." Medicine and Science in Sports and Exercise 29(3): 326-32.
• Andres, B.M. and Murrell, G.A.C. (2008) ‘Treatment of Tendinopathy: What works, what does not, and what is on the horizon’, 466(7).
• Brosseau L, Casimiro L, Milne S, Robinson V, Shea B, Tugwell P, Wells G. Deep transverse friction massage for treating tendinitis. Cochrane Database Syst Rev. 2002:CD003528.
• Cook, J.L. and Purdam, C.R. (2008) ‘Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy’, British Journal of Sports Medicine, 43(6), pp. 409–416. doi: 10.1136/bjsm.2008.051193.
• Mortimer, A. J. and M. Dyson (1988). "The effect of therapeutic ultrasound on calcium uptake in fibroblasts." Ultrasound in Med & Biol 14(6): 499-506.
• Munteanu, S.E. and Barton, C.J. (2011) ‘Lower limb biomechanics during running in individuals with achilles tendinopathy: A systematic review’, 4.
• Ramirez, A. et al. (1997). "The effect of ultrasound on collagen synthesis and fibroblast proliferation in vitro." Medicine and Science in Sports and Exercise 29(3): 326-32.
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