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staging and compression in tendinopathy physiotherapy and hand therapy
Tendon problems are common in
runners (and anyone who is active) and can become a persistent issue if not properly treated. In
recent years our understanding of the pathology of tendon pain and injury has
grown – we now know that it isn’t really an inflammatory process and
that load plays a large role. We also now know that it’s important to
determine the ‘stage’ of the tendinopathy and this will have a huge
influence on how tendinopathy is best managed and treated.
Jill Cook and Craig Purdam created a tendinopathy treatment model in 2009 that describes 3 different stages of tendinopathy:
- reactive tendinopathy
- tendon dysrepair
- degenerative tendinopathy
Think of these as a ‘continuum’ cycle rather than 3 completely distinct phases.
Reactive tendinopathy typically
involves the tendon responding to a rapid increase in loading. For
runners this often means
- a large increase in mileage
- a reduction of
rest days or
- a change in training type e.g. introducing up/down hill or speed
It can also be from direct trauma to a tendon.
It was thought
that this reaction involved inflammation but we now understand that this
isn't the case. The tendon does swell but this is due to movement of
water into the tendon matrix* and not inflammatory products.
feature of a reactive tendon is that structurally it remains intact and
there is minimal change in collagen integrity. Cutting the jargon for this means this is usually a reversible process.
Tendon dysrepair usually follows reactive tendinopathy if the tendon
continues to be excessively loaded.
It is similar to the reactive stage
but what happens is that the tendon structure begins to change with greater matrix breakdown.
There may be an increase in vascularity and neuronal ingrowth.
Degenerative tendinopathy is
more common in the older athlete and individuals. It represents a response of the
tendon to long term tendon overloading.
There are multiple tendon structure
changes making it less efficient at dealing with load. Collagen becomes
disorganised and advanced matrix breakdown takes place alongside further
increases in vascularity and neuronal ingrowth.
The tendon can appear
thickened and nodular and there is risk of tendon rupture with advanced
physiotherapy & hand therapy management of tendinopathy (tendon pains and injuries)
Cook and Purdam simplify the management by dividing tendinopathy into 2 stages which are
- Reactive / early dysrepair
- Late dysrepair / degenerative
Physiotherapy and hand therapy treatment varies considerably
between these stages.
Many runners will have heard of “eccentric”
exercise for tendon problems and may be trying ‘heel drops’ for Achilles
tendinopathy or other eccentric exercises.
This will probably make
things worse in a reactive tendinopathy but might help in the
degenerative stage – this is why staging is so important in tendon treatments.
tendinopathy treatment in the reactive/ early dysrepair phase
The most important treatment in this stage is truly managing the load on the tendon.
This means that we need to
- decrease tensile load
- decrease compressive load
on the painful and injured tendon.
tendons connect muscles to bones and because of that when muscle
contracts to move, the tendons undergo a huge amount of tension
repeatedly over a period of time each time. This is tensile load.
Food for thought for runners / joggers:
Each time your foot contacts the ground during running
your body has to deal with an impact force equal to roughly 2.5 times
your body weight.
Well the good news is that our tendons are able to take up to 8 times our body weight - whew! That's good to know too =)
For people who enjoy running, you can reduce the tensile load by:
- decreasing how fast you run
- decreasing how far you run
- taking a break as and when
That's for dealing with tensile loading of the tendon.
Next: Compression Load
Tendon injuries (tendinopathy) has a compressive element that needs to be considered and addressed as well.
with proximal hamstring tendinopathy the tendon is thought to be
compressed against the ischial tuberosity (bone in your bottom) when the
hip is flexed, such as during sitting. Reducing time spent sat is a
simple way to reduce this compressive load.
Let's continue using the example of hamstring tendinopathy,
running uphill and stretching the hamstring muscle can both place
tension on the hamstring while it’s tendon is compressed against the
As such both are likely to aggravate the condition,
especially in the reactive stage.
That being said, managing tendon load DOESN'T mean completely not using
or offloading the tendon such as not using the tendon at all - nonono -
it's more like decreasing any loads that cause pain or reinjury, and
allow the painful injury to recovery.
For runners and joggers, this can mean
- not going so fast or far
- not going uphills
- not doing sprints
typically it's modifying training, based on the severity of the tendon injury or tendinopathy.
Good news is that the reactive stage of tendon healing can be relatively short, and that pain can settle within 7-14 days (or shorter) BUT the healing tendon may still be sensitive to high (intensity / duration) and that's why training needs to be progressive to prevent tendon reinjuries.
