Mark: Hi there internet people, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby, near Vancouver, and the outskirts of Vancouver, the soul of Vancouver in North Burnaby. And we're going to talk about Achilles tendon pain. How are you doing Iyad?

Iyad: Good. How are you doing Mark? 

Mark: Good. So what's Achilles tendon pain. I have a sore ankle. How do I know it's the Achilles tendon? 

Iyad: That's a good question. Usually one of the first things we'd want to do is talk about how it started and the history and all that kind of stuff. And that usually helps us kind of figure out if we're going to look at the Achilles tendon or not.

And with most tendon issues, it tends to happen slowly over time. It's not like a sudden trauma. Obviously there is some of this kind of where I took a step and I felt something go and those tend to be a little different. So if we think about the classic Achilles tendon pain, it's either somebody who had taken lots of time off, I'm gone away on vacation. You know, just a bit of walking and then I come back. I'm like, okay, maybe I'm going to hit the gym at the same level I used to hit before. And that big spike from a big rest. So it's a period of disuse. And then you come back to where you used to be that sense tends to look like a spike on load on our body. And then we can kind of start to develop some of these issues. 

And where the issue happens, honestly, our best bet now is to do with maybe the resilience of that area or the training history. So for example, if this person's very well-trained they might have a bit more buffer, and they can withstand that jump in activity more, or not. 

The other really important one is the pain location. So tendon pain, you know, we expect it to hurt especially in the lower limb. So like the Achilles tendon, if somebody comes in and says, well, my foot hurts. I'm not going to be looking at the Achilles. Or if they feel painted like high up in their calf, we're going to look at something else.

So we'd like it to be in and around the tendon for us to have a pretty good confidence, that it is that. And then the other one, which is really, really important is how localized the pain is. So tendon pain is very localized. It doesn't really present where it jumps up and down and moves around a lot.

So if they have that, it doesn't mean necessarily that they don't have tendon pain, but maybe it's not the only thing that's on their plate that they're dealing with. So that's where we would want to dive in and assess all the things that could contribute to sensations there. 

Example, I had somebody who said, oh, I feel it when I run. And it turns out that they have some issue with their low back and we treated the low back and their leg pain right away. So it could look like a tendon, but if it doesn't behave like it, that's where we'd want to look a little more in depth. 

Mark: So let's just dig in a little bit deeper. Is there any relationship with pain the plantar fasciitis that pain down in the middle of your foot and tendon. Is this particular Achilles tendon pain.

Iyad: Could be. They're kind of connected, the two structures and you know, the name plantar fascia makes it sound like it's not a tendon, but it kind of behaves like a tendon. It's like a flat tendon. So they could be related or it could not be related. And sometimes you don't have to have one to have the other.

So some people only have heel pain, plantar heel pain, which is pain just at the inside of their heel, and that could be related to the plantar fascia getting a bit effected. So we would treat that with a multitude of ways, including figuring out why they're just so easily triggered with certain activities and try to modify that. We could do different shoe modifications for these people just to kind of help them continue to stay active, just because, you know, you're unable to maybe exercise the way you normally do doesn't mean you should stop exercising altogether.

And that's usually what happens, is people stop for a long period of time because they try to rest it. Then they lose function in other areas, and then all of a sudden, you know, they'll tell you I gained a bit of weight and I've lost my strength and all of this stuff that happens with just prolonged rest. 

So really our job as physios is to see okay, great. So you have this injury, how can we keep you as active as possible, while also trying to treat this injury at the same time. Instead of just completely cutting them off of any activity? So yeah, they can happen together or they can happen separately. But just because they're connected structurally, they don't necessarily have to go one and two, you can just have Achilles tendon pain sometimes.

And it's because the Achilles tendon is really important. We use it through our lifetime as a spring to help us recycle the energy that we use. So for example, when we walk or when we run, we're able to kind of recapture a lot of that energy that our body puts into the system and into the floor through this nice little spring function that it has.

