Tendonopathy is a term to describe injuries affecting tendons. It applies to acute injury with inflammation – tendonitis – and chronic injury - tendinosis - that includes dysrepair + degenerative tendons.(no inflammation).
Injured tendons are ‘staged’ from acutely injured to rupture according to its deterioration. The most common site of injury is the Achilles tendon (AT) at the ankle, the patellar tendon (PT) at the knee, the supraspinatus tendon + rotator cuff tendons at the shoulder and the common tendon of the wrist flexor (in golf) + extensors (tennis) at the elbow.
Traditional concepts of tendon injury suggested a mechanical tearing of tendon fibres, leading to an inflammation and full healing, Where full repair did not occur the risk of re-injury was greatly increased. Poor repair or failed repair is called dysrepair
Current models of tendinopathy show a progressive deterioration from reactive tendon on initial injury through to tendon dysrepair to degenerative tendon.
The following is a non-exhaustive list of some of these factors
Female – post menopause
Foot over Pronation / Supination
Muscle weakness / imbalance
Previous injury (strain, sprain
Hard Vs soft
Shoes and equipment
There are different types of pressures / loading that affect tendons – and that affect may be either Positive or Negative.
1. Tensile – good to maintain fibrous tissue in tendon
2. Compression – good to maintain junction with bone
3. Friction – gliding adjacent tissues / paratendon
4. Combined types – forms and maintains additional bone (spurs)
The normal healthy tendon is easily able to withstand the first 3 of these
but less well able to cope with the last type of stress – activities with the
need to store and then release energy.
Adjusting the loading on the tendon depends on altering; :
Load type - as above
Contraction type - load increases through static, concentric, eccentric
Eccentric load can help to strengthen damaged tendons but is not suitable for reactive tendons.
The Highest Tension Loading occurs where there is
Eccentric muscle work (getting longer as muscle contracts.
Rapid contraction of muscle
High resistance / weights being moved by muscle
Repeated (pre) Stretch – Shorten Cycle in muscle activity
High loads should be applied slowly at first, more quickly later.
Increased muscle length
Increased compression of the injured tendon *by shoes, clothing etc).
High tension loading is more damaging when combined with compression.
Compression alone is least damaging type of loading on tendon.
Long Tendons are prone to overloading in their middle part. Force on the tendon is greater when the muscle is holding a load statically while stretched.
Short tendons more prone to overloading at the end attachments (insertions)
Tendon pathology is most likely to develops when tendons are exposed to repeated stretch shorten cycles when the muscle tendon complex is already pre-stretched.
Tendons tissues adapt / respond slowly to rehabilitation.
The tendon needs up to 4 days to respond to training, especially to high loading . Therefore high load training cannot be done daily during early rehab but must be spread over a prolonged period of time (> 4 weeks).
Rehabilitation will depends on:
● The amount of pain arising from the tendon
● The stage of Tendonopathy.
Reactive tendons need to be calmed down
● Avoid eccentric work / loading
● Decrease / alter loading – heel raise, elbow strap
● Manage inflammation symptoms
Dysrepaired Tendons need to be stimulated to restore good structural tissues / normal tendon structure
● Possible concentric and eccentric loading
● Avoiding aggravating factors
Degenerative Tendons need to be stimulated to make the healthy parts of the tendon as strong as possible
● Strengthen the whole muscle tendon complex
● Manage biomechanical loading and internal factors as much as possible.
Rest - means where the tendon is relatively unloaded. It is
● Not good for tendons
● Provides no stimulus for protein or structural fibre production
● Provides no maintenance for muscle tendon unit capacity
● Provides no maintenance of musculoskeletal capacity
Adjusting the loading on the tendon is achieved by altering
● Load type – position,
● Muscle length,
● Contraction type
Eccentric load can be used to strengthen a damaged tendon but is not suitable for use with reactive tendons. During eccentric activity ensure
● Slow / gentle application of load.
● Reduced energy storage and release within sessions
● 2 days between high loads sessions
● Reduced loading at increased length
● Minimise compression at the attachment to bone
● Plan high (strength), Medium (energy storage), Low(power) loading days
● To avoid excessive unloading / avoiding load not good either
Tendons that recovered / rehabbed should not be allowed too much ‘time off ‘ training – These tendons are less well able to cope when resuming normal training and will breakdown again if they are not protected by regular load tolerance / capacity training..
High Load Rehabilitation should begin with training on every third day.
To increase the tendons tensile strength apply slightly higher loads than those normally experienced on the training days. Progress to alternate day training. Aim to move through from static loading, to concentric loading (muscle shortening) and finally to eccentric loading (muscle lengthening) of the tendon.
Sample Tendon rehab
1. Unload the Tendon initially, later manage the loading
2. Get Strong – address muscle weakness
3. Static / slow tendon loading during early rehab
4. Progress speed of activity
5. Progress volume of functional activity
6. Apply elastic loads in final rehabilitation
1st Stage – Strengthening
0-3 months, Exercises 1 – 2 x daily using
Isometrics / very slow concentric / eccentric contraction
Sustained loads in inner ROM (30-60 secs x 4-6 reps)
Avoiding tendon compression
Progress as tolerated
2nd Stage – Functional Strengthening
2 – 4 months, Exercise on alternate days
Slow concentric / eccentric contraction
Moving loads into middle + outer functional ROM
Increase resistance / load in weightbearing – use speed
Increased emphasis on eccentric later
Mostly low and medium loading used
Build muscle endurance
Progress as tolerated
3rd Stage – Speed
Increase speed on every second or third day.
