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Tendon Troubles
A common area for injury
If you’ve ever experienced a tendon injury, you know first-hand how disabling it can be. Whether it happens with a sudden snap or appears as weakness that worsens over time, tendon injuries need appropriate care. Tendons are tough, fibrous connective tissues that join muscles to bone throughout the body. As muscles contract, tendons pull on bones, creating movement. Tendon injuries are very common, affecting both the elite athlete and the everyday person. Damage to tendons occurs in two ways – as tendon tears or as tendinopathies.
Tendon tears
Tendon tears can be acute or chronic. Acute injury to a tendon happens suddenly, as when a tendon is cut or torn with movement. With tearing from movement, people often feel a painful snap, and may hear a loud pop. Those who have torn their Achilles tendon often say it felt like someone hit the back of their leg with a racquet. Traditionally, surgery was used to treat acute complete tendon tears. However, recent research suggests that such tears, including damaged Achilles tendons, can be treated just as well without surgery. In any case, all suspected acute complete tendon tears should be seen by a doctor.
With chronic tendon tears, the tendon breaks down (degenerates) over time. Such injuries are often described as wear-and-tear injuries. They are so common that some studies suggest as many as 80 per cent of people over the age of 80 have some type of shoulder rotator cuff tear.
Think of the tendon as a rope fraying over time. The damage may cross the entire tendon (a complete tear) or be only partway across (a partial tear). If the surrounding tendons and muscles adapt, people with these types of tears may be completely unaffected. Others may experience pain and weakness. Such tears are almost always treated without surgery.
Tendinopathies
Tendinopathies include a wide range of tendon injury, including acute inflammatory tendinitis, degenerative tendinosis, tendon sheath tenosynovitis, and partial and/or complete tendon tears. People often complain of thickening and pain in a specific area along the affected tendon.
Tendinopathies can occur over time. They begin when the tendon is repeatedly put under more load than it can handle. At first, the tendon will try to manage the added load by thickening. However, the newly-made tendon is not strong enough to handle the extra load and may begin to break down. Not only will the tendon be unable to handle the extra load, it can lose the ability to accept the load it was once able to bear.
Eventually, the tendon will completely break down. New blood vessels will develop within it as the body tries to repair the area. This further reduces the tendon’s ability to handle load. Next, surrounding healthy tendon becomes burdened with the extra load that the diseased tendon cannot manage. Eventually, healthy surrounding tissues break down too, creating a cycle of injury.
Increased risk
A number of risk factors exist for tendon injuries. The most obvious is an increase in load, often resulting from added training time or intensity. While not an exhaustive list, other risk factors include:
- aging
- a heavier body weight/body mass index (BMI)
- surrounding muscle weakness or tears
- bad form (doing an exercise or activity in a way that is hard on the body)
- biomechanical abnormalities causing malalignment of body parts, resulting in abnormal forces through a given tendon. For example, hip width, the shape of the patella (kneecap) and the shape of the femur (thigh bone) combined with various surrounding muscle imbalances can all contribute to patellar tendinopathy.
- changes in training surface or environment
- changes in footwear
- antibiotic use (such as fluoroquinolones).
| Tendon | Activities that aggravate the tendon |
|---|---|
| Rotator cuff (supraspinatus, infraspinatus, teres minor, subscapularis) |
Heavy lifting
|
| Biceps | Similar to rotator cuff (above) |
| Triceps | Repetitive straightening of the elbow
|
| Lateral epicondylitis (tennis elbow) |
Repetitive straightening of the fingers and bending back the wrist
|
| Medial epicondylitis (golfer’s elbow) |
Repetitive forward bending of the fingers and wrist
|
| Patellar (jumper’s knee) |
• running • jumping • walking • cycling |
| Achilles Usually associated with a significant increase in activities |
• walking • running (especially uphill or sprinting) • jumping |
| Table 1 | |
Treatment
If you suspect you may have injured a tendon, get a properly trained health care professional to assess the injury as soon as possible. As previously mentioned, a few people will require surgical attention and should be seen early. However, most tendon injuries can be treated without surgery. Reducing tendon load is the most important first treatment. It is usually done by cutting down on any activities that may cause strain.
Without doubt, appropriate strength exercise training is the best thing you can do for the long-term health of a tendon. As underlying injury exists, it can be hard for tendons to heal on their own without a specific strengthening program. Injuries can easily linger if not addressed properly.
- Isometric exercises are usually the first type of strengthening recommended. These exercises involve holds where the muscle is active and the tendon is under tension, but the joint is not moving. Slowly add as much weight as possible, without making it so heavy that you cannot control the movement.
- The next step usually involves isotonic strengthening. These are slow, controlled muscle contractions through the midranges of the joint.
- As strength improves, add eccentric strengthening exercises. Such activities involve loading the tendon while the muscle gets longer. (This process is sometimes called ‘negatives’ in the weightlifting world.)
Like isometric and isotonic exercises, eccentric strengthening should be done for all the muscles related to the injured tendon that are not working properly. As the tendon heals over time, the eccentric exercises should get faster and faster.
- Once the tendon can tolerate higher energy storage movements without causing pain, begin doing sport-specific movements in a controlled setting. The idea is to progress movements over time to mimic sport, gradually returning to normal activity levels and competition. Trained athletic therapists, physiotherapists, and strength and conditioning coaches can best guide you through adequate individualized strengthening programs as you return to sport activities. These professionals also help identify and correct other risk factors that could contribute to tendinopathies. These include abnormal biomechanics, poor form, improper equipment, and other training errors.
Trained athletic therapists, physiotherapists, and strength and conditioning coaches can best guide you through adequate individualized strengthening programs as you return to sport activities. These professionals also help identify and correct other risk factors that could contribute to tendinopathies. These include abnormal biomechanics, poor form, improper equipment, and other training errors.
Pain is often the biggest obstacle to good rehabilitation. Pain control is an important aspect of treatment. It is often a short-term solution allowing people to do the exercises. However, it is not enough to solve the problem by itself. Underlying factors must still be corrected with strengthening exercises.
The most common form of pain control is anti-inflammatory medication. Depending on which tendon is injured, these medications can be topical (rubbed on the skin), oral (taken by mouth) or injectable (given by needle, such as a steroid or cortisone injection). Other pain control options include:
- using hot or cold therapies
- stretching
- tissue manipulation
- and anti-pain medications like Tylenol.
Physical and manual therapists can also provide pain treatments including:
- massage
- ultrasound
- acupuncture
- dry needling
- and electrical stimulation.
If one’s symptoms do not improve with these treatments, other less proven treatments that could be tried include:
- shockwave therapy
- topical nitrates
- and injections like platelet-rich plasma (PRP) injections, sclerotherapy, prolotherapy, and targeted needling.
PRP injections are the injection of a hyperconcentration of one’s clotting cells (platelets). Sclerotherapy is the injection of a sclerosing substance into the neovascularity of a tendinopathy to hopefully reduce both neovascularity and pain.
Prolotherapy is injection of an irritant (usually hyperosmolar dextrose) into a tendon. It appears to stimulate an inflammatory healing response.
These additional treatments can be expensive. They should only be used when recommended by a health care professional specifically trained in sport and musculoskeletal (bone, joint and muscle) medicine. As well, these treatments should only occur after an appropriate assessment, and once other treatments have been tried. Surgery may be considered if all other treatments fail.
If you suspect that you have injured a tendon, get medical help as soon as you can. With time, care, and progression with the right exercises, healing should occur.
