Tendinopathy

By Prem Parmar | Feb 22^nd, 2021

Tendinopathy

I wanted to make a post on Tendon pathology because of how prevalent it is and how understanding the condition a bit better would help people understand their rehab. I hope this post helps anyone with tendinopathy or anyone with an interest in it learn about it. The latter half of the post is rehabilitation concepts I found useful when reading up on the topic and I thought it may help my fellow clinicians.

What are Tendons?

Tendons are tissue in your body that connect muscle to bone. They have many functions, but primarily they help transmit force from your muscles to help you move.

What is Tendinopathy?

Tendinopathy is a failed healing response of a tendon with abnormalities of tenocytes (tendon cells), and a disruption of the environment around the cell including collagen fibres, and other proteins³.

Tendon pathology does NOT always mean inflammation²
Collagen tearing in your tendons is NOT the primary driver of tendinopathy²

A Continuum

Current research believes Tendinopathy is a continuum with different parts of the tendon potentially being in different stages of healing¹

You have structurally normal parts of the tendon
As well as the degenerative portion of the tendon, which appears mechanically silent and therefore unable to transmit muscle force like normal tendon tissue¹

What About Pain?

Interestingly, the degenerative/pathological section of the tendon does not seem to be related to pain².
- The nerves that transmit pain information in the tendon are in the peri-tendon² (the outer region).
Therefore, pain management often targets the peri-tendon¹:
- Shockwave therapy
- NSAIDs
- Corticosteroid injections
Addressing pain is critical, it’s the primary reason patients will see a physiotherapist. However, interventions directed solely at pain have a minimal effect on the function of the tendon, and may result in the recurrence of pain¹.

Treat the donut, not the hole!

Newer research shows that pathological portions of tendon have limited reversibility².
Luckily, the healthy portion of tendon can compensate for the pathological portion by increasing the amount of “healthy tendon tissue”².
However, the amount of healthy tendon is not enough to prevent further tendinopathy²; To prevent tendinopathy, we must strengthen the healthy portion of tendon through progressive exercise².

Exercise!

Deficits are not only seen in the tendon with tendinopathy^1,2. Deficits are also seen in:

The attached muscle
The kinetic chain
Brain function/motor control

That’s why Physical Therapy and exercise are crucial to helping you get back to doing the things you love!

Four Stages of Rehabilitation

Stage 1

Isometrics

To reduce pain
No compression

Stage 2

Strength

Muscle/kinetic chain strength
Functional strength
Strength endurance
No compression

Stage 3

Energy storage

Faster
End of range eccentric
Add compression

Stage 4

Energy storage and release

Sport specific loading
Compression

For Fellow Clinicians

As physiotherapists I feel we need to better identify, consider, and treat the specific loads tendons are meant to withstand.

Energy storage loads (Spring loading of our tendons)
Compressive loads (compression of tendons on bony prominences)
Friction loads (between the tendon and different surfaces surrounding it)

As clinicians I feel we do well at early rehabilitation; I want to draw attention to later stages of tendon rehabilitation, as these are concepts I myself tend to neglect.

Energy Storage Loads

At the necessary point in rehabilitation, therapists should introduce exercises with speed².
This allows the tendon to act like a spring, by storing and releasing loads that are necessary for relevant physiological function.
The speed and functional activity should mimic functional loads of that specific tendon.

Compressive Loads

At a similar point in rehabilitation where function is improving, therapists should aim to introduce movements that increase compressive loads².
This allows for tendons to withstand compression that mimics “normal” physiological function.
An example is compressive load of the Achilles tendon at end-range dorsiflexion⁴.
These loads are typical during the push-off phase of gait.

References

Cook, J. L., et al. "Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?." British journal of sports medicine 50.19 (2016): 1187-1191
Jill Cook – Current concepts in tendon rehabilitation. Web seminar.
https://physiopedia.com/Tendinopathy?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal
Cook, Jillianne Leigh, and Craig Purdam. "Is compressive load a factor in the development of tendinopathy?." British journal of sports medicine 46.3 (2012): 163-168.