Do you have a tendinitis, tendinosis or tendinopathy?

Recent research has changed the thoughts behind what happens with tendon injuries to areas such as the Achilles' tendon, the rotator cuff and tennis elbow problems. It was previously thought that the tendon became inflamed but in many instances, there is minimal inflammation meaning accurate physio diagnosis as to the pathology behind your tendon pain is essential to get the right treatment. Tendons are the tough fibres that connect muscle to bone. Most tendon injuries occur near joints, such as the shoulder, elbow, knee, and ankle. A tendon injury may seem to happen suddenly, but usually it is the result of repetitive micro tendon overloading. Health professionals may use different terms to describe a tendon injury. You may hear: Tendinopathy literally means a disease or disorder of a tendon. Tendinopathy can be used as an umbrella term to describe all tendon conditions, whilst others may use it to describe a chronic, degenerative tendon condition. Tendinitis: “Itis” means "inflammation”, however, true tendinitis is rare but the term is still used by many doctors which may cause confusion about the appropriate treatment. When present there is usually acute pain, swelling, redness and the area may be warm. Tendinosis (or often tendinopathy) is the accumulation over time of repetitive, micro-trauma to the tendon with the inability of the tendon to adapt quickly enough to stress placed upon it. Why does tendinopathy happen? Tendons are designed to withstand high, repetitive loading, however, on occasions, when the load being applied to the tendon is too great for the tendon to withstand, the tendon begins to become stressed. When tendons become stressed, they sustain small micro tears, which encourage inflammatory chemicals and swelling, which can quickly heal if managed appropriately. However, if the load is continually applied to the tendon, the repair process cannot keep up with the stress placed upon it and healing is in complete and changes occur in the tendon.

Causes?  A sudden increase in the intensity, frequency and duration of activity.  A sudden fall or trip  Forceful jumping or pivoting, or sudden accelerations of running  Inadequate recovery time between activity.  Wearing inadequate or incorrect footwear.  Running on hard or uneven surfaces.  Change of surface (seasonal).  Poor muscle flexibility or strength (e.g. tight calf muscles, weak calf muscles).  Inadequate warm up, stretching and cool down.  You are most at risk if you are diabetic, post or peri-menopausal or have a high BMI. Stages There are generally 3 stages that a tendon injury may go through and should be regarded as a continuum or natural progression: 1. Reactive tendinopathy – This is the normal tissue response to a sudden, increase in loading of the tendon eg. adding hill running or cutting hedges. There may be some inflammation initially, although, this is largely the body adapting to the increased load and is essential for the body to repair. The use of anti-inflammatories is currently controversial with some authors advocating the use at this stage and others believing it will suppress the body’s natural ability to heal. This stage is reversible, lasting around 5-10 days if managed correctly and the prognosis is good. 2. Tendon disrepair – If the excessive load is not being reduced in the reactive stage or the healing process fails to repair, the tendon structure begins to change. The injury rate is greater than the body’s ability to repair. Prognosis remains good as the tendon is attempting to heal but it is important to prevent deterioration with good advice and management. 3. Degenerative tendinopathy –It is characterised by collagen degeneration in the tendon due to repetitive overloading and it becomes less efficient at dealing with load. Tendon will appear thickened and may be more at risk of rupture. These injuries take much longer to heal. 4 Tendon tear of rupture - full disruption of the tendon causing complete loss of function. Poor prognosis and operation may be the only option. What are the Symptoms of Tendinopathy?  Pain – worse with use  Stiffness – often after activity or in the morning  Loss of strength in the affected area.  The area may be tender, red, warm, or swollen if there is inflammation.  You may notice a crunchy sound or feeling when you use the tendon. Physiotherapy Tendon injury is best managed by a physiotherapist with an interest in tendinopathies as accurate diagnosis and a good rehabilitation program are essential for recovery. They will:  Assess – general health, behaviour of the symptoms, physical examination, diagnosis  Determine the stage of the condition  Understand the changes in load preceding the onset  Give you appropriate advice and exercises. Doing eccentric exercises during the wrong stage of the condition will make it worse! What's the Treatment? 1. Reduce the load –Rest is not always about total rest but enough reduction in the load to reduce stress on the tissues. Initially avoid aggravating activities but keep the rest of your body moving. Your physio will advise how best to do this and guide you are how to adjust load appropriately. 2. In certain areas, tendons become compressed for example around the hip in sitting. Avoid sustained compression where possible. Stretching often causes compression eg. Calf stretching will cause additional stress and compression on the achilles tendon and may prolong the reactive phase of an injury. 3. Ice for swelling and when very acute in first few days of onset. 4. Massage – avoid massaging the tendon in the reactive phase but use of myofascial techniques and foam rollering the muscle belly may prove effective. 5. Strengthening – Rest alone will not be sufficient. It is vital to address any strength issues. Exercises need to be specific for the phase of the condition and are not the same for every person. Isometric exercises where the muscle is held in a static potion can be helpful. These can then be progressed to eccentric and resistance training and loaded drills once the tendon is ready. These must be taught by an appropriately trained physio as many examples on the internet do not show them correctly performed. It is also essential to strengthen up adjacent areas and correct movement patterns 6. Be patient! You may need to modify how you do things - making long term changes to improve your technique or biomechanics will take time to become habitual. 7. When you resume your activity take time to build up gradually so that the tendon can take time to get stronger and adapt to the new loads. Tendons often don’t react until 24 hours later so make sure you do not load the tendon each day initially until you are sure whether it has reacted positively. Prevention  Using correct technique to limit excessive stress on the tendon – have lessons and use video feedback  Do regular strengthening and stretching sessions to maintain muscle strength and flexibility not just relying on your sport or activity to keep you fit. Get fit to play sport – do not use sport to get you fit.  Always warm up and cool down carefully – Physiofit can help you with this to teach you sport specific and individually specific drills.  Gradually increasing the intensity and duration of training – no sudden peaks in volume or intensity  Take care at the beginning of a season, after a lay off or when starting a new activity to avoid the mistake of too much too soon.  Allowing adequate recovery time between workouts or training sessions.  Don’t train when you are ill or tired. Injury risk is higher when you are ill or tired.  Listen to your body – if it is hurting address the issues as to why – don’t ignore it!  Eat well, drink plenty of water and keep a normal BMI.  Wearing appropriate shoes for the activity.  Stop ageing!! Tendon strength can lessen with age so avoid getting old!

Call 01625 590444 to talk to Jean or make an appointment.