Busting Myths for Tendon Problems
Myth One - Eccentric exercise is the best exercise for rehabilitating tendon.
Whilst eccentric exercise (strengthening exercise where the muscle is lengthening) is the most researched, evidenced based program that is used, world renowned tendon specialist Professor Jill Cook from Latrobe University states that upon reflection, eccentric exercise by itself is deficient because it doesn't address the specific requirements of a person. They may be OK for the middle aged male runner, but they aren't that great for the younger sprinter or for the older person.
More importantly, eccentric exercise doesn't address the strength deficits of the muscle or of the body in general and they don't address the new research findings of the brain's and nervous system's deficiency in activating the muscle. Therefore, eccentric exercises by themselves are quite deficient in being able to restore full function.
What is the best treatment program for tendon problems?
The best treatment for tendon problems is really tailoring a program that best matches each person's individual wants, needs and requirements. For example, a young sprinting athlete with a hip tendon pain will have a different program to an older woman with the same condition.
Likewise a shoulder tendon problem will have a different program to an elbow tendon or an Achilles tendon problem. And even further from this, an Achilles tendon problem where the pain is in the mid portion of the tendon, the same as if the pain is at the insertion (attachment) and you can't treat either the of these the same as if the problem is in the covering of the tendon (peritendon).
This is why people need to be treated so individually. The purpose of treatment is to restore function to the level that a person wants. Anything after this is a bonus.
What are the key principles in tendon treatment?
The key principles include:
1. Promoting muscle strengthening which can only be achieved with strengthening exercises that involve both shortening and lengthening of the muscle. If you have good muscle strength, this will protect your tendons as well as other structures;
2. Having the ability to restore and release energy in the tendon if you are a higher level athlete;
3. Ensuring that the whole body is working efficiently and effectively with good mechanics;
4. Correcting faulty functional movement patterns.
What stages are involved in tendon rehabilitation?
To restore people back to high level function is a four stage process. For a person who doesn't need to meet high level athletic demands, they will not need to go through all four stages.
Stage 1 involves using isometric exercise (strengthening exercise where the muscle is contracting but there is no movement at the joint) to reduce pain and the brain's inhibition to activating muscle;
Stage 2 involves implementing a good strength program for the muscle/tendon unit as well as all other associated parts of your body. For example, the higher up your leg that you go, the more that you need to restore below the problem. If you have an Achilles problem, it is mainly calf that needs to be restored. If you have a knee tendon problem then the quadriceps and calf will also need to be restored. And finally, if you have a hip tendinopathy, it is glutes, quadriceps and calves that need to be restored.
In particular, you need to restore the strength of your anti-gravity muscles and then depending on their activity level, you need to restore the spring. As the tendon act like springs, you need to make them work again especially with the faster the movements and energy storage movement.
Stage 3 involves adding to this is endurance. For example, if someone wants to play football, they not only need to have a great general body strength and control and a great set of springs, they also need to spring repeatedly and therefore their tendons must have great endurance. It is this lack of endurance, or the capacity of the tendons to tolerate prolonged stress, that failure occurs.
Stage 4 involves adding spring strength and endurance. This is why tendons often take so long to get better. They often present extremely debilitated and damaged. There often has been long term pain with the tendons being robbed of their energy, endurance and muscle strength and bulk. And all of this needs to be restored, before the tendon can be made resilient enough to cope with the stresses that a person want to place upon the tendon in the activities that they want to get back to.
People who leave treatment early will often find that their pain will return in a couple of weeks because the tissue is only as good as the load that is placed upon it. And this is the same for tendon, muscle and bone. This means that if tissue hasn't been restored to a capacity that is needed in an activity or sport it will fail again. It's just physics. You cannot continue to load a tendon greater than what is has been trained to do. It isn't rocket science and just self-evident.
Physiotherapy should the first treatment of choice because tendons need exercising and correct loading. Physiotherapy shouldn't come after medication, injections or other intervention.
Myth Two - Tendon problems always involve inflammation
Tendon problems were originally thought to be an inflammation of the tendon (i.e. Tendinitis) in the 1970's until a fantastic study showed that tendon pain was primarily due to degeneration rather than inflammation.
Of course, like any other tissue, there will be some inflammatory markers and there will be some inflammatory cells because it's a tissue that is injured. However, inflammation is not the driving process. It is not the thing which is creating the pain and it is not the thing which is creating the ongoing pathology.
What causes the pathology is due to the over-loading of the tissue either on a prolonged or a short term basis. What causes the pain seems to be the tendon cell releasing pain chemicals.
If a person has an acute injury and ice doesn't help, then don't waste your time putting ice on the injury. Spend your time doing exercise. If ice does help, this is an indication that the injury probably has some peritendon (sheath covering the tendon) involvement. Therefore, ice and anything else which you perceive to be helping can be used along with exercise that has the correct loading. The evidence however, is that rest, ice, compression and elevation won't help you.
Myth Three - Once the tendon is pain free and you have returned to sport you don't need to do your exercises any more.
It is important that you understand that even if your tendon is pain free and you have returned to sport that the pathology in the tendon is still there.
Tendons don't heal even if the pain goes away. Once a tendon, always a tendon. If you do the right things your tendon will stay pain free. If you don't do the right things, your tendon will become painful again.
In addition to this, your brain is still inhibiting the activation of your muscles, because it is worried that you are going to re-injure your tendon again. Consequently, this means that if you return to sport and you stop your strength training, your muscle strength will decrease markedly if you stop your exercises and you will be prone to re-injuring yourself.
To prevent re-injury, it is important that you continue with your strength training exercises at least twice each week for at least a year following full recovery and then you may have a chance to give up the exercises.
For elite athletes they need to continue with their strength exercises 3 times a week for the rest of their careers. This is because these strengthening exercises are acting like an insurance policy. If you can stay strong, you keep your tissue (muscle and tendon) capacity up, you will be less likely to get into trouble again.
Because of your brain protective inhibition on your muscles and tissues, it means that when you have been injured, when you return to sport, you won't run, jump, twist, turn or just move quite the same way that you did before your injury. Therefore, the first season following a major injury is a building season. Following this you will need to do a really good pre-season and the second season back will be a "cracking" season.
It can take this long to be able to use your tendon as a spring and be sure that it is not going to cause your pain.
Myth Four - The tendon will get better quickly
It is critically important that you are educated regarding your tendon pathology.
You need to see how much swelling there is, how much muscle bulk you have lost, how your tendon store energy and how badly you hop.
You need to understand how your tendons react to pathology and how pain is caused and how we need to build capacity.
You need to understand that once a tendon, always a tendon and though you can become pain free and you will be able to return to sport, we want you to be able to play as well as you can.
You might be a bit sore the day after sport, but you will be able to train the day after this.
Understand that unless you are prepared to buy in to a 3 to 6 months rehabilitation process (and sometimes longer), there is no point in starting. You need to understand how long it will take and why, so that you can work with your tendon and your body to achieve the best outcome. Unfortunately there is no quick fix.
If you have tendon problem and you want to get better as quickly as possible, call Bodywise Health on 1 300 Bodywise (263 994) for a no obligation, complimentary assessment and advice.
You have nothing to lose except your pain!
Until next time, stay Bodywise,
Professor Jill Cook; Busting Tendon Myths Conference; San Diego 2016