Tendon pain: Tendinopathy

Tendon pain or tendinopathy can be a real pain and a tricky condition to manage. Anyone that's experienced tendinopathy will know they can be really annoying i.e. slow to improve and easy to aggravate. Tendons will not get better with rest alone, and they will not get better if you ignore the pain. Despite recent developments in tendon rehab a number of patients remain unresponsive to treatment and recurrence rates of tendinopathy are high, even after treatment. Therefore, it’s very important tendon treatment is based on the latest evidence based practice (e.g. research). Tendons are subject to a lot of mechanical loading particularly during running. For example, the achilles tendon has been shown to take 6-7 times body weight during running. Tendons are part of a muscle-tendon unit, working together with muscle to absorb load and behave like a spring during running and jumping.

It’s important that we don’t just think about load capacity of the tendon but also consider the capacity of the entire kinetic chain (leg muscles). For example, for a runner with achilles tendinopathy it's likely we'll want to strengthen the calf muscles to improve local load capacity and other muscles which may help manage the load during sport. For example, the quadriceps are the largest contributor to absorbing load during running, with the gluteal muscles assisting them. Therefore, it’s important to strengthen these muscles too to improve the load capacity of the entire kinetic chain.

Tendon Neuroplastic Training (TNT) is neuro science enhanced exercise used to treat tendon pain. It involves using a metronome to externally pace tendon exercises. The metronome provides stimuli that connects visual, auditory and the motor cortex during exercise. Research (Rio et al. 2015) has found cortical inhibition to be a feature of tendinopathy. Basically, in simple terms the area of brain that is responsible for controlling the muscle isn’t functioning properly. With tendinopathy there is an imbalance between excitability (the car accelerator) and inhibition (car brake). Every movement we perform is a balance between the accelerator and brake. So, if we want to elicit changes in our motor drive (accelerator and brake) we need focus during our exercises, rather than being distracted thinking about what we are going to cook for dinner or about our weekend plans. TNT adds external pacing to tendon rehab exercises to help restore this balance and improve motor control (movement accuracy).

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(Rio et al. 2015)

There are four phases of Tendon Rehab:

  • One: Isometrics (typically used to reduce pain)

  • Two: Strength

  • Three: Energy Storage

  • Four: Sports Specific/Elastic Function

During isometric exercises; listening to the audio helps clients maintain their focus on the exercise, decreasing inhibition from your brain and speeding up your recovery to full pain free activities or sport. With isotonic training, the metronome is a great way of facilitating contraction speed and improving motor control.

During phase three, it’s important only one thing is added or changed at a time breaking up absorption and propulsion initially before combining. Likewise, in the final phase once the tendon is coping with power, we increase load and add speed but not together. Progression of these phases are based on Physiotherapy assessment and close attention to monitoring the 24 hour behaviour of pain.

Tendon pain is complex and requires a thorough understanding of tendon pathology and capacity. If you are frustrated that your tendon pain is still hanging around book in to see one of our experiences Physiotherapist’s today!

Rio et al., (2015) Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. British Journal of Sports Medicine

BlogMiranda O'Hara