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TENDINOPATHY

What is Tendinopathy?

Tendinopathy

Tendinopathy refers to localised tendon pain that is associated with load-bearing activities.  Commonly affected tendons are the Achilles, patellar (knee), gluteal, hamstring, elbow, and rotator cuff (shoulder). 

 

The most frequent trigger for tendinopathy is an unusual or unaccustomed loading event (doing too much, too soon, or something quite different from normal).   Other factors can make us susceptible due to the underlying health of the tendon. 

 

The onset of symptoms can be gradual or sometimes there is a clear ‘moment’. Repeated mechanical overloading alters the homeostasis of the tendon tissue, moving it from a healthy to an injured state. The tendon then begins to undergo structural changes, including: 

 

  • Increased tendon cell activity and metabolism 

  • Disorganisation of collagen fibres  

  • Release of substances within the tendon that can sensitise it (e.g., substance P, glutamate) 

  • An increase in blood vessels, nerve supply, and water content  

 

In this state, activities that previously were pain free may now be painful.  In the very early stages of tendinopathy there appears to be some level of inflammatory response, however, inflammation is not a key component of this condition as it progresses.  

Risk Factors

Risk factors for tendinopathy fall into two broad categories: 

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tendon_edited.png

Factors that can impact stress on the tendon, including:

  • Activity and training loads 

  • Muscle weakness  

  • Previous injury  

  • Biomechanics 

tendon_edited.png

Factors that can impact repair and adaptation of the tendon, including:

  • Age  

  • Genetics 

  • Systemic health (obesity, diabetes etc) 

  • Medications  

  • Lifestyle factors such as sleep, stress, and sedentary behaviour  

Diagnosis

Taking a thorough history is key in determining relevant changes to recent activity levels and the presence of additional risk factors.   

 

Clinically, tendinopathy is diagnosed when the following are present: 

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  • Pain localised to the tendon  

  • Pain provoked by activities that load the tendon  

  • Pain on palpation  

  • Thickening of the tendon. 

 

If the above are present, imaging is generally not required. Imaging might be requested if the diagnosis is uncertain, other causes are suspected, or the tendon fails to respond to rehabilitation.   

Role of Exercise in Management & Treatment

Current best evidence points towards a structured and progressive loading program for tendinopathy. Aims of rehab include: 

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  • Manage pain symptoms  

  • Stimulate normal cell activity – tendon cells respond to loading (high loads appear to be most effective)  

  • Increase load bearing capacity of the tendon  

  • Restore neuromuscular function of the surrounding muscles – this will act to shock absorb and protect the tendon, allowing it to remodel and repair  

 

There isn’t one ‘best’ rehab program. The details will be dependent on individual circumstances, including pain severity and irritability, risk factors, and end goals.  To increase the likelihood of a positive outcome, the following underpinning principles should be adhered to: 

 

  1. Give rehab enough time – 12 weeks minimum  

  2. Structured, progressive overload of the tendon and tendon-muscle unit  

  3. Respect but don’t be scared of pain – focus on improving function rather than focusing on pain 

tendon Achilles rehab program

Interventions that do not help with the health of the tendon over time include:

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  • Ice 

  • Massage 

  • NSAIDs (non-steroidal anti-inflammatories)

  • Needling (may irritate the tendon)

  • Stretching (evidence is not conclusive but it appears stretching isn’t relevant in tendinopathy, and in some cases may be detrimental).

 

Ice, massage, and NSAIDs can help reduce pain temporarily, and of course, there is value in this.  It is useful to recognise, however, there is a difference between interventions that make us feel better temporarily and those that help with tendon structure and health over time. Rehab for tendinopathy primarily requires an active approach rather than a passive one. 

 

Shown here is an example framework for a tendon (Achilles) rehab program.

 

The end goal of rehab is different for each individual. High level sports people must progress to dynamic power work to ensure the tendon is ready for a return to sport.  For a majority of those with tendinopathy however, this end stage rehab is not necessary.  Returning to normal everyday activities without pain is a common goal, and importantly, an achievable one.   

The Vitruvian Team.

Lower limb tendinopathy 

O’neill. Physio network. 2022 

 

International Scientific Tendinopathy Symposium Consensus: Clinical Terminology 

Scott et al. British Journal of Sports Medicine. 2019 

 

Early development of tendinopathy in humans: Sequence of pathological changes in structure and tissue turnover signalling 

Tran et al. FASEB Journal. 2019 

 

Dutch multidisciplinary guideline on Achilles tendinopathy 

de Vos et al. British Journal of Sports Medicine. 2020 

 

Diagnosing Achilles tendinopathy is like delicious spaghetti carbonara: it is all about key ingredients but not all chefs use the same recipe

de Vos et al. British Journal of Sports Medicine. 2020 

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