Tendons are connective tissues that connect your muscles to bone. Most people injure their tendons when they are over-used. Tendinopathy occurs when damage to the tendon is unable to heal properly, disrupting the structure of the tendon that can lead to pain, weakness, and impaired function in their daily activities. Many tendon injuries happen from being more active while playing sports or running. Some of the common tendons that are injured include your Achilles tendon in your heel or your patellar tendon in your knee. As we all try to become more active, it’s important to understand the proper physiotherapy treatment to get you back to your activities in a safe and quick manner.

 

Signs of tendinopathy:

  • Pain around the affected tendon
  • Reduced activity and exercise tolerance
  • Reduced strength in the affected muscle

 

Tendinopathy can also cause:

  • Swelling and heat around the affected tendon
  • Stiffness and reduced range of motion in affected tendon

 

Exercise, Exercise, Exercise!

Exercise with the appropriate load on the tendons are the current treatment recommendation for tendinopathies. Exercise helps to stimulate reorganization and growth of the tendon structure and has a pain-relieving effect. However, it is important to determine what is the appropriate to ensure that we aren’t loading the tendon too much too quickly. When we have a tendinopathy, it is important that we first remove the cause of the tendinopathy in the first place. Identifying what the unaccustomed load was will help us protect the tendon and prevent further damage as we take a break from any high-load activities that would overload the damaged tendon. 

 

Initial Treatment Plan for Tendinopathy

Once we can identify and avoid initial aggravating movements, we want to begin strengthening the tendon and muscle right away. We would first begin with isometric exercises for immediate pain relief and low-intensity loading of the tendon. Isometric exercises are static contractions with no change in joint angle or change in the muscle length/tendon. This immediate pain relief is important as it allows you to participate in more physical activity and reduce your fear of movement. As the pain reduces and the load capacity of the tendon increases, we begin to load the tendon through range in the form of isotonic exercises. Some examples include squats, lunges, etc. We will adapt the training volume to ensure that we are providing a sufficient load to the tendon without excessive pain. 

 

How do I know what is Excessive Pain?

Progressive loading in these exercises involve self-management and awareness of how you are feeling and tolerating the load.

For isometric exercises, if there is no pain for the next few hours after your static hold, gradually increase the time you are holding the contraction. If there is pain that lasts for the next 2 days, decrease the time you are holding the contraction.  

For isotonic exercises, if you are not feeling more pain the next day, gradually increase the load/weight of the exercises. If there is pain that last for the next 2-3 days after your exercises, reduce the load in the exercises.

 

Return to Activity and Sport

Building up strength and reducing pain is important in initial stages, but that does not mean the tendon is ready yet for the high load activities that injured it in the first place. Like our initial treatment, we have to progressively load in the load absorption and release ability of the tendon. This stage will include plyometric exercises and return to running. Some examples of exercises in this stage include jump squats, box jumps, and agility/cutting exercises. In respects to specific sports and activities you would like to return to (i.e. basketball, volleyball, running, etc.) your physiotherapist will work together with you to prescribe sport-specific exercises in a progressive manner. 

 

About the Author:

Kyle Lau

Physiotherapy Resident

Book with Kyle at our Spadina location!

 

References:

Breda, S. J., Oei, E. H., Zwerver, J., Visser, E., Waarsing, E., Krestin, G. P., & de Vos, R. J. (2021). Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. British journal of sports medicine, 55(9), 501-509.

Mascaró, A., Cos, M. À., Morral, A., Roig, A., Purdam, C., & Cook, J. (2018). Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy. Apunts. Medicina de l’esport, 53(197), 19-27.

Rio, E., Van Ark, M., Docking, S., Moseley, G. L., Kidgell, D., Gaida, J. E., … & Cook, J. (2017). Isometric contractions are more analgesic than isotonic contractions for patellar tendon pain: an in-season randomized clinical trial. Clinical Journal of Sport Medicine, 27(3), 253-259.