What are tendons? Why are they troubled?

Tendons are elastic pieces of tissue that connect muscle to bone. Their job is to transfer the force from the muscle to the bone to allow movement. They also work to absorb forces that movement creates. They are a huge part of the stretch reflex during high impact or high speed activities. When they are not working properly muscles and joints don’t work effectively and things become painful.

Tendon troubles often come under a number of different guises: Tendinopathy, tendonosis, tendonitis, tendinitis, tendinopathy, tendon tears, degenerate tendon, inflamed tendon. In truth they are all one and the same. Controversy has existed as to the true cause of why tendons become painful so therefore it’s a case of semantics. A painful tendon will likely have a bit of degeneration, a bit of inflammation and a bit of sensitisation. As tendinopathy covers all these this is my preferred term.

Where do tendons become sore

Tendinopathy occurs at various sites of the body

• In the upper limb: the shoulder (rotator cuff), the elbow (golfers elbow and tennis elbow), and the thumb (DeQuervains).

• In the lower limb: the hip (glueteal), the knee (patella) and the ankle (achilles and tibialis posterior). Often also tendonopathy is the true cause of pain in other diagnoses.

Diagnoses such as shoulder impingement, hip bursitis, and greater trochanteric pain syndrome often have a large tendinopathy component. As you can probably guess tendinopathy is a widespread and very common problem. The purpose of this blog is not to discuss each individual condition separately. However this may be in future blogs so look out. The purpose of this blog is to explore what is tendinopathy and what is the best way to treat it.

Why do tendons become sore?

Tendinopathy often occurs when too much load is put through the tendon. This may be a sudden increase in load or activities or repeated load over time. The tendon reaches a point where it cannot cope and then becomes painful to protect itself. Regardless of how the tendon trouble started it always results in the tendon losing its ability to tolerate load. This reduced load tolerance is due to both physical changes to the make-up of the tendon, as well as an increase in the sensitivity of the tendon

What is the best treatment

The best evidence based treatment by and large is the same regardless of the tendons that are sore: careful, graded and progressive loading. This may take time and sometimes this is difficult for people to take but there really are no short cuts

Common mistakes in treating troublesome tendons

Things that I feel are really important to know if you have tendinopathy are as follows:

• Complete rest will not help! Pain may settle but will be back. We may have to modify load to initially get going but total rest really is never the answer.
• Stretching often does not help. Stretching can put a compressive load on the tendon. This has been shown to cause further irritation and is generally not recommended in physiotherapy circles.
• Passive treatments rarely help in the long term. Massage, deep tissue frictions, acupuncture, therapeutic ultrasound. They all have the same problem, they do not address the tendons problem of not tolerating load.
• Injections are not are good idea Whilst they can reduce pain in the short term, they do not increase load tolerance. Furthermore there is evidence to suggest injections, particularly repeated injections weaken the tendon. This can leave you prone to further problems. In my view injections should only be reserved for cases where without them you can’t load the tendon due to high pain. They should never be given alone and should always be completed with rehab, otherwise in 2-3 months the pain is back.
• Imaging (Ultrasound and MRI) can be useful however do not tell us the full picture. We know a lot of people have tendinopathy on scan with no pain. Equally we know that some people who recover from tendinopathy have no changes on their scans before and after pain. Treat the person and not the condition!

Summary

Tendinopathy is a very common condition and affects many areas of the body. It is ultimately an issue of a tendons ability to tolerate the load or demand that is being placed on it. The best treatment involves building up the tendons capacity to tolerate this load. Many other things that purport to help actually don’t and in some cases can make it worse.

Get in contact today if you have tendon troubles.

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