Chronic Tendon Pain
Key Concepts:
- It is very common and often prevents participation in sport/work/daily activities
- It is a degenerative process not an inflammatory one
- Follows 7 recognizable phases that can be used for early detection
- 97% of tendon tears occur in already degenerated tendons so early detection is critical
- Aggressive stretching and strengthening exercises should be avoided
- Corticosteroid injections are extremely detrimental to full recovery and should also be avoided
- Soft-tissue therapy and a tiered eccentric exercise program can reverse the degeneration of the tendon, restoring the cell-matrix back to healthy and normal in most cases.
What You Need To Know if You Think You Might be Experiencing Tendon Pain:
Tendon pain is very common and often related to overuse in sports/workplace activities. In fact 30-50% of all injuries related to sports are tendinopathies (Jarvinen 2005). Tendinopathy is the accepted umbrella term for the different types of tendon injuries. Although these tendon pains do occur in those living a more sedentary lifestyle as well, they are seen primarily as an overuse/repetitive stress injury. The main feature of chronic tendon pain is known to be degeneration of the tendon matrix and not inflammation. This means the term tendinitis (inflammation of the tendon) is often misused when in fact referring to tendinosis (degeneration of the tendon).
Under the Microscope: The tendon tissue becomes more disorganized as it degenerates making it weak and susceptible to tearing. Note the progression. A is healthy, B is more disorganized, and C is a completely disorganized and degenerated. (Rees 2006)
Tendon: The collagen dense tissue that anchors your muscle to bone.
The most common tendon injury sites are:
- Achilles tendon
- Patellar tendon
- Rotator cuff tendons
- Tibialis posterior tendons
- Wrist extensors/flexors which originate at the elbow (aka tennis elbow and golfer’s elbow).
However, all tendons are susceptible to the same degenerative process of chronic tendon pain (tendinosis).
97% of tendon tears occur in already degenerated tendon, so it’s important to recognize if you might be going through this cycle:
The 7 phases in chronological order (Kaushaar and Nirschl 1999)
- Phase 1: Stiffness and mild soreness after activity that resolves within 24 hours
- Phase 2: Stiffness and mild soreness after exercise that lasts more than 48 hours, relieves during warm up exercises, not felt during activity, and relieves afters 72 hours after cessation of activity.
- Phase 3: Stiffness and mild soreness before activity, partially relieved with warm up exercises, mild pain during activity that does not prevent participation, minor adjustments in technique, duration, and intensity of activity are noted.
- Phase 4: Pain is more intense than phase 3, produces changes in performance of a specific sport or work-related activity, mild pain noted in daily activities, may be indicative of tendon damage (micro/partial tears).
- Phase 5: Moderate to severe pain before during and after activity, greatly alters or prevents performance of the activity, pain accompanies but does not prevent activities of daily living, complete rest controls the pain, indicative of tendon damage.
- Phase 6: Similar to phase 5 but complete rest no longer controls the pain and the pain even prevents the performance of activities of daily living.
- Phase 7: Pain is consistent, aching pain that intensifies with activity, and regularly interrupts sleep.
Treatment approaches that are detrimental or have proven to be ineffective:
- Aggressive stretching and strengthening exercises: Exercise must be tiered and performed appropriately for positive results. Arbitrarily adding load with the idea of creating flexibility and strength can slow down the healing process. Tensile load on an already degenerated tendon can cause further damage, especially in someone who is beyond phase 2 above. (see graph below) (Rees 2006)
- Corticosteroid injections (cortisone) (Coombes 2010)
In the past it was believed that much of the tendon pain was inflammatory in nature and therefore anti-inflammatory medication and cortisone injections would have been logical remedies. However, overuse injuries are no longer thought to be inflammatory in nature. The advent of advanced imaging technologies have proven that the majority of tendon disruption is due to degeneration and not inflammation.
Therefore, anti-inflammatory medication and corticosteriod injections have not proven to be effective treatments to tendon injuries. Injections remain popular because of they can quickly decrease pain, but they do nothing to address the underlying cause of tendon degeneration and in fact promote it.
Here are the problems with this quick “fix”:
- Corticosteroids further degenerate and degrade the tendon and surrounding tissues
- There is a lower rate of full recovery post-injection despite temporary symptom relief compared to those that never had an injection and just worked through the discomfort
- There is a 63% higher risk of recurrence with only 1 injection anytime within 12 months post injection.
- There is an ever increasing rate of recurrence directly related to the number of injections that were given. More is definitely not better!
“It is better to move slow in the right direction then fast in the wrong direction”
-Simon Sinek
Diagnosis and Treatment:
Our Evidence-based and Clinically Proven Treatment Approach:
It starts with the diagnose of the exact areas of tendon degeneration (tendinosis) and its related causes.
An evaluation of both internal and external causes is performed in order to provide appropriate care and load management advice:
- Internal factors: health of surrounding tissue, biomechanics, age, weight, nutrition, joint laxity/restriction, muscular imbalances, presence of systemic disease (e.g. diabetes.)
- External factors: Occupation, sport, physical load (excessive force, repetitive loading, abnormal/unusual movement), Training errors (poor technique, fast progression, high intensity, fatigue), shoes and equipment, temperature, running/training surface.
An understanding of tissue healing times with treatment is reviewed:
- Phases 1-2: early presentation with slight tissue damage 6-10 weeks
- Phases 3-7: late presentation with moderate to severe tissue damage 3-6 months
Finally, once all of these factors have been evaluated, highly targeted and specific soft-tissue treatment and a tiered eccentric exercise program are performed in order to minimizing degenerated tissue and promote the remodeling of new healthy tendon tissue (Rees 2008). Think back to these slides to visualize treatment reversing this degenerative process back to healthy tendon tissue (A is healthy C is degenerated and disorganized):
References:
Coombes, Brooke K., Leanne Bisset, and Bill Vicenzino. “Efficacy and Safety of Corticosteroid Injections and Other Injections for Management of Tendinopathy: A Systematic Review of Randomised Controlled Trials.” The Lancet 376.9754 (2010): 1751-767.
Järvinen, Tero A.h., Pekka Kannus, Nicola Maffulli, and Karim M. Khan. “Achilles Tendon Disorders: Etiology and Epidemiology.” Foot and Ankle Clinics 10.2 (2005): 255-66. Web.
Kraushaar, Barry, Nirsch, Robert. “Current Concepts Review: Tendinosis of the Elbow (Tennis Elbow).” Journal of Bone and Joint Surgery 1999. 81: 259-278.
Millar, N. L., G. A. C. Murrell, and I. B. Mcinnes. “Alarmins in Tendinopathy: Unravelling New Mechanisms in a Common Disease.” Rheumatology52.5 (2013): 769-79. Web.
Rees, J. D., G. A. Lichtwark, R. L. Wolman, and A. M. Wilson. “The Mechanism for Efficacy of Eccentric Loading in Achilles Tendon Injury; an in Vivo Study in Humans.” Rheumatology 47.10 (2008): 1493-497. Web.
Riley, G. “The Pathogenesis of Tendinopathy. A Molecular Perspective.”Rheumatology (2003): 131-42. Print.
