Tendinopathy: 10 Things You Need to Know - Pt 1
Tendinopathy (also known as tendonitis and/or tenosynovitis) is a tendon disorder that can develop in any tendon in the body and results in pain and impaired function. Here are 10 things you need to know - part 1!
WARNING: While I've done my best to make this series interesting, it's slightly more information dense than some of our other posts - but persevere! Knowledge is power and the reward for your hard work is manifold! Of course, you could always book in with of our physios here and let us do the hard work for you if you prefer!
1. Tendinopathy has three different stages:
i) reactive tendinopathy,
ii) tendon disrepair, and
iii) degenerative tendinopathy.
It’s best to think of these stages as a continuum rather than three distinct phases (see figure below).
a. Reactive tendinopathy "is a short-term adaptation to overload that thickens the tendon, reduces stress and increases stiffness. The tendon has the potential to revert to normal if the overload is sufficiently reduced or if there is sufficient time between loading sessions" (Cook and Purdam, 2009). Expert physiotherapist, Tom Goom, writes, "[we] thought this reaction involved inflammation but we now understand this is not the case. The tendon does swell but this is due to movement of water into the tendon matrix and not inflammatory products. A key feature of a reactive tendon is that structurally it remains intact and there is minimal change in collagen integrity."
Histopathological appearance of reactive tendinopathy/early tendon dysrepair. Note the increased cell numbers and intermittent cell rounding with some evidence of increased ground substance (light blue shading)
Histopathological appearance of late tendon dysrepair/degeneration. Note the markedly increased cell numbers, the loss of collagen evidenced by the loss of longitudinal rows of cells, and the increase in vessels.
Tendon dysrepair "describes the attempt at tendon healing, similar to reactive tendinopathy but with greater matrix breakdown. [...] There may be an increase in vascularity and associated neuronal ingrowth. [...] Some reversibility of the pathology is still possible with load management and exercise to stimulate matrix structure." (Cook and Purdam, 2009)
Again, it's important to note that attempts at staging tendinopathy include modest degrees of subjectivity. As we're dealing with a continuum, no objective "lines" exist whereby one can positively assert that someone has progressed/ regressed from one stage to another.
c. Degenerative tendinopathy involves "areas of cell death due to apoptosis [planned cell death], trauma or tenocyte [tendon cell] exhaustion [...] As a result, areas of acellularity have been described, and large areas of the matrix are disordered and filled with vessels, matrix breakdown products and little collagen [boo!]. There is little capacity for reversibility of pathological changes at this stage.
An analogy might be when you piss off the missus - if you apologise quickly and admit you're a moron, all may be forgiven (reactive tendinopathy)! But if you persist in your stupidity (keep overloading the tendon), the relationship may not heal and you could be kicked out for good (degenerative tendinopathy)!
Pathology continuum; this model embraces the transition from normal through to degenerative tendinopathy and highlights the potential for reversibility early in the continuum. Reversibility of pathology is unlikely in the degenerative stage.
2. Management of tendinopathy depends on its stage:
i) reactive/early dysrepair and
ii) late dysrepair/degenerative.
Management varies considerably between these two stages so getting assessed by a physio is very important. Goom writes, "Many runners will have heard of “eccentric” exercise for tendon problems and may be trying ‘heel drops’ for Achilles tendinopathy or other eccentric exercises. This will probably make things worse in a reactive tendinopathy but might help in the degenerative stage – this is why staging is so important! If you don’t identify the correct stage you could well be making your problem worse!"
To continue the analogy, if you think your wife is mad because you continually leave your beard trimmings in the sink when in actual fact you forgot your wedding anniversary (and you continually leave your beard trimmings in the sink), she gon' be mad! And your problem may be made worse if you think some $15 flowers from Woolies will suffice!
The 'donut analogy' for tendinopathy: the unhealthy part of tendon is the hole and the healthy tendon is the yummy donut bit. If you don't rehab the tendon appropriately the disruption can worsen (i.e., make the donut hole bigger).
3. Tendinopathy does not improve with complete rest
Rest is one fo the most important variables in managing tendinopathies. We often hear that because some activity is painful it should be completely avoided. This is not helpful. Completely offloading the tendon (e.g., bed rest, couch time/Netflix, hopping around on crutches, etc.) may settle the pain, but returning to activity is often painful again because rest does nothing to increase the capacity of the tendon to load. Tendons will adapt to load if given appropriate rest. Sometimes a tendon may be able to be loaded more than once in the same day. Sometimes a tendon will need a few days to recover - it depends on the individual and on the exercise/s chosen.
For those of you who enjoy running almost every day, some sensible options to manage pain include rest days after longer or more intense sessions, performing some other mode of exercise instead (this is called 'cross-training'), or opting for some slow 'recovery' runs.
This has been part one of our tendinopathy series. Part two coming soon!
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Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy, British Journal of Sports Medicine 2009;43:409-416.