Tendon Pain with Iyad Salloum

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.