Tendon problems (also known as tendinopathies) are extremely common in Athletes. Whether it be the Patella, Achilles or Hamstring tendon at fault, it is important to know what is happening within the tendon itself and what you can do to aid recovery.
The most surprising and relatively recent discovery in tendinopathies is that there is no actual inflammation involved in tendon problems. As yet the chemical compound which is released in tendinopathies causing pain has not be found, however what has been confirmed is that inflammatory cells are not seen in these types of problems. So what is actually happening in your tendon when it starts to hurt?
According to world reknown tendon specialist Jill Cook, tendinopathies can be divided into 3 stages.
Stage 1: Reactive phase: This is generally the most acute and painful stage of a tendinopathy. It occurs due to a large increase in the volume, frequency or intensity of a load on a tendon without enough rest time for recovery to take place. It can also occur by a direct blow to the tendon (ie falling off your bike onto your knee). Tendons can appear swollen in this phase- however if this swelling is not inflammatory, then what is actually causing the swelling?
Our tendons are made up of collagen fibres and ground substance (which is a gel like substance consisting of water and other proteins). Overload of the tendon causes a stimulation of the proteins in the ground substance specifically a protein called glycoaminoglycans . This protein is hydrophilic and attracts water molecules. The attraction of additional water molecules causes the swelling one sees in a reactive tendinopathy. If this problem is not treated, tendons can progress to the next phase…
Stage 2 the dysrepair phase of the tendinopathy.
During the dysrepair phase of a tendinopathy an increase in water molecules in the tendon causes a disruption of the collagen fibres. The tendon tries to repair itself by stimulating more cells, new blood vessels and nerves in the area. These changes further disrupt the tendon
Stage 3– also know as the degenerative phase of a tendinopathy is more common in older athletes and occurs due to chronic overload of the tendon. Tendon can be nodular with thickening. The degenerative tendinopathy can lead in some cases to tendon rupture. .
How to manage the different phases of tendinopathy.
Being able to identify what phase of tendinopathy you are in, is important as treatment and management during these phases differ from one another.
During the Reactive phase of a tendinopathy load management is extremely important. This means reducing the load to a level in which recovery can take place. In some people this may mean stopping running and substituting it with activities like cycling or swimming. In others just modifying training parameters may be enough- it all depends on the severity of the problem.
Once pain has reduced , GRADUAL build up of activity is important. Paying attention to tendon reaction not only during activity but also with 24hours of activity is extremely important. Tendons may have a latent reaction to loading and therefore one may feel great during activity but pain the next day.
The reactive phase of a tendinopathy can last from 5-10 days (often more). One may have heard of eccentric exercises when it comes to tendinopathies. In the reactive phase these exercises are not recommended and may infact aggravate symptoms. What is recommended are isometric exercises. These have been shown to reduce pain and maintain muscle strength in the reactive phase. Interestingly stretching the muscle tendon unit may not be beneficial in the reactive phase and may even aggravate symptoms. Soft tissue massage may be a better option to manage muscle length in this stage.
Eccentric exercise has been shown to stimulate cell activity, increase collagen production in and improve tendon structure in abnormal tendons. These exercises are therefore recommended in the degenerative phase of tendinopathy.
Identifying which stage of tendinopathy you are in and what to do about it can often be difficult. Seeking help from a physiotherapist can be useful even just for some guidance about a specific exercise regime or advice about how much activity is beneficial to promote tendon recovery.