Tendinopathy

Did you know that Bronwyn is one of the five Advanced Osteopaths in Australia that has an extra qualification into Exercise Rehabilitation? This means she lives and breathes injury management of tendinopathy pain! Bronwyn is a bit nerdy, in that she loves to listen to upcoming research on tendinopathy and injury rehabilitation in her spare time as well. Let’s have a look at what tendinopathy pain is, and the frequently asked questions on how to manage and heal your injury.

What is tendinopathy

So you’ve been googling “why does my calf hurt while running?” It could be a tendinopathy injury. Tendinopathy is a broad term for injuries involving our tendons in our body, but let’s take a step back and understand the basics first.

What is a tendon?

A tendon is that connects muscle to bone. If you eat meat, the tendon is usually the grizzly part of a steak, it has a different texture, and it's also a different colour to the meaty (muscle) part.

This is the same in the body. Our tendons are a different structure, they are strong and pliable, and similarly to a steak, they are “whiter” in colour, meaning less blood supply and less oxygen goes to these structures. This means they can (unfortunately!) take a little longer to recover and heal from injuries.

A tendon is very strong. So it needs a lot of strength to help it get better. Our achilles tendon is a great example of how explosive our tendons are. When we walk or run or jump - all that force is coming from the tendon.

Here’s a fun fact - when we walk we put 4x our body weight into our achilles tendon, when we run it's 8x our body weight. So these are not weak structures at all, but they can weaken over time. Tendons are prone to overload type injuries - too much load too soon, not enough recovery and changing environments can lead to degeneration of the tendon.

Why does tendinopathy happen?

Think about it like our tendon is running a marathon without training or recovery, it's going to complain after a short while! Injuries are a seesaw balance of load and recovery. When one element is out of sync, then the seesaw tips over.   We injure ourselves when our load (effort, workload, poor biomechanics, changing a surface or changing footwear) is out of balance with our recovery (sleep, healthy eating, stress management, hydration, mobility, stretching or strengthening)

Tendons are like the overworked employee, they are doing a lot for us, sometimes more than they should. To help them recover optimally, they need love (recovery) in return!

But I’ve rested for two weeks, but when I go for a run I feel like it's the same and not getting better?

We hear you, this is very classic for tendinopathies. Rest doesn't actually improve your injury. If you rested for two weeks, and if you didn't rest for two weeks - your pain most likely would still be the same. What we actually need for tendon rehab and recovery is load management and strengthening.

What is load management?

This is where professional advice comes in. Load management is a broad term for a few areas. Maybe you are doing too much too soon - a lot of people might set themselves a “number” in terms of time/repetitions/distance in their training - but their body may not be ready for that type of workload. In running, load management can look like a run/walk interval or a slow steady run instead of a faster 5km sweaty run. Load management can also look like strength or cross training sessions included - seated or standing calf raises, single leg squats, lunges, yoga, Pilates, foam rolling, and also, osteopathy treatment to help offload the tight muscles and correct biomechanics, to allow your joints to move more freely and without restriction.

Your osteopath will look at your load management as it relates to your biomechanics. Maybe you are slouching into your run, maybe your cadence is too low, maybe you are lifting through your back instead of your glutes in a squat or your knee is tracking inwards with your lunge. All these movement patterns we can pick up, assess and figure out the most beneficial way for your body to move optimally. Sometimes this takes a while to change (it took me 6 months to change my running style to prevent injury!) but consistency takes time, and in the long run, correct mechanics prevents further injury, which is the main aim!

How does strengthening help tendinopathy?

Strengthening is the most important part of tendinopathy injury rehabilitation. As we mentioned, tendons are strong so they need a strong load to help them. We look at strength training as the three phases of muscle contractions

• Isometrics (the muscle stays the same length over the contraction) - an example of this is a plank exercise for the abdominals.

• Concentrics (the muscle shortens over the contraction) - an example of this is a bicep curl

• Eccentrics - (the muscle lengthens over the contraction) - This is the last phase of rehabilitation, if you can strengthen your tendon eccentrically under load and its not painful - you have clearance to return to sport. An example of this is performing a dead lift action for the hamstrings, if this is not painful, then you can return to running, kicking based tasks.

