As mentioned in our article last week, a reactive acute tendon can respond nicely to a period of unloading and anti-inflammatories. After the tendon itself has settled down then it is important to load the tendon with a tailored exercise program. Both clinically and in the literature it has been shown that tendons respond to progressive heavy loads.
Wait, didn’t you say that loading the Tendon caused my pain in the first place?
Yes and No! Yes, tendon overload can be one of the main reasons for the increase in pain initially but once this acute pain has settled, then the tendons NEED to be loaded in order to be able to cope with the everyday loads we place on our body with our day to day activities such as walking. However, tendons are very sensitive to load and so this is why too much load too soon can cause tendon pathology. It’s all about load management to rehabilitate tendon injuries. At Janet Brandt-Sarif Physiotherapy we help you find the correct training load and progressively increase it to enable you to return to full function.
So what exercises can I do?
Each individual tendinopathy is different and so an exercise program must be specific to that person and progressed according to that person’s symptoms, age, activity levels and systemic risk factors. Not only this but the exercises are specific to the part of the body where the tendinopathy occurs. However, it has been demonstrated clinically that isometric exercises are key in tendon rehabilitation. Isometric exercises are suggested to have a pain inhibiting response and they can be started immediately, even in the reactive phase of tendinopathy. They are good exercises for management of pain.
Isometric exercises are those exercises that the muscle doesn’t change length during the contraction, such as for your calf/Achilles, lifting up onto your toes and holding this position for a period of time. Exercises then need to be progressed into through range exercises (isotonic) and eventually into incorporating endurance and plyometric movements in order to place higher loads on the tendon.
How much exercise can I do?
As mentioned earlier, a tendon is very sensitive to load and will generally let you know if they have been overloaded, this can take 24 hours to develop and so you need to be aware of this when increasing your exercise and training loads.
What about stretching?
Tendons do not respond to stretching as the stretch can compress the tendon and so increase the symptoms of tendinopathy. Jill Cook suggests that massage to the muscle can help loosen the tight feeling and using a spiky ball or foam roller with guidance may help reduce areas of increased myofascial tone and tension.
Sounds like a lot of work, can I just get an Injection?
Unfortunately, as with most things, there is no “quick fix” for tendinopathies. Common injections for tendinopathies include PRP (plasma rich protein injections); however, the recent research has indicated that when compared to placebo, it may not be any more effective. Cortisone injection is another commonly used intervention for persistent tendinopathies, there is limited efficacy of cortisone in the management of tendon pathology and some research is now showing that cortisone used for patients with tennis elbow actually had a worse outcome in terms of pain and recurrence in the long term (at one year follow up) than those patients who received a placebo injection.
Should I get an MRI or Ultrasound?
Pathology shown on imaging such as MRI or Ultrasound does not relate to clinical outcomes or symptoms. As a tendinopathy moves through its continuum of stages, we know that there are cellular changes that take place. These changes do not reflect pain and dysfunction. In fact it has been suggested that as many as 59% of asymptomatic individuals (individuals with no pain or symptoms) show abnormal changes in tendons when imaged.
It is also known that the pathology shown on imaging is not likely to reverse in most cases, and so despite rehabilitating the tendon and making a full clinical recovery, the abnormal tendon, if imaged again would still show pathology.
In the future perhaps imaging may be useful as a prognostic tool particularly in elite sports and in determining risk of developing injury, however in a general setting, there is no real addition to imaging in this way.
So how can Physiotherapy help me?
Physiotherapy can aid in the management of tendinopathies by identifying the reasons why the tendon was overloaded in the first place. Massage and dry needling are nice adjuncts to treatment, both of which are offered at Janet Brandt-Sarif Physiotherapy. We will prescribe an individualised exercise program based on a thorough biomechanical and functional assessment. Your specific history and progress in this program will enable you to return to your meaningful activity, be it playing in the park with your kids or running a marathon!
There is no recipe in the management of tendons, and as each body is different and responds differently, it is important to have an individualised program, persistence and patience when tackling tendon pain.