VITRUVIAN EXERCISE PHYSIOLOGY
News & Information
TENDINOPATHY
What is 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:
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Increased tendon cell activity and metabolism
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Disorganisation of collagen fibres
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Release of substances within the tendon that can sensitise it (e.g., substance P, glutamate)
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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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Factors that can impact stress on the tendon, including:
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Activity and training loads
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Muscle weakness
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Previous injury
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Biomechanics
Factors that can impact repair and adaptation of the tendon, including:
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Age
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Genetics
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Systemic health (obesity, diabetes etc)
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Medications
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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
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Pain provoked by activities that load the tendon
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Pain on palpation
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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
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Stimulate normal cell activity – tendon cells respond to loading (high loads appear to be most effective)
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Increase load bearing capacity of the tendon
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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:
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Give rehab enough time – 12 weeks minimum
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Structured, progressive overload of the tendon and tendon-muscle unit
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Respect but don’t be scared of pain – focus on improving function rather than focusing on pain
Phase
Aim
Treatment
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4
5
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Sports specific training
Prescribing isometrics in mid range, reducing compressive loads and using stretch-shorten cycle
Reducing pain
Prescribing slow heavy resistance training in
non-compressive positions
Improving strength
Progressing strength work into more functional tasks with a focus on treating movement dysfunction
Building functional strength
Reducing reps but increasing speed of muscle contraction to build power
Increasing power
Introducing plyometric exercises +/- graded return to running
Further developing stretch- shortening cycle
Adding specific drills to sport and lifestyle
The stretch-shorten cycle (SSC) refers to a biomechanical phenomenon whereby a tendon undergoes a “pre-stretch” phase or countermovement action typically observed in human actions such as jumping. This “pre-stretch” allows the individual to produce force or move quickly due to the storage of elastic energy in the tendon (think the stretch and bounce back of an elastic band).​
Some interventions can help reduce pain temporarily, which of course adds value, but may not help with improving the health of the tendon in the longer term.
These include:
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Ice
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Massage
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NSAIDs (non-steroidal anti-inflammatories)
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Needling (may irritate the tendon)
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Stretching (evidence is not conclusive but it appears stretching isn’t relevant in tendinopathy, and in some cases may be detrimental).
Rehabilitation for tendinopathy primarily requires an active approach rather than a passive one.
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