The Truth about Tendinopathy
Tendinopathy refers to the breakdown of collagen in a tendon. This causes burning pain in addition to reduced flexibility and range of motion. Although there are some inflammatory biochemical and cells involved in tendinopathy, it is not considered to be a classic inflammatory response. Anti-inflammatories may help if you have very high pain levels but it is unclear what effect they have on the actual cells and pathology. Tendinopathy is a very common injury due to vulnerability of tendons to repetitive and wear and tear injury. The most common types are Tendinopathy of the lateral epicondyle of the elbow, Rotator cuff tendinopathy, Achilles Tendinopathy and Quadriceps Tendinopathy. The wrist extensors and the Rotator Cuff are the most overuse tendon of the upper extremity while the Achilles and Quadriceps tendon are in the lower extremity.
Tendinopathy can be caused by many different risk factors. The main factor is a sudden change in certain activities – these activities include 1) those that require the tendon to store energy (i.e. walking, running, jumping), and 2) loads that compress the tendon. Some people are predisposed because of biomechanics (e.g. poor muscle capacity or endurance) or systemic factors (e.g. age, menopause, elevated cholesterol, increased susceptibility to pain, etc). Predisposed people may develop tendon pain with even subtle changes in their activity.
Tendinopathy does not improve with rest – the pain may settle but returning to activity is often painful again because rest does nothing to increase the tolerance of the tendon to load but Modifying load is important in settling tendon pain. This often involves reducing (at least in the short-term) abusive tendon load that involves energy storage and compression.
Exercise is the most evidence-based treatment for tendinopathy – tendons need to be loaded progressively so that they can develop greater tolerance to the loads that an individual needs to endure in their day-to-day life. In a vast majority of cases (but not all) tendinopathy will not improve without this vital load stimulus whereas it rarely improves long term with only passive treatments such as massage, therapeutic ultrasound, injections, shock-wave therapy etc. Exercise is often the vital ingredient and passive treatments are adjuncts. Multiple injections in particular should be avoided, as this is often associated with a poorer outcome.
Exercise needs to be individualised. This is based on the individual’s pain and function presentation. There should be progressive increase in load to enable restoration of goal function whilst respecting pain. Lastly, Tendinopathy responds very slowly to exercise. You need to have patience, ensure that exercise is correct and progressed appropriately, and try and resist the common temptation to accept ‘short cuts’ like injections and surgery. There are often no short cuts.