Mark: So how related is an ankle sprain, say like a high ankle sprain or something like that, to this Achilles tendon pain? 

Iyad: They're pretty different. They're remarkably different I would say. High ankle sprains will happen from impact. They'll happen from some kind of trauma, some fall. You know, some people say, oh, I rolled my ankle, but then it happens usually from some kind of mechanism and direct episode.

I've rarely seen it happen just from a slow buildup, an insidious onset like that. The Achilles tendon also functions very differently. It's an active structure. It's a contractile structure. Meanwhile, in the high ankle sprain, the job of that structure in the front of our ankle just the top, is to hold the two bones together. So it's literally just acting as a binding so that we don't get excessive wiggling between the two bones. Meanwhile, our Achilles tendon is constantly contracting and releasing in conjunction with our calf. 

Mark: They're opposite of each other then, really? 

Iyad: Yeah. So you could think of them as one of them is kind of like connecting bone to bone, the other one's connecting muscle to bone. So functionally very different. Structurally very different. Location very different. One's going to hurt primarily in front, the other one's going to be at the back. And one of them is primarily like, again, the key thing with Achilles tendon pain is there has to be some kind of load change that we see and it doesn't have to happen last week. It could happen weeks and weeks ago. 

But then the idea is you do is huge kind of spike in activity. And then you kind of maybe go back to normal, but your body might not have enough time to repair and adjust and it slowly builds up where you start to become symptomatic. And then in that case, what we would do is just try to see what are we actually dealing with?

Is this actually the Achilles or is this something else? We can have, for example, pain in the structure, just around the tendon tissue itself, like the sheath, which could look very different. And this is where you can get something like a cyclist saying my Achilles hurts, even though what we consider biking is not really that heavy on the Achilles tendon. Not quite like running or jumping. It's not considered a high elastic activity. It's not a high springing activity. 

Meanwhile, if you have a jumping athlete, you're kind of going to look at that a bit more or a soccer player, or even a runner where they have to constantly be using that tendon. So yeah, we would look at that first and then we would kind of figure out where their symptomology is. And then we can modify lots of things. 

Same with the plantar fascia. We can modify the load. We can put them on a different exercise routine to keep them healthy, but also do some small modifications that we can again, modify footwear. That's a temporary solution obviously, that's not going to fix the tendon, but it helps them continue staying active and training. Especially if somebody, for example is training for a marathon and their time is a little limited. So they don't have this big window of opportunity to drop six weeks off their training program.

Mark: So if we kind of narrow down to the core here, the history is really important. That's how you're going to get to the exact diagnosis and where the pain is, of course. And then you got to keep moving is basically the other message. 

Iyad: Absolutely. So the way we diagnose tendons is it's mostly functionally diagnosed. So we have a bunch of tests and the idea is you'd expect it to hurt more, as I progress the load on you, I'd expect you to be more symptomatic if it's actually a tendon that's hurting.

So progressing load is just as general term, but it means if it's heavier, if it involves maybe more pressure on the tendon, if it's faster, those are all considered higher loads, but those are the parameters that we tinker with when we're designing, for example, somebodies running program within the Achilles tendon.

We would definitely want to keep you as active as possible, but also we want to put you on a loading program for the tendon. That's how we think the tendon restores its function best. It's not an inflammation only problem. You don't just want to rub an ice cube over it and let it rest. If it's actually a tendinopathy we're dealing with, so we want to kind of put you on the best regiment and it's not necessarily just doing heel drops, because you can think about just if you're a runner, how just doing heel drops off a stair might not be enough to get you back to full function.

So we need to start restoring some of that activity. Obviously we can definitely do lots of calf strengthening and we can work on muscles of the knee and the hip to kind of help support the chain a little more because that just helps any runner. And it can definitely help people with Achilles tendon problems.

And then we could do things like gait retraining, if it's that, that we suspect caused it. Somebody's a new runner, they haven't run before. We can kind of do some modifications to how they run and that could help them continue training, but ultimately they need to load the tendon. And that's where we come in and we design a program that's appropriate for that.

