Tendons are those flexible cords of collagen tissue that attach muscles to bones and thereby move the parts of our body. They protect against the muscles from damage by absorbing external forces. When there is excessive load on tendons, for example during vigorous physical training such as sprinting or high jumping, damage and degeneration occurs as a result, AKA tendinopathy which will take you down the road of pain, swelling and impaired performance. If you are wondering how is someone likely to get tendinopathy, there are actually several risk factors that could lead to this painful condition such as:

• Repetitive movements (i.e. skipping rope)
• Training on hard or slanting surfaces,
• Fatigue
• Overstretching or repetitive stretching
• Quick directional changes (i.e. tennis, rugby, football)
• Poor technique (landing wrong from a jump),
• Muscle imbalance
• Improper joint alignment (i.e. foot pronation, hip rotation)
• Sudden forceful muscle contraction (i.e. high kick of ball, sudden jump)

All of the above factors can cause changes in tendon which if persisted can lead to tendinopathy; and the tendons commonly involved are Patellar tendon (knee), Achilles tendon (ankle), Hamstring tendon (hip). Now to discuss the important part of dealing with a tendon problem, this is what you should keep in mind:

1. Complete rest is not the solution, as complete rest will cause stiffening and scarring of the tendon. Introducing gradual loading exercises will actually allow healing (despite old beliefs) because it encourages collagen fiber repair.

2. Don’t ignore your pain. Pain management is important as pain can limit activity and function, preventing you not only from doing your exercises but also carrying out your daily activities such as stair climbing, getting up from a chair and so on. So pain relief using manual therapy, taping, icing, needling and more will help in reducing the pain to be able to do some form of activity as long as you’re not overloading it.

3. Load Tolerance: start with easy light isometrics exercises (such as static heel raises, static wall squats), then progress to eccentric/lengthening exercises (such as heel drop or single leg slides) and then progress to energy storage (such plyometric or explosive movements like jump/land or balance exercises).

4. It is okay to feel some pain or discomfort (especially in the beginning) after tendon loading exercises as long as pain, during exercises or after, does NOT exceed 5/10 (on a Numerical Pain Scale where 0 is no pain and 10 is maximum pain). Continue performing exercises until pain-free; stop exercises if it becomes disabling; progressively add load if pain-free after several sessions.

5. Functional activities. Always integrate functional exercises to develop and strengthen the body and joints in all movement patterns to allow you to continue your activities of interest.

6. Don’t do wrong exercises and waste time like stretching only or running:
   Tendons need to be loaded with spring-like exercises such as jumping, changing directions, and agility drills.

7. Don’t rely on passive treatments. Research shows that exercise-based treatment is more effective than using treatment modalities such as ultrasound, TENS, or stretching alone because increasing tendon tolerance (by loading it through exercise) is what is needed for it to heal and recover.

8. Don’t rush rehabilitation. Tendons take longer time to heal than muscles. Take your time until you build comfortable tolerance and are able to perform tendon-loading tasks with no pain such as single leg hops, jumps, sprints and so on.

9. Don’t use friction massage directly on tendon! It is already sensitive and tender to touch and this can irritate it further and create more inflammation, which will delay healing. Instead, release tissues around it like muscles, fascia, nerve mobilizations, dry needling and stimulation around the tendon.

10. Find out what caused or led to the person to develop a problem in the tendon in the first place and start by correcting it before allowing them to return to training or sports participation. For example, if pronated feet, suggest foot orthoses, taping or exercises to correct foot mechanics. If poor form/technique, assess movement pattern and use corrective exercises.

Bottom line, the key factor in managing tendinopathy is: RELATIVE REST and LOAD MANAGEMENT.  Also prevention is just as important so efforts should focus on identifying and correcting underlying risk factors and preventing them from causing a problem in the first place.

References:

Maffulli, N., Sharma, P. and Luscombe, K.L., 2004. Achilles tendinopathy: aetiology and management. Journal of the Royal Society of Medicine, 97(10), pp. 472-476.

Silbernagel, K.G. and Crossley, K.M., 2015. A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation. J Orthop Sports Phys Ther, 45(11), pp. 876-886.

Nermine F.