The correct strength training is key, not rest.  Guidance from your Burwood Osteo & Rehab Osteopaths here in Melbourne, helping local runners and athletes manage tendinopathy pain.

What are the top five myths of tendinopathy?

• Rest will make it better

As we mentioned, rest rarely helps, but load management, recovery and strength work is more important.

• Should I stretch?

This is a great question, stretching doesn't help either. Without getting too anatomical (sorry, remember I’m the nerd that loves this stuff!)  Let’s look at the achilles example: when we stretch our calf, if our tendon is thickened (you can see this on someone with an achilles injury!) - then when we stretch, the tendon is more “compressed” or closer to the foot and ankle bones, so it can be like a rubbing sensation or irritating that area, as there isn't much space to begin with in a healthy achilles, but a thickened sore achilles, there is even less space there! So the rubbing sensation is increased.  

Stretching isn't beneficial in the short term. You are better off to use a foam roller or massage into the thickness of the leg muscle (calf) and this gives a better response to the achilles tendon rather than stretching the calf/achilles region directly.

• Strengthening will hurt me

Incorrect. Strengthening correctly will be beneficial. This can be a bit tricky to manage, as it's about how you feel “the next day.”  A general rule of thumb for tendon pain is that your discomfort levels should NOT be over 4/10 the next day. If you did go for a test run or jog and pushed it a bit more; then tomorrow’s pain should be under 4/10 levels. If it's over this threshold (and we appreciate it’s difficult to know retrospectively) - then your activity was too much for the body to handle and your body is having a response against what you did.  If this occurs, go back into the management strategies of foam rollering, mobilising and strengthening the surrounding areas of your body to help your achilles.

• Tendinopathy =  inflammation

Tendinopathy vs Tendinitis: Terminology has changed over the years. The old term used to be tendin-itis, and “itis” in medical terms implies an inflammation response. But we have learnt that tendinopathies aren’t due to inflammation they are due to degeneration and failed healing responses instead. This is why we have moved our language away from inflammatory processes. Yes, inflammation is present in a new and acute complaint, but this is generally under 6 week duration, in chronic tendinopathies, inflammation is less present, and it's more about the body not healing effectively without the presence of inflammation.

• I can’t do the things I love anymore

Incorrect. You can, we just modify. Very rarely do I say to someone “stop your activity.” We know rest doesn’t help, but chat to your practitioner. In the short term, maybe we lessen the load so you have more chances to recover, but yours and our goal is to get you back to what you love doing so we will work with you, your outcome and your injury to bring you back!

What actually helps:

• Gradual/progressive overload (isometric, concentric, eccentric) loading as to what the tissues can tolerate without the next day pain.

• Managing training load - if this means skipping a sprint session for a longer easier run, or choosing to do a Pilates class instead, this is load management

• Patience! The body needs time and we have to give it time to heal. Muscles don’t grow in a day. Being consistent is the best thing for you

• Professional guidance. We can help. We will work on your biomechanics, offloading strained structures and strengthening areas that need more work. 
  

What to avoid:

• Complete rest - If you have read this far, you know our thoughts and feelings on this -  it doesn’t help 

• Pushing through sharp worsening pain - you don't need to be a hero. It's ok to miss a session or two so that you can return to what you love sooner than pushing through and making your injury worse that would require more recovery.

• Quick fixes - you need to do the strength loading to help it the most. 
  

When to seek help:

• Straight away! In early stages we can help address biomechanics and overloaded tissues sooner, to stop things lingering too long. Some people think it will get better on its own and then look back to realise it's already been 2-3 months of a niggling persistent pain. We can definitely help you get over your injury sooner!

• If you have left it a bit longer, and it's been over 6 weeks of pain, definitely book that appointment in! Our body starts to make changes when it gets acclimatised to discomfort. We can definitely still work with these types of injuries, they just require different treatment, different management and different timelines.

• If you aren't sure why you are not getting better on your own, that's where we come in - guidance, reassurance, management, treatment and load progression!

Tendinopathy can be very frustrating, especially if you are in your groove of routine and rhythm and this stops you in your tracks. But with the right approach, treatment and management, you can get better faster and return to the thing you love doing the most. Our Osteopaths can help you stay moving for longer.

#burwoodosteoandrehab #staymoving