Troublesome Tendons – Aimee

What is a tendon?

We talk about them a lot, but do we actually know what they are? Tendons are fibrous connective tissues which attach muscles to bones. Their job is to transmit forces and store elastic energy allowing muscles to generate force.  

What causes a tendinopathy?

This can generally be categorised into one of two groups: Trauma or overload. Trauma refers to an unforeseen accident and direct injury to a tendon whereas overload is essentially when a tendon is exposed to loads that it does not have the resilience or tolerance to withstand. A classic example of this is my own personal experience which I will share with you shortly. Cue the comments along the lines of 'well if a physio gets injured then what hope is there for the rest of us?' The truthful and defensive answer to this is that yes as Physiotherapists' we are well equipped to diagnose and treat/manage problems, but we are still human and come with our own ailments  just like you. My injury was sustained during a run when I competitively sprinted up a hill in order to win a race against my partner. Result; I lost the race and sustained a hip flexor tendinopathy. Was it worth it? Absolutely not!

Diagnosis

This is always such a key factor in any rehabilitation program and requires the expertise and thorough analysis of a Physiotherapist. Although I was near enough able to self diagnose my injury, I still required the expert help of my fellow Four Sides colleagues in order to thoroughly assess mechanical faults that may have contributed to my injury. Ascertaining these are pertinent to recovery and in preventing future injuries of this nature.  

How is a tendinopathy managed?  

(The long and complex part)

There are many components to this phase and ultimately there is no one size fits all approach. Treatment and management plans need to be tailored to each individual presentation and aligned with each client's personal goals. Once establishing that a tendon is the structure at fault, I always feel that it is important to manage expectations. While some individuals are lucky enough to suffer a very mild tendinopathy, see a physiotherapist quickly and subsequently recover within a few weeks, it is far more common (like me) that these types of injures can actually take several tedious months to recover. Unfortunately it is well known that tendons do not have a very good blood supply like muscles do and therefore can take a while longer to recover. This is the most challenging part and one that really tests your patience and this is why I will often acknowledge the anticipated timescale to recover in session one.

My next port of call is how to modify activity to support recovery and this varies from person to person and is usually aligned with individual irritability and aggravating factors. It is important to identify what specifically is increasing pain and aim to reduce this in order to support recovery. This can vary from needing to eliminate almost all physical activity, to simply reducing the frequency, intensity or duration of exercise. That said, we know that a big part of tendon recovery is progressive loading and therefore within our assessment and treatment process, it is necessary to establish what level of loading your particular injury will make the most progress with. Our goal thereafter is to gradually increase this as loading tolerance improves.

The above aims to target the injury site itself which is obviously a key and essential component of rehab but as I touched on earlier, we must also address other potential factors such as differences in range of motion, postural imbalances, non optimal running styles and global strength limitations. Addressing components such as these will result in a thorough recovery which will ultimately prevent similar issues arising upon returning to physical activity. If you have had physio before and been provided with exercises that may not seem relevant to your pain site, this is the probably the reason why!

Understanding pain and what it means

Without going into too much science, I have also found it helpful to discuss with my clients what pain really means as this can help us to understand what we should and shouldn't be doing to promote recovery. Contrary to popular belief, pain does not necessarily attribute to tissue damage, it is the body's natural response to perceived danger, and while we want to keep pain levels fairly low, we do not need to go into panic mode the moment we feel pain and worry about 'damaging a structure'. Many clients working with a tendinopathy can actually continue with some exercise albeit to a modified level. You will often hear us asking you questions like, what is your pain out of ten? Trust me, we don't ask this to be annoying, it simply allows us to understand if the exercise plan we have provided you with is suitable for your level of recovery. Generally it is ok if you are experiencing mild/low level symptoms during an activity but not if this pain persists beyond 24 hours after.  

How can I prevent a tendinopathy?

My best advice here, is to avoid big increases or changes to your physical activity. Most people sustain injuries when they do too much too soon after doing too little for too long. Lockdown for example! A lot of people around this time either got injured from significantly increasing activity very quickly through sheer fault of having nothing else to do, or sat around for several months doing not much and then decided to resume too much exercise too quickly. Be strategic and consistent with your exercise using a gradual progression approach rather than erratically dipping in and out of exercise with rapid changes in duration, frequency and speed. In short it's simple, don't race your partner up a hill!

For any individuals wanting to get back into running, I can highly recommend attending a Pilates for strength class or a strength and conditioning class at Four Sides London. These are targeted at building strength in the key and major muscle groups of your body which will help in preventing injury. Speak to your teaching Physiotherapist if you have known individual target areas or physical activity goals that you wish to focus on, we will all be delighted to assist you to your best, and safely!