Note: tendons have latent response to loading, so it can take up to 24+ hours before you can notice what or how your tendons react to load. Bear this in mind when doing any sports or activities - it may feel alright at the moment...but oh man the next day may be painful tendons.
the lack of inflammation anti-inflammatory medication is thought to be
helpful in the reactive stage. This is thought to be because it inhibits
the production of proteins responsible for tendon swelling. Ibuprofen
is considered one of the best drugs for this role and is not thought to
have a detrimental effect on tendon repair. Note: please always consult your doctor before taking any medicines.
Isometric Exercise can
reduce pain and maintain muscle strength in the reactive stage (provided
it’s not done in a position where the tendon is compressed). Isometric exercise is
where the muscle works against resistance without creating joint
movement or changing muscle length.
Aka tightening muscles without moving the joints.
Don’t Stretch – this sounds a little counterproductive but the main issue we find with stretching is
the potential for tendon compression. The hamstring tendon, for example,
is often compressed during stretching which is likely to aggravate
Sometimes muscle length is an issue you need to address but it
is probably wiser to do this after the reactive stage. You might find
using a foam roller or trigger ball can help improve flexibility without
causing tendon compression.
We recommend regular sports massage and deep tissue massage to keep muscle supple and flexible - it works great especially for compressive tendinopathy issues.
It can be a difficult debate and comparison. Do we push through the pain? Or rest?
So to decide, it depends right on:
- are you training for a race / competition? Or off season?
- how bad are the symptoms?
- can you exercise without pain (during exercise and 24-48 hours later)?
- do your body feels tired / lack of rest?
Generally, i take a "big picture" approach - I dont want to win small battles but lose the war ie go for small exercises that could kill my chance of competing or put me in hospital for some time?
Of course not...right?
Will timely rest stop this problem from becoming a bigger, persistent long term problem? If yes, then rest. I prefer to lean onto the side of caution and conservative, so i will prefer to rest.
As a general rule of thumb or guide, i would recommend that when you go back to exercise, don't go back like nothing had happened - decrease the intensity and duration by 90% first for example:
- if you used to lift 10 kg weight, try with 1 kg first
- if you used to run 10 km, try 1 km first
Go slow, and if it's too easy and no pain, then increase more in progressive 10% add-ons the NEXT session. See how your healing tendon responds and then take it from there.
Late dysrepair / degenerative tendinopathy
The late dysrepair or degenerative tendons
tends to affect the older athletes and individuals more than in younger
people. Of course we will have to note that one CAN have BOTH reactive
and degenerative at the same time...
This is because
parts of the tendon may become degenerate while other parts remain
non-degenerate areas of the tendon can
respond like any other tendon to excess load and enter a reactive
stage...but if your tendon has been aching and tender for a while,
gradually the tendon is
thickened and has palpable ‘nodules’ within it then it’s likely you have
a degenerate tendon.
At the same time, if you’ve suddenly had an increase
in pain in response to increased mileage you may well have a reactive
tendinopathy alongside a more chronic degenerate one. If this is the
case the principles of managing a reactive tendon apply – manage load,
consider anti-inflams and use isometrics until things settle.
Management: Load management – Key here is know what aggravates your symptoms.
this is particularly important is because when you know what makes
things worse then you can focus specifically on changing that.
There are two parts to this theory and practice. Know the theory and see what happens in practice.
For example proximal hamstring tendinopathy:
- Theory – symptoms will
be aggravated by compression of the tendon such as sitting on firm
surfaces, stretching the hamstring, leaning forward with the knees
straight and by high tensile load such as running fast, over-striding
when running or carrying a heavy load (e.g. Running with back pack).
Running up hill is thought to combine both compression and tensile load
and is especially provocative.
- Practice – make a note
of what actually aggravates your symptoms as you may not fit the
textbook! A training diary is very useful for this. Note what running
you’ve done and any symptoms each day and this might give you a better
idea of what to change.
- Management – avoid
hills and speed work initially. Stick to a comfortable pace with smaller
stride length. Gradually re-introduce potential aggravating factors but
allow the hamstring tendon time to adapt and monitor symptoms.
Rest – a big part of
managing tendinopathy is how you use rest as a tool for healing your injured and painful tendons.
Tendons can adapt to load
given adequate rest time.
This process takes around 3 days following
exercise but you may find just allowing 1 rest day between runs is
enough to prevent repeated tendon overload.
- For those of you running 5
or 6 days a week a rest day after your long run may be more beneficial
than a ‘recovery run’.
- If you have a degenerate tendon it might be
sensible to replace 1 or 2 of these runs with rest or cross-training.
Graded increase in mileage or training intensity – in
order to allow the tendon to adapt to load, changes to training need to
be done gradually while monitoring symptoms.
So if say you want to increase something, add one thing a time eg
- add more intensity / load / speed
- add more duration
- add more varied uphill / downhill
Just ONE addition per week and see how it goes from there.
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