Tendinopathy is a term used to described pain or dysfunction in a tendon with structural changes that are often chronic in nature. It is frequently seen in clinical practice with the most commonly affected tendons being the Achilles, patella, rotator cuff and elbow. Tendinopathy is a complex condition that can often take many months to recover from. Often referred to as tendinitis, tendinopathy does not involve inflammation of the tendon. Therefore, traditional methods used to control inflammation, such as medication, rest and ice do not seem to improve a person’s long-term function.
Tendinopathy is largely a clinical diagnosis based on symptoms and patient history. Common symptoms include:
- Pain with tendon loading (e.g. running, throwing, jumping)
- Reduced exercise tolerance/impaired function
- Pain with palpation over the tendon
Tendinopathy often develops due to a change in loading through the tendon. This can be due to a sudden increase in training load or due to having a long period off exercise, leading to a weak tendon. Unlike muscle, tendons take a long time to adapt to new stimuli and can easily get damaged if changes in load are to large.
Although imaging such as ultrasound and MRI is accurate for diagnosing tendinopathy, it often does not have a direct relationship to the amount of pain you may be experiencing. It is useful in determining if any structures near the tendon may be irritated that could be contributing to your pain. Structures such as bursa can often be inflamed and which may respond to medication or short periods of rest or ice. It is not uncommon to have inflammation in structures around the tendon in addition to tendinopathy.
A review by an experienced physiotherapist in addition to some imaging can help to be as specific with your diagnosis as possible and determine the best course of treatment and long-term management.
There are a few key points to consider when rehabilitating your tendinopathy. It is a complicated condition and will often take many months for your pain to settle and return to normal sporting activities pain free. The majority of this blog will focus on exercise, as this is the most evidence-based treatment for tendinopathy. Before discussing exercise options to improve tendon strength we will touch on a few common treatment options:
- Rest: tendinopathy does not improve with rest as it does not improve the affected tendon’s response to load. Although pain may initially settle, it often returns with a return to activity
- Anti-Inflammatories: these may help reduce pain levels but have no effect on tendon structure, as it is not considered an inflammatory condition.
- Shockwave Therapy: Evidence on shockwave therapy is mixed, mostly due to the type of study conducted. The best evidence is in plantar heel pain (e.g. plantar fasciitis). It does seem to have a good short-term effect on pain and therefore is often a useful adjunct to exercise.
- PRP Injections: Overall, there is poor evidence for any type of injection in tendinopathy. Currently one of the most common options is a PRP injection. PRP injections are derived from spinning a blood sample to separate the platelets that contain growth factors and promote healing. This is then injected into the tendon to stimulate healing. In good quality studies PRP does not perform better than placebo. In fact, it was removed from the Medicare rebate scheme due to lack of evidence and the high cost. It therefore should only be considered a last resort in stable tendon pain.
Tendons need to be loaded progressively so that they can adapt and develop a tolerance to each individual’s specific activity. In most cases, tendinopathy will not improve without this increase in loading. Although rest does not heal tendons, there is a need to modify some aggravating factors in order to allow the tendon time to adapt to the exercises. Exercise needs to be individualised based on your individual pain, function and goals. Current evidence supports a progressive exercise program that is progressed over months according to each person’s response. These programs can be broken down in to 4 key phases:
- Isometric Exercise (pain relief): recent evidence shows long sustained holds for 5×45-60sec may have a pain relieving effect in tendinopathy.
- Strength: once symptoms allow, progressing to specific heavy, slow exercises of 4×6 up to 3x per week allow for muscle growth.
- Power & Speed: reducing weight from phase 2 but increasing speed, up to a maximum of 3 sessions per week.
- Sport Specific: every 2-3 days while continuing strength exercises.
As you can see, tendinopathy is a complicated condition that requires a very clear and multifaceted approach to achieve the best possible outcomes. Unfortunately, there is no shortcut or quick fix to treating tendon pain. Exercise is the best medicine, with everything else being an adjunct to a well planned, personalised and progressive rehabilitation program. It is important to get a review by a therapist confident and experienced in treating tendinopathy as it can often be a debilitating condition that will hang around for months without appropriate treatment.