Many of us know the feeling. You go for a run after not having exercised for a while. Or you play a game of netball, basketball or touch footy for the first time in years. You feel good at the time but the next morning reality sets in as soon as your feet hit the floor. Those first few steps feel like agony. Your tendons are screaming at you! This is what we call a tendinopathy injury.
Tendinopathy injuries (or tendinopathies) are caused by overuse or overloading of the tendon. Up until recently you might have heard your Physiotherapist use the term tendonitis (inflammation in the tendon), but studies have shown that inflammation is rarely associated with an overuse tendon injury. So tendinopathy (pain in the tendon) is the term we now use.
Tendons are fibro-elastic structures that attach our muscles to our bones. Two examples are the patella tendon that attaches the quadriceps to the front of the knee, and the Achilles tendon that attaches our calf muscles to the heel bone. The tendon’s job is to send the the forces that are produced by our muscles to the bones. This is what creates movement. For example, when force is produced by the quadriceps muscle the tendon sends that force to the shin bone which then produces the movement of kicking a football.
Tendons are made up of uniform collagen fibres. These are linear and bundled tightly together. There is minimal ground substance, blood vessels or nerves.
Tendons are load dependent. This means they respond to loads placed on them during activity. The patella and Achilles tendons are like springs. They help us perform power type movements like jumping, skipping, hopping, bounding, sprinting or changing direction. This is why tendinopathy injuries are more common in sports such as basketball, netball, volleyball and high jump.
So what happens if the capacity of our tendons is too low to handle the loads placed on them? The result is the tendon becomes overloaded which can then cause a tendinopathy injury to occur. This usually occurs after a period of de-loading. For example returning to sport after a long time, or during pre-season training after a lengthy off-season. The tendon’s collagen fibres become disrupted by an increase in water molecules and ground substance. There can also be an increase in nerves and blood vessels into the tissues.
Patients commonly present with pain after exercise. Or more often with pain the morning after they’ve exercised. They may find they are stiff and sore when they start exercising, but that the pain reduces once they warm up. Stiffness and pain then tend to return once they stop the activity or once they’ve cooled down.
People might be able to continue training with some discomfort in the early stages. However at its worst tendinopathy is extremely painful, and may force the person to rest from the activity that’s causing the problem.
There are 3 stages of tendinopathy. Patients and athletes move along this continuum depending on their activity:
Stage 1: Reactive
This usually occurs after a bout of exercise that causes an acute response from the tendon (such as playing basketball for first time in months or skipping). It can also result from a direct blow to the tendon (like a kick to the Achilles). It can even occur during a sudden burst of activity (such as sprinting across the road) in a person who is usually relatively inactive.
Symptoms can be reduced quickly with appropriate rest and a gradual return to loading.
Stage 2: Dys-Repair
This is where you get worsening of the tendon pathology and breakdown of the matrix/ground substance. As a result the collagen separates and loses some of its uniformity. There may also be new blood vessel and nerve growth.
During this stage there is a limited ability for the tendon to repair.
Stage 3: Degenerative/Failed Healing
This is the end stage of the tendon injury. At this point collagen fibres can’t be returned to their original structural integrity.
It’s not usually painful, but the tendon can become reactive again if you begin increasing the load on it. This is thought to be due to healthy tendon fibres starting to surround the degenerative ones. During this stage it is important to strengthen the healthy fibres.
The main aim of rehabilitation at this stage is to increase the capacity of the tendon to handle the loads placed on it. Exercises that build strength are the only way to do this. But it can take time so patience is the key.
Passive treatment modalities will not help the tendon to build load. They can provide some relief of your symptoms, but a complete rehabilitation program needs to include strengthening exercises if it’s going to be effective.
The Infographic in the references below gives some handy tips on what not to do if you have a tendon problem.
If you are suffering from a tendinopathy injury please make an appointment with your Physiotas physiotherapist. They can help diagnose the stage of tendinopathy you are in and determine the appropriate course of treatment.
Cook et al., (2017). Revisiting the continuum model of tendon pathology: What is its merit in clinical practice and research? BJSM, 50, 1187-1191.
Brukner & Khan, (2017). Clinical Sports Medicine (5th ed). McGraw Hill Education.
About the Author:
Ryan Carroll is an APA Sports Physiotherapist and Director of PhysioTas. He has worked at PhysioTas for over 10 years and is also the physiotherapist for the Australian U’17 (2017) and the North West Thunder Basketball teams. Ryan has a particular interest in knee, ankle and tendon injuries as well as adolescent sporting injuries.