Most people are quite surprised by how much they could do load wise with a tendinopathy. And that's where, you know, sometimes getting the confidence from somebody who's telling you this is safe and here's how we do it. That could be very, very useful to kind of get things started. 

Mark: There you go. If you need some help with your Achilles tendon pain, you've got pain down your heel, around your heel. Get it diagnosed, know exactly what's going on and get expert help on what to do to get it better. You got to keep moving, but you need to know what the heck's going on and how to do it properly. And the experts, they've all been trained in this extensively at Insync Physio are the people to see. You can book online at their website insyncphysio.com or you can call the Burnaby office at (604) 298-4878. They're also in Vancouver at (604) 566-9716. Get in there and get some help. Get back fully active. Thanks Iyad. 

Iyad: Thanks Mark.

Mark: Hi there, internet people. It's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby. And we're going to talk about tendon pain. What's going on with pain in your tendons. Can even feel pain in your tendons? 

Iyad: Hi Mark. Good question. So we have tendons all over our body. In the upper limb and the lower limb. And it's kind of I guess the function of a tendon is to transmit the force of your muscles to your bone. And just saying my tendons hurt is probably doing the condition a disservice, because it's oversimplifying it. Because if you think about how we use our shoulders, it's nothing like how we use our legs and our Achilles tendon.

It's very different. You know, just all you need to do is see what a baseball pitcher does versus a hurdler, for example. And then you'll see how markedly different the structure is and the function is. And if you think about also the uses that tells you that the problems that you get in one is very different than the problems you would get in another. And this is kind of where I was hoping to explore with that today. 

Mark: Okay, well, let's compare and contrast then. What's the difference with Achilles pain versus knee pain? 

Iyad: So we have two different tendons there, like the knee gives a lot of structures there, but if we want to compare the tendons specifically, so we have patellar tendon, which is where our quads would be acting primarily. We see this primarily in adolescent males with a patellar tendon. And that's usually in adolescent males doing lots of jumping sports because that's where you need a lot of that explosive power to come in. It does affect females as well. But where we see in the data is that they show a market kind of selection towards that group.

And it tends to be just like repetitive jumping, and it tends to be tons of stuff involving like group of activities that involve the stretch shortening cycle of the muscle, where the muscle has to kind of start at a stretch contract and then explode out, think of like how you would compress the spring and let it recoil.

That's kind of what we use our lower limb tendons primarily as. And then the Achilles tendon will affect everybody from the adolescent, all the way up to our seniors and geriatric population. So it tends to affect everybody. But because we use them differently through the lifespan. You need your Achilles tendon to walk. That's a good way to kind of think about it. So imagine when you walk around a 5, 10 K walk, you're doing a few thousand steps. The way we're able to do that is a lot of that energy that we put into our system gets recycled by our tendons. So we don't have to put external energy all the time to carry over that function.

But then at the same time, I can't ask somebody to do 10,000 calf raises in a row because that won't work that same way. So this is where you differentiate the function of let's say the calf muscle versus the Achilles tendon. So yeah, it'll affect things differently. The function is different, which is really, really important because we always want to think about the function when we're thinking about how does this issue develop, but also what can we do to help them after a tendinopathy develops.

Mark: Right. So is tendon pain, always tendinopathy, which is basically the inflammation of the tendon? 

Iyad: So good question. And it's not inflammation. We used to think it's inflammation. So we used to treat these with rest and anti inflammatories and ice. The traditional kind of approaches and lo and behold, it didn't really work out so well.

And we know this, we have a ton of data now showing that the tendon itself starts to lose its ability to do that job that I was talking about, that springy job, where you get to compress it and spring out of it. And we think the way it happens is it goes through, like the healing is just, it's not a normal repair, it's a disrepair.

