Tendinopathy: 10 Things You Need to Know - Pt 2
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 2! Click here to go back and read part 1 if you missed it!
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!
4. Managing reactive/early dysrepair tendinopathy
The most important concept in this stage is load management; both tensile (tension along the tendon) and compressive (compression across the tendon) loads must be considered. Tensile and compressive loads can occur at any tendon in the body.
An example of tensile load -> tension along the achilles tendon that occurs with running.
An example of compressive load -> compression across the hamstring tendon at the ischial tuberosity (bone you sit on). Compression here can occur with hamstring stretching/hip flexion (lifting the knee up).
Each time your foot contacts the ground during running your body has to deal with an impact force equal to roughly 2.5x your body weight. Fortunately tendons are thought to be able to withstand up to approximately 8x body weight.
An example of three ways to reduce the tensile load through the achilles tendon include:
- decreasing how far we run,
- decreasing how fast we run, and
- taking a short break from running.
An example of compressive load can be seen with proximal hamstring tendinopathy (right image above). In this condition, the tendon is thought to be compressed against the ischial tuberosity when the hip is flexed; and even more compression occurs with sitting. Reducing time spent sitting is a simple way to reduce this compressive load. And, obviously, combining compressive and tensile loads is even more provocative. Consider lunging, running uphill, or stretching the hamstring muscles; in these examples both tensile load and compressive loads are occurring - ouch!
Cook and Purdam (2012) have created the following table summarising common compression sites and potential modifications that could be made:
The reactive stage often settles relatively quickly - provided you don't continually piss it off! Prof Jill Cook (Aussie tendon guru and researcher) says pain may settle in 5 to 10 days - but the tendon will still be sensitive to high loads and training needs to be progressed gradually to stop further deterioration.
Be guided by how the tendon responds NOT just immediately following exercise, but also 24-48hrs after! Tendons are known to have a latent response to loading; they can take 24hrs or more to react to what you've done. Bare this in mind when running – it may feel fine at the time but react the next day!
Isometric exercise is where the muscle works against resistance without creating joint movement or changing muscle length. Isometrics work the muscle without movement. Specific isometric exercises are recommended depending on the area of the tendinopathy. I recommend asking your physio to show you specific exercises pertinent to your case.
Isometrics are my favourite intervention for reactive tendinopathy for a few reasons:
1) it can reduce pain in the short term,
2) it can maintain muscle/tendon/bone health and strength,
and 3) it fosters independence (rather than reliance) regarding pain management.
A very bored looking gentleman performing an example of isometric hip adduction.
Don't perform isometric exercise in a position where the tendon is compressed - duh!
Exercise or rest?
Choosing to exercise or rest is can sometimes be a complex decision as a number of different factors can come into play.
- Are you training for some event or just training in your off-season?
- How severe and irritable are the symptoms?
- Can you find a way to exercise without pain?
- Both at the time and 24-48 hours later?
- How is your body generally?
- Are you struggling with a host of niggles that need some rest?
- What is the bigger picture here?
- Will timely rest now stop this from becoming a chronic, long term issue?
This tip is a little bit controversial. However, I think as a general rule, it's sensible to avoid stretching reactive tendinopathies as this often annoys them! Occasionally, your muscles can feel tight - if this is you, still don't stretch! Instead, try a foam roller or massage ball. However I would work the main bulk/belly of the muscle and avoid pressure over the tendon area.
As we've seen, load management is the most important concept in managing a tendinopathy. It s a balancing act though. Do too much and you'll piss it off, do too little and there's no stimulus for positive adaptation. Finding the balance is a little bit of trial and error. But the take-away is that complete rest is crappy advice; you should find some tolerable amount of exercise and progress slowly from there. If I'm dealing with a runner, a good place to start is pain-free walking, then progress to brisk walking, then jogging on the spot, then running. The best guide though is to see a qualified health professional and take their advice.
Moreover, starting with short distances or commencing with a walk-run pattern seems sensible. The temptation to increase the distance and/or pace may be there if the pain is negligible - however you must resist this urge! Observe how it responds over the next 24-48hrs and slowly progress if there are no flare-ups. Anecdotally, some patients report feeling worse when running first thing in the morning so make sure you toy around with the time you choose to exercise.
If your tendon is really pissed off and you're desperate to train/worried about losing some fitness, cross-training is usually a good option. Simply choose exercises with little tensile or compressive load - think, swimming, cycling, some resistance training, cross-trainer etc.
This has been part two of our tendinopathy series. Part three coming soon!
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