Tendons – why are they so painful and annoying, and reluctant to get better?
Tendon related complaints are one of the most common things we see in the clinic. They are painful, annoying, and typically take fooooorever to resolve (not helped by the fact that most people wait forever to come in and get them checked out).
This is because:
- Symptoms start slowly and are usually just a mild niggle for a long time first
- Activity isn’t usually impacted until the tendon becomes really unhappy
Tendon related problems are characterized by persistent pain around the tendon sites of a muscle. Stiffness and pain in the morning, at the onset of exercise and following exercise. As the condition progresses pain and discomfort will also be felt during the aggravating activity. The most commonly seen tendon complaints in clinic would be within the rotator cuff (shoulder), gluteus medius (hip/backside area), patellar tendon (knee) and achilles (back of calf/ankle).
Nine times out of ten problems occur due to load mismanagement. Overloading muscles and tendons heavily over long periods of time without time spent at lower intensity alongside poor recovery is the perfect recipe for tendinopathies to occur. There are a couple of reasons for this. Tendons take longer to adapt to changes in stimulus than muscular tissue. And crucially tendons take significantly longer to recover from a bout of loading than muscles; which means that they are usually in the state of breakdown rather than a net positive rebuild following a loading stimulus by the time we load them up again.
I’m able to give a practical example of this – following the 2020 COVID lockdown, there was a dramatic increase in gym related injuries following the ‘opening up’. A common complaint during this time was knee pain in squats that began to onset 3-4 weeks after returning to the gym. This is a classic example of an early stage tendinopathy; a large time away from exercise, loss of conditioning, change in habits and (perhaps most importantly) immediate return to high intensity frequent exercise.
Ideally, a return to exercise following a hiatus, or beginning a new exercise program is done so with consideration of these factors. This means a gradual increase in frequency and load, and modifying around aches, pains or niggles that may emerge during training.
Identifying the key factors individual to the patient is key in treating any condition but especially so in tendinopathies where the risk for chronicity is elevated (the natural history of tendinopathies tends to be one of a persistent, fluctuating course; recovery times after diagnosis can be 6-12 months!). Management of tendinopathies is multifaceted, involving a combination of load management, exercise therapy, and other interventions as necessary.
In a more applicable sense we need to ‘calm shit down, then build shit up’. Initially a period of rest or aversion from aggravating activities is prescribed, then tolerable exercise directed at the tendon is utilised. Ultimately, injured tendons need to be loaded. But loaded appropriately. Tendons need enough load to be challenged to adapt (leading to increased strength, exercise tolerance and positive structural changes) but not so much that further damage occurs. Finding this balance can be tricky and often requires a few attempts. Monitoring pain levels during this process is critical to establishing the right dose of exercise.
Exercise for the purpose of rehabilitating tendons will aim to be specific to goals (e.g. being able to squat pain free for a patellar tendinopathy, being able to press without pain for a rotator cuff tendinopathy), adjusted to someone’s current level of tolerance, enjoyable (this is a big one!) and progressable.
Tendinopathies are common, frustrating and often place a large barrier between yourself and your exercise goals. However, they are treatable! If you think that you may be suffering from a tendon related issue – don’t hesitate to reach out and book in!
Article by Campbell Waldron-Smith | Physiotherapist