There are broadly two types of injuries I see…
Firstly, sudden-onset, acute, traumatic injuries – sprains / strains / tears / twists / falls / contusions / knocks / bumps, etc., that have an obvious, known mechanism.
Then there are “overuse” type, gradual-onset injuries.
Of the gradual onset injuries, back pain is the most common, followed by tendon pain (tendinopathy). Sore tendons are very common.
Tendons anchor muscles onto the bone. When we contract a muscle, “load” is transferred through our tendons. Tendons have to cope with a lot of load. Tendon pain / tendinopathy is the tendon failing to cope with that load.
Firstly, sudden-onset, acute, traumatic injuries – sprains / strains / tears / twists / falls / contusions / knocks / bumps, etc., that have an obvious, known mechanism.
Then there are “overuse” type, gradual-onset injuries.
Of the gradual onset injuries, back pain is the most common, followed by tendon pain (tendinopathy). Sore tendons are very common.
Tendons anchor muscles onto the bone. When we contract a muscle, “load” is transferred through our tendons. Tendons have to cope with a lot of load. Tendon pain / tendinopathy is the tendon failing to cope with that load.
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When we exercise, we want to cause some stress to the muscular system. We want to overload the muscle, causing a degree of tissue damage, or micro-trauma. The muscle then responds by growing bigger and stronger so it can cope with that load in future.
Stress/load => damage => rest/recovery => adaptation/growth. When we overload a muscle, we find it’s the tendons that give us trouble. If you look at a muscle anatomy poster, we draw the muscle bellies as red because they have a great blood supply. The blood brings nutrients and flushes out metabolites, meaning our muscle bellies recover well from overloading and injury. We draw the tendons as white because it doesn’t have as good blood supply. So we find when a muscle is overloaded it’s the tendon that breaks down and gives us pain, because it doesn’t have the same capacity to adapt to the load. |
A lot of common injuries are tendon pain:
- Achilles
- Jumper's knee (patellar tendon)
- Runner’s knee (ITB tendon)
- Lateral hip pain (gluteus medius tendon)
- Lateral shoulder pain (rotator cuff tendon)
- Tennis elbow (forearm extensor tendons)
- Golfer’s elbow (forearm flexor tendons)
- Medial ankle pain (tibialis posterior tendon)
- Lateral ankle pain (peroneal tendon)
Tendon pain can begin with either:
Most commonly, tendon pain comes on gradually with an increase in exercise load. This can be adding extra sessions getting ready for a race, pre-season training having had some time off, or coming back to training after an injury. Or it may be one hard session – adding hill sprints or plyometrics at the end of training, or a tournament playing multiple games in a day.
For non-athletes: a long walk with extra hills, or getting a big job done around the house - painting / hammering. Quite often it’s from introducing novel exercise or movements.
Examples of overload:
- A direct blow on the tendon,
- Excessive load, or
- Insufficient rest / recovery / sleep
Most commonly, tendon pain comes on gradually with an increase in exercise load. This can be adding extra sessions getting ready for a race, pre-season training having had some time off, or coming back to training after an injury. Or it may be one hard session – adding hill sprints or plyometrics at the end of training, or a tournament playing multiple games in a day.
For non-athletes: a long walk with extra hills, or getting a big job done around the house - painting / hammering. Quite often it’s from introducing novel exercise or movements.
Examples of overload:
- Single high-intensity session
- Repeated uphill running
- Increased frequency of training
- High-load training more than five times a week
- Different drills
- Rapid introduction of plyometric training
- High loads when fatigued
- Sprints at the end of training
- Change in footwear
- Shoes that provide less support, or stiff soles
- Shoes that mandate a forefoot strike or have a lower heel wedge
- Change in surface
- Running in soft-sand
- Running on uneven surfaces
- Training with muscle or joint stiffness
Tendons can be more vulnerable to excessive load from biomechanical factors. Tendons are more vulnerable when they are loaded while being stretched. For example: hitting a backhand late, where the forearm muscles are on a stretch – causing tennis elbow. Or running up hill - putting the Achilles / calf on a stretch while it’s contracting. Also, the combination of load and compression – for example, compression of the rotator cuff in the shoulder causing rotator cuff tendinopathy.
Other examples of biomechanical factors contributing to tendon pain could be a restricted ankle joint from a previous ankle sprain, reducing the potential energy absorption from the ankle joint structures while landing, transferring an increased load to the Achilles or patellar tendons.
Other examples of biomechanical factors contributing to tendon pain could be a restricted ankle joint from a previous ankle sprain, reducing the potential energy absorption from the ankle joint structures while landing, transferring an increased load to the Achilles or patellar tendons.
The "continuum model" of tendon pain names three stages of tendinopathy:
A tendon’s initial reaction to excess load is an emergency response to make itself stronger/stiffer. It does this by flooding with water, - analogous to how a flat football can be kicked a lot further when it is “pumped up”. The tendon triggers this inflammatory response to make itself more resilient in the short term.
This initial inflammatory or "reactive" period can be called tendonitis (meaning inflammation of the tendon). It generally lasts one to three weeks, and is best managed with a period of rest, Ibuprofen, and regular icing.