Speed significantly increases load
Continue with similar exercise faster
4th Stage – Athletic Function
2-3 months, Schedule high and medium load days
Increase the speed of loading
Sport specific activities
Capacity to absorb repeated elastic loading
Repeated concentric-eccentric activities (hopping, skipping)
Acceleration – deceleration, change of direction
The PDF file below is a scholarly paper assessing the the relative benefits of differing loading programmes for Rehab of Achilles and Patellar Tendonopathy in the lower limbs.
Tennis + Golfers Elbow
‘Tennis elbow’ is a generic term used to describe a tendonopathy which is an overuse injury of the tendons at the outside of the elbow. It may also be called lateral epicondylitis or as a tendonitis if the injury is acute / recent
‘Golfers elbow’ is a similar condition affecting the tendons on the inside of the elbow and is also called medial epicondylitis.
Neither is necessarily associated with playing tennis or golf but more with the excessive use of the muscles attached to the bone at the elbow - the wrist extensors affecting the outside and the flexors affecting the inside of the elbow..
It occurs where there is excessive repetitive activity, excessive gripping with the hand or working with the hand in an awkward / poor ergonomic position.
Epicondylitis or tendonitis around the elbow responds well to treatment by physiotherapists.
Assessment will determine what the key causative factors are and how they have led to the development of the condition.
Treatment may include:
Avoiding the provoking activity for a short period
Soft tissue massage
Exercises for stretching and strengthening of the affected muscles and other tissues
Adjusting work + playing postures, sports equipment
Medications - prescribed by a GP
A support brace can be worn over the upper part of the affected tendon. This relieves some of the strain + allows ‘rest’.
For a detailed assessment and advice or treatment contact us
Coaching + Biomechanical Correction
Seek coaching advice on sport technique
Gripping / paddling
Walking gait - podiatrist
Shoulder Tendinitis + Impingement
The shoulder joint has a large range of multi directional movement. Highly mobile joints tend to be more unstable. The shoulder joint depends more on dynamic stability, from rotator cuff muscles, than on static stability from ligaments.
The position + movement of the shoulder blade, swelling of the AC joint + the shape / orientation of the acromion (point of the shoulder) significantly impact shoulder movement and the risk of developing tendonitis or impingement at the ‘rotator cuff’.
Tendonitis of the rotator cuff is a common cause of shoulder pain and is provoked by overuse (repetitive) or over exertion. It also occurs secondary to poor posture in older people Repeated use of the arm, at or above shoulder level, can provoke inflammation. A fall onto the limb or a sudden drag on the shoulder can also provoke acute symptoms.
Impingement of the tendon can occur between the head of the humerus and the acromion during vigorous, repetitive activity at or above shoulder level.
The usual movements that cause impingement are a combination of forward flexion to 90' and inward rotation of the arm. Swimmers, throwers, racquet players etc are all at risk.
In older people there are changes within the acromion, the ligaments around the shoulder and the position of the scapula which increase the risk of impingement. The tendons can become inflamed, swell and sore.
If this becomes chronic it can cause scarring, weakness and ultimately tearing. It may lead to significantly reduced movement and pain, possibly leading to ‘frozen shoulder’. It responds slowly but well to conservative treatment pf exercise and joint mobilisation. Increased strength, good flexibility of the muscles around the shoulder and postural retraining all help recovery.
For further information and an assessment please contact us at the clinic.
This video shows some possible exercises that may be suitable for someone with shoulder + rotator cuff problems. An alternative video which has some more basic exercises and an explanation is at this link. These links are for information only and specific advice should be sought from a chartered physiotherapist.
Achilles Tendinopathy + Tendonitis
Achilles tendon injury is frequent + occurs in all populations. An acute injury is inflamed (Achilles tendonitis) and a chronic non-inflamed injury (no inflammation) is referred to as Achilles tendinosis.
Overuse tendinopathy is associated with gradual onset of pain and morning stiffness after an increase in activity. Symptoms diminish with activity but return after rest. Heat is reported to alleviate symptoms.
Acute symptoms are associated with partial tear or rupture of the tendon. In the latter people often report being kicked on the heel / tendon and of hearing a loud ‘shot’ like noise. The tendon is often thickened + ‘creaks’ during movement.
Other things to consider are foot mechanics, tight calf muscles, weak calf muscles, poor balance, stiffness at the joints of the ankle + foot and an ability to single leg heel raise / hop.
Injury in sports people is often associated with changes in intensity of training or sudden increases in training loads.
In the general population it may be associated with a sudden change in activities or in footwear - to little or no heel or support as in walking barefoot or in flip flops (as in when on holidays)
Treatment of Achilles Tendinopathy Tendonitis
Treatment can be provided at Ennis Physio Clinic
Treatment is primarily aimed at restoring the pre-injury tensile strength of the tendon.
Where inflammation is present it must be controlled and reduced.
In the acute phase use the RICE regime.
Gradually increase the loading on the tendon during activity - once pain is controlled. Simple heel raises using both concentrically and eccentric work - coming down slowly - are begun as soon as possible + integrated into functional activities.
Progress to rapid heel raises, rapid alternate heel raising, hopping, skipping and then jumping.
Re-education of gait without a limp prior to rapid steps,, striding, jogging, running and jumping.
Varying rate of acceleration / deceleration in a controlled manner - changing walking and / or running speeds.
A variety of walking and running drills are available if needed.
Treatment duration will vary depending on severity of injury and the demands you intend to place on your healed tendon.
The following video gives an indication of some but not all of the treatment possibilities. Please note Physical Therapy / therapists is the equivalent to a Chartered Physiotherapist in Ireland.
It is recommended when doing the exercise shown on the step in the video below that you start by not dropping below the level of the step (or indeed begin by doing this exercise standing on the floor before progressing to doing it on a step).