Hey everyone! This article is a quick information session on tendon rehabilitation – specifically, what tendons require vs. what is detrimental in their recovery. There are a lot of misconceptions out there about how to best manage tendon pathology, so I encourage you to read along if you have any tendon pain.
When we develop a tendinopathy, whether it is our Achilles, patellar tendon, or rotator cuff, it often occurs after a period of doing an activity at a level we are not accustomed to. For example, you might decide to sign up for a half marathon in a few months, so you start training – even though you haven’t gone for much of a run in a long time. Or, volleyball season just started up, and you jump right into the season opener weekend tournament. Or, you start a new job that involves a lot of repetitive motions of the wrist or arm over the course of your day. What all of these examples have in common is that they are a new level of load on your tendon that it is not currently accustomed to.
You see, tendons are very particular about what they want. In order to have a healthy, non-pathological tendon, it needs a certain level of load on a relatively regular basis. Without load, tendons become weaker and less tolerant of activity (1). On the other hand, however, with too much load that it is not accustomed to, the tendon can sometimes react negatively and can cause you nagging pain that sticks around for much longer than you would like it to. You can think of a tendon’s tolerance as a threshold at a specific level of exercise/load/repetitive movement. This threshold is different for everyone, based on many factors such as usual activity level, genetics, nutrition, stress, etc., and can be surpassed when one of these factors or a combination of them is simply too much for the tendon to handle (2).
With gradual exposure and appropriate load management, with the help of your physiotherapist, you can build up the tolerance threshold of your tendon. This takes time and patience, but it is ultimately what tendons need to heal when they are aggravated. Many people will choose to rest their tendon when it hurts and avoid activities or exercise as they believe this will fix the problem. Unfortunately, all this does is make the tendon more sensitive and less capable of handling load! (4) With this approach, a tendon can never properly heal.
This is a difficult concept for some people to grasp – but exercise/activity is what caused my tendinopathy; how on earth is it going to help it?! The devil is in the details here - even though load is what got your tendon into this issue in the first place, it is also what will be its saving grace. Tendons are meant to withstand loads and absorb different forces; it is arguably their most important function in our bodies. Because of this, the tendon cells actually need to be mechanically loaded at the appropriate intensity in order to adapt and recover (4).
But what about injections for my tendon pain? It is important that you make an informed decision about utilizing passive treatments for tendinopathy management. While a corticosteroid injection has the potential to relieve your pain for a month or two, there is little evidence to show any benefit beyond these initial months (5). Recent research done on rotator cuff tendinopathies has shown that the doctor would have to inject 5 different people for 1 person to get a good result (5). Furthermore, the results are short-lived, and there is no evidence to show that an individual can get continued relief from injections (if they work, they only seem to work the first time) (6). Additionally, there is evidence to show that injections can actually cause a tendon to become more pathological at the cellular level; in other words, it promotes deterioration of tendon cells as opposed to formation of new ones (6). At the end of the day, by choosing passive treatments for your tendon, it will not make the tendon more tolerant to load which is not only what it needs to truly recover at an anatomical level, but also what it needs to avoid future episodes of the same tendon pain.
Key messages I want you to take away:
The term “tendinitis” is frequently used by injured individuals, family practitioners, and medical specialists. Commonly present in the Achilles, lateral elbow, and rotator cuff tendons, many still believe that there is a large inflammatory component in overuse tendinitis and anti-inflammatory medication can be used to treat this condition.
According to Assistant Professor Khan of the Department of Family Practice at the University of British Columbia (2002), “ten of 11 readily available sports medicine texts specifically recommend non-steroidal anti-inflammatory drugs for treating painful conditions like Achilles and patellar tendinitis despite the lack of a biological rationale or clinical evidence for this approach.”
Patients who present with a painful overuse tendon condition more likely have a non-inflammatory pathology. Studies have revealed that the cause of tendon pain arises from collagen separation. Collagen is the main structural protein found in connective tissues. When these tendon fibrils become thin, frayed, and fragile, they begin to separate and become disrupted in cross section. This leads to an increase in tendon repair cells rather than inflammatory cells.
There is limited evidence of short term pain relief and no clear evidence of effectiveness when relying on anti-inflammatory medications. A more appropriate term would be to use “tendinopathy” to acknowledge that the overuse condition is not in fact tendinitis. Correctly utilizing this term provides patients with a more accurate description of their condition, prevent ineffective pharmacotherapy, avoid medical costs, and allow time for collagen to repair. Tendon disorders realistically take months rather than weeks to resolve. Allow time for rest and slowly incorporate exercises for area of concern. See a physiotherapist for proper diagnosis and treatment options.