When excessive loading continues during this reactive stage, the tendon tissues become progressively more damaged, progressing through "disrepair" and "degenerative" phases. This quickly becomes a chronic injury that is much harder to treat, which we call tendinopathy.
- Reactive phase
- Disrepair phase
- Degenerative phase
A tendon’s initial reaction to excess load is an emergency response to make itself stronger/stiffer. It does this by flooding with water, - analogous to how a flat football can be kicked a lot further when it is “pumped up”. The tendon triggers this inflammatory response to make itself more resilient in the short term.
This initial inflammatory or "reactive" period can be called tendonitis (meaning inflammation of the tendon). It generally lasts one to three weeks, and is best managed with a period of rest, Ibuprofen, and regular icing.
When excessive loading continues during this reactive stage, the tendon tissues become progressively more damaged, progressing through "disrepair" and "degenerative" phases. This quickly becomes a chronic injury that is much harder to treat, which we call tendinopathy.
The anatomy, biology, and physiology of tendon pain are not fully understood. We know when we see a tendon that has been sore for a long period of time there is structural change to the tendon tissue. We know that even when the pain is gone the structural changes remain. We know that the extent of tendon damage does not necessarily correlate with pain, - we often see tendons that look ugly on imaging, that don’t cause pain, and conversely, a very painful tendon can look good on a scan.
What is actually causing the pain is not fully understood. Potentially some of the pain may come from the ingrowth of new nerve fibres (nociceptors / pain nerves) filling the degenerative tissue space. There may also be "central sensitisation" as the brain is overly “tuned in” to feeling the pain messages from the tendon.
What is actually causing the pain is not fully understood. Potentially some of the pain may come from the ingrowth of new nerve fibres (nociceptors / pain nerves) filling the degenerative tissue space. There may also be "central sensitisation" as the brain is overly “tuned in” to feeling the pain messages from the tendon.
There is a range of treatment options for tendinopathy but the most beneficial are load management and mechanotherapy.
Load management essentially means avoiding the activities that cause pain. Of the total volume of work that the tendon must cope with, I get patients to dial down the load by about a quarter, and stop the most aggravating activities – most likely the more demanding / explosive activities: hopping, skipping, jumping, sprinting, hills, plyometrics. So usually, total rest isn’t required for a chronic tendon pain. Patients can keep going with their cardio, but possibly trialling a lower impact, cross-training option, depending on how the tendon responds.
I judge how the tendon "is", based on a daily measure of a designated activity. This may be the length of time it is sore in the morning, or a quick test like a single leg squat, or hop, or an activity that is done at the same time every day, like coming down the front steps. If the pain is better on tomorrow’s test we are going well. If the pain is worse, we need to modify what we’re doing.
Load management essentially means avoiding the activities that cause pain. Of the total volume of work that the tendon must cope with, I get patients to dial down the load by about a quarter, and stop the most aggravating activities – most likely the more demanding / explosive activities: hopping, skipping, jumping, sprinting, hills, plyometrics. So usually, total rest isn’t required for a chronic tendon pain. Patients can keep going with their cardio, but possibly trialling a lower impact, cross-training option, depending on how the tendon responds.
I judge how the tendon "is", based on a daily measure of a designated activity. This may be the length of time it is sore in the morning, or a quick test like a single leg squat, or hop, or an activity that is done at the same time every day, like coming down the front steps. If the pain is better on tomorrow’s test we are going well. If the pain is worse, we need to modify what we’re doing.
Just resting the tendon doesn’t get it better. The pain will improve but any return to previous activity levels will make it sore again. It’s a common story for a footy player to only remember he finished last season with a sore Achilles when he returns to pre-season training and it’s sore again. The off-season doesn’t magically cure tendon pain. Mechanotherapy is required.
Mechanotherapy is essentially strengthening exercises. I like a graded strengthening program to increase the load bearing capacity of the tendon.
I start with isometric exercise. Isometrics are great for reducing pain in the tendon. This can progress to slow/heavy exercises, progressing to more ballistic sport specific requirements.
Strengthening exercises are the most important factor in recovery from tendinopathy.
Mechanotherapy is essentially strengthening exercises. I like a graded strengthening program to increase the load bearing capacity of the tendon.
I start with isometric exercise. Isometrics are great for reducing pain in the tendon. This can progress to slow/heavy exercises, progressing to more ballistic sport specific requirements.
Strengthening exercises are the most important factor in recovery from tendinopathy.
Adjunct treatment options may also help to a degree. Ibuprofen can decrease pain through inhibiting tenocyte cell activation and proliferation. Extracorporeal shock wave therapy can decrease pain. Supportive strapping or bracing, orthotics, footwear changes, and other equipment choices such as a smaller grip size, can decrease the biomechanical load on the tendon.
There are a number of injectables for tendon pain that have limited evidence to support their use.
Surgery is not commonly offered for tendinopathy, but when it’s successful I think it’s as much the post-operative enforced period of rehab that accounts for the improvement.
Have you had a tendon injury? What was your experience?...
There are a number of injectables for tendon pain that have limited evidence to support their use.
Surgery is not commonly offered for tendinopathy, but when it’s successful I think it’s as much the post-operative enforced period of rehab that accounts for the improvement.
Have you had a tendon injury? What was your experience?...