So it doesn't fix itself in a proper way. When it doesn't fix itself in a proper way, you lose that organization of the structure, which makes it not be able to do its job so well. And we know also the other thing about the, that it's not entirely inflammatory from this fact that exercise actually, and doing lots of exercise could be very helpful to fix the tendon and to help people with tendon pain versus making it worse. Because when you think of something that's really, really inflamed, you know, we'd want to usually just give it a bit of a rest, back off a bit. That seems to work in the short term only. And the only thing that rest from what we see in the data seems to do is just gets people better at rest. 

And I can talk about from the group of people that we work with at Insync, a lot of them are seeing us because they can't do their sports anymore. So it's not because they have pain when they're sitting and watching TV. It's usually you know, I can't walk as much anymore. I can't hit that hill. I can't run. I've lost the ability to jump. It depends on that. 

So I think making an important distinction that it's not inflammatory is really important from that point of view. And then, yeah, tendinopathy is the more accurate term to describe this because it describes all tendon pathology.

So first of all, when people would see us, we've got to figure out, is this actually the tendon or does this hurt somewhere near the tendon? So for example, if you have a patellar tendon issue, it would hurt just under your kneecap, but there's a lot of things that hurt in front of the knee. So that's where we want to test them, when we test their function. We test a few different things to make sure that we're actually dealing with the tendon problem. Because you wouldn't treat a tendon, a patellar tendon, the same way you treat a meniscus tear. Even though both of them can hurt them in front of the knee. 

So it's really important to differentiate the two. But yeah, tendinopathy is the term we would describe this general condition. And tendinopthy again, it just means tendon pathology and it could be for the upper limb or the lower limb.

Mark: Yeah. Or your digits, even your toes, I guess there's tendons everywhere throughout her body. 

Iyad: Absolutely. And then the other thing that we can have a tendon pain is sometimes an inflammation of the outer cover of it, which is a little different. And in that case you would treat it completely differently because like we said, inflammation needs its own kind of management strategy. So that's where you know, we've all done extra training on treating tendon pain and that's where we were able to just differentiate what we're actually dealing with. Is this just a an irritation of something that's near the tendon? That's looking like a tendon, but not behaving like a tendon.

So that's where you need a little more sometimes help. Because the stock approach of just ice and rest doesn't seem to help. And if you do sometimes general exercise, some people will tell you, yeah, I tried this thing that I found online and it worked. And then you get the same for one-to-one where the other person says it didn't work. It actually made it a bit worse. So this is where knowing what you're dealing with is really important. 

Mark: Absolutely. So one of the things I know from weight training, and being coached in that, is that the tendon now, is this true or not? I guess it's the first question. The tendon takes longer to get strong than the muscle does. And so that's why you need to be careful with your training regime and increasing the load. 

Iyad: That's a great question and it's true. So tendons and bones and muscles and all of our structures actually adapt to load. That's what we know about now. So for example, when you have a power lifter lifting really, really heavy weights they are keeping in mind, not just that their muscles need to grow and adapt, but also like that their bones need to be able to handle maybe a thousand pounds on a squat.

So that's where we don't want, for example, people to develop fractures and stuff like that, just from lifting weights, which again will happen with the powerlifter group maybe. And yeah, the tendons are a completely different structure. So you would imagine that they don't respond the same way as muscles. Muscles seem to be the quickest adapting of all of them, but then that's also generally speaking, there's always an individual that just struggles with this. And it could be a bunch of other factors, but yeah, a tendon is different and it takes longer to adapt. And this is really important when we're trying to program somebody who's exercise routine, that we don't just spike their volume willy-nilly, because that's a great recipe for an injury.

Mark: And what about the treatment options? You mentioned, it seems like there's a lot of exercise that can be done. And that's important depending on what the tendinopathy is. What kind of exercise would that be typically. 

Iyad: So we start with a different, it depends on the person, first of all. So some people where it's primarily a pain dominant presentation where they just can't do anything because it hurts so much. We would start them really light and the exercise tends to have a pretty decent analgesic painkiller effect. So we could pick something appropriate to that person. 

