TENDON DISORDERS

Tendon Disorders - Should I Rest or Not?

 

 

Nathan Chidwick MSc, BSc (Hons) Physiotherapy 2012

 

 

As a physiotherapist, one of the most common questions people ask me is “do I need to rest?”  In some cases I have to tell people that they do, be it from their sports, hobbies or work.

But rest should not be a passive thing and in rehabilitation one of the goals should be to continue with as much non-harmful activity as possible, resembling the sport, hobby or work as closely as possible.

Painful disorders of tendons are a major problem in competitive and recreational sports (Maffulli and Longo, 2008a) and can be found in repetitive strain injuries (Van Tulder et al, 2007).  They may need to be treated with rest as part of a rehabilitation programme.                                       

Tendons are body tissues that interface between muscles and bones and as such transmit forces to allow movement of a joint, stability of a joint or both. 

They are predominantly composed of strong fibrous bands called collagen, bound together in a mesh-like matrix with water and proteins.

 

Tendon disorders:

 

Overloading tendons in an unaccustomed way appears to be a very important factor leading to injury, pain and loss of function (Cook and Purdam, 2012).

Achilles tendonitis, tennis elbow and chronic groin strains are some common names of tendon disorders you may have heard of.   These can be caused when the tendon is not able to tolerate the physical demands placed on it.  There may be other factors that can contribute to or mimic these disorders but this article is focusing on the effects of load on normal tendons.

Imagine someone who regularly runs 3-4 miles on flat ground but then adds in hill running every day for a week.  Think of the different forces acting upon the Achilles tendon now.  Consider a warehouse worker who is used to driving a forklift truck all day but suddenly is expected to pick up hundreds of items with his/her hands for a week.  The wrist extensors (tennis elbow) may not tolerate this extra demand.  

 

Physiological reaction of tendon to load:

 

However, lots of us do put our tendons through additional unaccustomed loading so why don’t we all sustain tendon injuries?

One of the main reasons may be the amount of rest we give our tendons between the extra loading sessions.

Under normal circumstances the tendon is a very adaptable structure allowing it to cope well with unaccustomed loading.  It does this by producing extra cells and proteins within the matrix.  Changes to some of these proteins allow greater binding of water molecules, effectively thickening and expanding the tendon.

This reactive process can occur quickly and if the tendon is rested or unloaded to usual levels it will return to normal.  1-2 days rest may be all that is needed for this to happen (Cook and Purdam, 2012).

However, if the loading continues without relative rest the tendon may respond with further cell and protein production.  This can start to disrupt the normal collagen fibres in the tendon leading to a disorganised tendon structure that is less able to cope with the forces put through it.  If further loading continues this may progress to degeneration of the tendon as the cells can die, leaving empty spaces in the matrix.  At this stage even low intensity exercise or work may not be tolerated (Cook and Purdam, 2012). 

Degenerative changes like these mentioned have commonly been found in people who have ruptured their tendons.  This suggests a correlation between overload, degeneration and eventual rupture (Konggaard et al, 2005). 

 

Treatment planning:

 

Prevention is always better than cure.  Avoiding recurrent overloading of the tendon and allowing appropriate recovery time would appear to be essential for this.  However, it is not always possible and injuries do occur. 

It is very important for therapists to accurately diagnose the stage of tendon pathology before deciding what form of treatment is given.  If a person with early reactive changes is given loading exercises this may well aggravate the problem rather than help it.  Conversely if a degenerative tendon is not loaded appropriately it may not restructure the cells, protein and collagen to help reduce pain and recover function (Cook and Purdam, 2012). 

People may present to therapists at any stage of tendon disorder.  Pain and damage do not always correlate and pain may not be felt until the tendon has undergone more degenerative changes. 

There are many variables, including age, sex and genetics that can contribute to the susceptibility of a tendon to pathological changes and whether or not pain will be experienced.

And here’s an even more confusing fact.  You could have a degenerate section of tendon and a reactive section within the same tendon.  Treatment here must be very selective and based upon a thorough clinical examination. 

Many physiotherapy treatments exist for tendon disorders but as yet there is not a great deal of supporting evidence for their use (Maffulli and Longo, 2008b).  There is sound rationale behind these treatments and many people recover with physiotherapy, so why does the scientific evidence not demonstrate clearly that they work?  This could be due to the fact that most clinical studies have included all tendon disorders and trialled a “one size fits all” treatment on them (Cook and Purdam, 2012).  However, what may work for reactive tendon changes may not work for degenerative tendon changes.

If the tendon disorder presents with more reactive changes, Cook and Purdam (2012) have proposed that rest is a vital component of the treatment.  Exercises and movements that do not aggravate the tendon should be encouraged.  For the lower limbs this could simply be cycling instead of running.  It may also be essential to look at working arrangements or training programmes for the individual and agree a more appropriate load/rest routine allowing for more graded exposure to loading activities.  This will give the tendon time to adapt physiologically to cope with the loading forces.

For the more degenerative stages, soft tissue mobilisation techniques and strengthening exercise programmes could be more beneficial. 

Rest from further aggravating activities may be essential, although some pain with exercise is generally considered acceptable at this stage (Alfredson, 1998).

This should all be part of a holistic approach to treatment, which may include biomechanical analysis and correction of movements and postures.  Strengthening weak muscle groups and mobilising stiff segments of the body may also be advocated.   

Sports and workplace adaptations, for example footwear review for Achilles tendon problems or workplace ergonomic review for Tennis elbow sufferers, should also be considered.  

Discussions regarding use of medication may also be relevant especially regarding anti-inflammatory drugs with reactive tendon changes.

 

Prognosis:

 

Tendon disorders should theoretically respond to treatment quicker in the reactive stages than the more degenerative stages. Therefore, the sooner a problem is identified and treated, the better the outcome.

If modified activity is all that is needed, the treatment could work in a matter of days to weeks.  Degenerative changes may take a longer time to respond to treatment, perhaps weeks to months, as changes to the tendon cells and matrix require longer time periods to remodel. 

 

Conclusions:

 

Tendons are tissues that may be damaged by increased exposure to excessive loading without relative rest in between episodes.

Progression from reactive to more degenerate changes in the tendon may occur with repeated overloading and there is some evidence that this could lead to tendon rupture.

Pain may occur at any stage of tendon disorder.

The best advice is to plan your work, sports and hobbies appropriately to avoid the problem in the first place.  However, if problems do arise then sound clinical assessment, diagnosis and treatment by a physiotherapist will help in the recovery.

 

 

 

References:

 

Alfredson H., Pietila T., Jonsson P., et al (1998) Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis.  American journal of sports medicine 26:360-366

 

Cook J.L. and Purdam C.R. (2012) Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.  British Journal of sports medicine 43: 409-416

 

Kongsgaard M., Aagaard P., Kjaer M., et al (2005) Structural Achilles tendon properties in athletes subjected to different exercise modes and in Achilles tendon rupture pateints.  Journal of applied physiology 99: 1965-1971

 

Maffulli N. and Longo U. (2008a) Conservative management for tendinopathy: Is there enough scientific evidence? Rheumatology 47: 390-391

 

Maffulli N. and Longo U. (2008b) How do eccentric exercises work in tendinopathy? Rheumatology 47: 1444-1445

 

Van Tulder. M., Malmivaara. A. and Koes. B (2007) Repetitive Strain Injury.  The Lancet.  369: 1815-1822

 

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