Tendon problems commonly referred to as tendonitis are often associated with sporting activity and in particular with overuse. With it being reported that tendon problems affecting the leg probably account for around 30% of all running injuries and elbow tendon issues accounting for around 40% of injuries in those playing tennis.
However they are also fairly common in those who do not participate in sporting activity and their frequency seems to be increasing in terms of the patients that present to our clinic in Eskbank just outside Edinburgh.
Why do we get Tendon pain?
Historically the pathology present in those with tendon pain was referred to as a tendonitis, which implied that the tendon was inflamed and that this was the source of the pain being experienced. However the finding that no inflammatory cells or inflammatory mediators; were present in those individuals with chronic tendon pain forced a re think.
Instead the concept of tendinopathy was born, this states that the underlying issue is degenerative change in the structure of the tendon. Whilst the mechanism isn’t fully understood at present, the key changes are the in-growth of new blood vessels or neovascularisation, which may be the source of pain; and changes in the orientation and organisation of the collagen fibres.
Instead of those collagen fibres being orientated in a organised parallel fashion as mentioned here, the fibres are organised in a haphazard disorganised non parallel fashion. The result is that tendons which exhibit these changes demonstrate adverse changes in their mechanical performance.
Do I have a Tendinopathy?
The common sites of tendinopathy that we see here in the clinic are at the achilles, the patellar tendon(often referred to as Jumpers knee) and the shoulder(often one or more of the rotator cuff tendons are affected).
Commonly patients will describe a gradual progressive onset which initially presents as pain or discomfort following activity or morning stiffness the next day. This will then progress to pain on the onset of activity, which eases as the patient “warms up” and then returns following activity.
Patients will often present to us at the third stage when they will have had symptoms normally for quite some time. By this point they are complaining of pain and discomfort during activity, that limits or possibly completely prevents participation in their chosen activity.
Patients will normally be aware of their tendon being thickened or swollen when the tendon is near the skin; for example the achilles or quadriceps tendon, it will often be painful if there is pressure exerted on the tendon or if the tendon is stretched or the muscle attached to the tendon contracts.
So if you have a tendon problem what should you do?
We would advise that you seek advice or treatment sooner than later. Tendinopathies will in general progressively worsen over time, eventually getting to the point where you forced to curtail or even completely stop your activities. In extreme cases one of the risk factors of tendon rupture, is that there has been a previous history of tendinopathy. Generally speaking the quicker you are assessed, modify training or other activities and start rehabilitation; the quicker you can return to normal with less disruption to your ability to train or participate in your chosen activity.
Your physio would initially take a full subjective history, this would include discussing your training and any changes that you had made to your training programme.
In keeping with the renowned tendon researcher Jill Cook’s maxim that “tendons don’t like rest or change”. We commonly find that the onset of tendon pain is associated with changes in training type, intensity, volume or frequency. For example returning to training after a layoff, the introduction of interval or hill training or a general increase in the amount of training undertaken.
They would then carry out a objective assessment, thoroughly assessing the painful area and the areas above and below it. For example in the case of suspected Achilles or Quadriceps tendinopathies, they would assess your foot biomechanics and hip/pelvis stability; in addition to the affected tendon, the joint and the other structures surrounding the tendon. For example a loss of ankle dorsiflexion is commonly associated with Achilles tendinopathy.
Your treatment programme will be tailored to your needs and may include manual therapy, soft tissue techniques, and offload taping amongst other modalities; to address any loss of range of movement or pain in the short term. The physiotherapist would also discuss any modifications that would be need to be made to your training programme in the short term to medium term. For example reducing training volume or reducing the intensity of the training in the short term.
However a graded strengthening and stretching programme would be the backbone of the treatment programme. As there is good research evidence that both stretching and progressive strengthening exercise have a beneficial affect on the structure and mechanical properties of tendon tissue and symptoms.
Additionally there is evidence from trials using both MRI and US scanning that have that found that the adverse changes in tendon structure persist for a significant period of time after the resolution of symptoms. Therefore our advice would be that it can take a significant period of time for symptoms to fully resolve and that you should persist with your rehabilitation even after your symptoms settle.
Therefore if you are experiencing tendon discomfort, stiffness and/or pain then please contact us to make an appointment.
Our clinic is in Eskbank, near Edinburgh. Our expert clinicians can normally see you within a few days and sometimes on the same day. We have appointments from 8 am to 8 pm, so we can see you at a time that is convenient for you. If you are paying yourself then there is no need to wait to see your GP as you can self refer. If you are planning on using health insurance we would advise contacting your insurance company as different insurers have different policies and procedures. They may require you to be referred by your GP.
The role of surgical intervention in the management of tendinopathies is relatively minor, as conservative management if adhered to is normally successful. However if your complaint does not respond to rehabilitation your physio is in a good position to liaise with your GP with a view to referral onwards for a surgical opinion or for further investigation.