Back in the day, we all used to assume that the same thing happened to a tendon when it got injured as when anything else in the body got injured – it became inflamed, and then following a period of rest you essentially rehabbed it and it got better and went back to what you were doing. Except that this approach didn’t produce very good results.
At the end of the nineties and into the ‘noughties, some clever researchers discovered that inflammation was NOT a characteristic of painful tendons, which in turn explained why taking anti-inflammatories were not particularly effective either. This also meant that we could no longer refer to tendinitis using the suffix –itis, which refers to inflammation (think appendicitis, hepatitis, arthritis, and so on). Thus, the term tendinopathy was born, and is the term currently used to describe tendon damage.
So what does happen in Tendinopathy?
Without wanting to blind you with science, tendinopathy is what is now considered a ‘failed healing response’. When you do something like exercise, in essence you are challenging your body’s tissues. They respond by reinforcing themselves, thereby gradually getting stronger. Leg bones in runners will be subtly thicker & denser that those in swimmers on account of adaptations to repetitive impact, for example. Muscles will of course respond the same way when subjected to stress by lifting weights at the gym.
A critical component of this response is the time it takes for the body to adapt to an episode of stress. Too little recovery time leads to tissue breakdown, like a stress fracture, in the case of bone, or the development of tendinopathy in a tendon. A tendon takes longer to recover than muscle does, so if you ramp things up too quickly, there isn’t enough time for the tendon to adapt before it’s being hit with another load of work. This ‘kicking it while its down’ approach sends the cells driving the adaptation response haywire (aka tenocyte activation), leading to pain and eventually to degenerative changes in the tendon. It also explains why anyone, from a recreational exerciser through to an elite athlete, can develop tendon problems, as it’s about how fast things get progressed, not the level of activity someone is operating at.
These discoveries led to a further flurry of research, out of which have developed improved assessment and more specific management options, although tendons remain a testing tissue to treat…
How we treat tendinopathy today
The pathology of tendinopathy has been further refined in the past 5 years such that we now look at it as having a number of stages. What stage of tendinopathy you have influences what type of management is most appropriate.
Management techniques range from different forms of exercise (isometric, eccentric, isotonic, ballistic), hands-on treatment, medications, injections & surgery. Physical Therapists, with their training in pathology and therapeutic exercise, are uniquely placed to guide you through the how’s and why’s of getting your tendon healthy again.
Underpinning all of this is a carefully designed and progressive exercise program. The challenge in formulating such a program is juxtaposing the need to bring a patient’s activity level up to where they want it to be with the knowledge that a damaged tendon will get angry if you progress things too quickly, and that it take.