We have lots of different exercise options that have been studied. And the good news is a lot of it works, but it works differently. So for example, it's not a one size fits all. And if you come and see me and you're like, Hey, I hurt at kilometre 10 of my run when I'm trying to train for my marathon, I'm not going to treat you the same as the person who can't just walk down the street. And that makes a lot of sense. So this is where we want to avoid protocolized doing this thing and just making it a cookie cutter recipe. 

The exercises, there's all a whole bunch of stuff where we just train sometimes the muscle at the beginning to make sure that the muscle that helps scaffold the tendon almost, is able to do its job properly and help the tendon.

And then there are tendons specific things where we would try to train that ability of the tendon to absorb energy and release it. And usually we will do that depending on the person's tolerance and function and where they are in their training history as well. 

Mark: Is that more of an eccentric exercise?

Iyad: So eccentrics are useful for the muscle primarily. They do work a bit on the tendon, but they're not enough to get the tendon to restore its elasticity. And the first training program that came out was by Dr. Alfredson who tried to use eccentrics to tear his own Achilles tendon. So you can get a surgery on it and in doing so he ended up helping his issue.

So that's how we kind of first delved into this. Because nobody wanted to operate on him. He had achilles tendon pain and it was hurting him a lot, but then nobody's going to operate on it and then it's not sore. And so he tried to do this really aggressive eccentric program. And then eccentric is when a muscle starts really short, then it has the contract as it's stretching out as it's stretching out.

So that's what he tried to do with lots and lots of reps and ended up helping his condition instead of tearing his tendon. So, which takes me to my other point is that this is the other issue where people get scared. You know, especially when you see videos of, for example like in the NBA where somebody is doing a crossover and their Achilles just snaps and it makes them very fearful of movement and fearful of putting actual stress through the tendon. But we know it's pretty safe. We know it's the way forward. As of yet, as of where are our evidence is.

Mark: Tendon pain. It's complicated. Basically you need an expert to make sure you're being treated in the appropriate way. Because is it tendinopathy? Is it something else? What's actually going on? And the experts at Insync Physio in North Burnaby can drill into exactly what's going on and prescribe a course of treatment that will get you better quickly. As quickly as possible. So you can book online at insyncphysio.com. You can book at both locations. They have one in Vancouver as well. And the Cambie office is at (604) 566-9716. The North Burnaby office is (604) 298-4878. Thanks a lot Iyad. 

Iyad: Thanks Mark.

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:

1. Tendons need an appropriate and gradual loading program in order to recover
2. Rest is the most detrimental thing for a tendon
3. Passive treatments may temporarily help your pain, but they can be worse for your tendon in the long term 
4. PHYSIO CAN HELP! Walking the line between too much and too little load for your tendon can be difficult to navigate – this is what we are here for ☺ 

References

1. Lipman, K., Wang, C., Ting, K., Soo, C., & Zheng, Z. (2018). Tendinopathy: injury, repair, and current exploration. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5865563/.
2. Rio, E., Kidgell, D., Moseley, G. L., Gaida, J., Docking, S., Purdam, C., & Cook, J. (2015). Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. British Journal of Sports Medicine, 50(4), 209–215. doi: 10.1136/bjsports-2015-095215
3. Cook, J. L., Rio, E., Purdam, C. R., & Docking, S. I. (2016). Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British Journal of Sports Medicine, 50(19), 1187–1191. doi: 10.1136/bjsports-2015-095422
4. Cook, J. L., Docking, S.I. Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ‘tissue capacity’: a core concept for clinicians, (2015). Retrieved from https://research.monash.edu/en/publications/rehabilitation-will-increase-the-capacity-of-your-insert-musculos.
5. Gelber, J. D. (2016). CORR Insights®: Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clinical Orthopaedics and Related Research®, 475(1), 244–246. doi: 10.1007/s11999-016-5044-4
6. Dean, B. J. F., Lostis, E., Oakley, T., Rombach, I., Morrey, M. E., & Carr, A. J. (2014, February). The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24074644.