Injury & Rehab: tendonopathy

It is now recognised that most issues with tendons are a degenerative process rather than an inflammatory one. Adam Floyd looks at a three-stage model of tendon breakdown and identifies treatment options for this often frustrating problem.

Eccentric wrist extension start position

Eccentric wrist extension end position

A frustrating problem, both for the client and for the personal trainer, tendonopathy can affect a number of tendons and is commonly slow to heal. Mismanagement also often results in a prolonged recovery process.

The medical profession is moving towards the term tendonopathy from the previous term tendonitis. The word 'itis' means 'inflammation of', such as appendicitis or bursitis. However, histological studies of tendon injuries have revealed very few inflammatory cells, and it is now recognised that most issues with tendons appear to be more degenerative (think of a rope fraying from the inside) than inflammatory. As a result the term tendonopathy, which is less specific and means 'something is wrong with the tendon', is now used. You may also come across the suffix 'algia' such as lateral epicondylalgia, a term given to tennis elbow, also a form of tendonopathy.

Some tendons seem to develop issues in the body of the tendon, such as Achilles tendonopathy. Others, such as lateral epicondylalgia, seem to more commonly develop issues at the bone/tendon interface (sometimes called an enthesitis). Issues can also arise with the tendon sheath (common with the Achilles), and these are known as paratendonitis.

The main causative factor for tendonopathy is excessive tensile loading with inadequate rest periods. Tendons rarely have issues unless they are overloaded, although problems can occur in older individuals and clients with underlying connective tissue disorders. In the ideal situation, the tendon adapts to the loads applied and strengthens over time. In the case of a young person training for basketball who introduces some plyometric training twice per week on top of the usual training and games, there is inadequate rest time between loading. Consequently, the tendon starts to break down, causing pain and mild swelling. Some tendons can quickly become quite thickened and swollen, and the Achilles can even develop sizable nodules along it.

Diagnosis should, of course, be made by a qualified health professional, such as a physiotherapist or sports physician. Diagnosis is usually determined by client history and clinical examination. Scans such as ultrasound and MRI can be used to confirm the stage of tendonopathy and to exclude other pathologies. For example, with shoulder pain it is common to scan the rotator cuff tendons which are prone to tears (commonly supraspinatus), especially in older clients. Both ultrasound and MRI are useful to determine the size and extent of tears and thus to determine whether surgery is required. With most other tendonopathies, scans are used less commonly (except with high level athletes) unless conservative treatment fails. Tears are less common in other tendons such as the patella, Achilles and the common extensor tendon of the elbow. While physiotherapists do see clients present with ruptured Achilles tendons, studies would suggest that the majority of these were already degenerative (although not necessarily painful) before they ruptured.

Two of the world's foremost experts on tendon pathology and treatment, Dr Jill Cook and Craig Purdam, have proposed a three-stage model of tendon breakdown to assist in the diagnosis and treatment of tendon pain;

Stage 1. Reactive tendonopathy: A proliferative response (resulting in a thickened tendon) that occurs with acute tensile or compressive overload. The tendon has the potential to revert to normal if the overload is sufficiently reduced or if there is sufficient time between loading sessions.

Stage 2. Tendon disrepair: Describes the attempt at tendon healing similar to stage one but with greater matrix breakdown. There is separation of the collagen and disorganisation of the matrix. On ultrasound you start to see some 'black holes' in the tendon, indicating significant breakdown. This stage represents the more chronic overloaded tendon and the ability of the tendon to revert to normal is far less likely.

Stage 3. Degenerative tendonopathy: Areas of cell death are present, and there is significant matrix breakdown and little collagen. This stage is mainly seen in older people or elite athletes with chronically overloaded tendons. There is little chance of reversibility, and the tendon can rupture if placed under a high load.

Therefore, it is essential to have any client with a suspected tendonopathy assessed by a physiotherapist or sports physician as soon as possible so that the injury can be graded and the appropriate management advised in terms of treatment and loading. Do not expect your client to rest for two weeks and then return to the same activity levels!

Treatment for tendon injuries

Eccentric loading programs: The gold standard for tendonopathy management is a well-guided eccentric loading program. For example, physiotherapists will often prescribe clients with tennis elbow a wrist extension exercise whereby a weight is lifted concentrically with two hands and then lowered eccentrically with one. In Achilles rehabilitation the client can perform a calf raise upwards with both legs and then eccentrically lower with the injured side. Exercise does not have to be pain free, but we try to keep the pain score to 4 out of 10 or less (with zero being no pain). These loading programs are best prescribed and monitored in conjunction with a physiotherapist. The thought is that eccentric loading stimulates production of tenocyte (cells within a tendon) and assists in tendon repair.

Cortisone injections: A well placed cortisone injection can provide some good pain relief to allow a window for the client to perform their eccentric loading program. It is thought that cortisone has a temporary weakening effect on tendons so any explosive activity is avoided initially. A cortisone injection is best performed by a sports doctor, often under ultrasound guidance.

References

Cook, J.L and Purdam, C.R. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendonopathy. Br. J. Sports Med. 2009;43;409-416
Józsa, L. G., and Kannus, P. [editors]: Overuse injuries of tendons. Human Tendons: Anatomy, Physiology and Pathology. 164-253. Champaign, Illinois, Human Kinetics, 1997. 
Leadbetter, W. B.: Cell-matrix response in tendon injury. Clin. Sports Med,11: 533-578, 1992.11533, 1992 

Platelet-rich plasma injections: These are the new 'fad' in the treatment of tendonopathy, and involve the client's own blood being taken and then separated into red cells, white cells and platelets/plasma. This platelet-rich plasma is then injected into and around the tendon under ultrasound guidance. The growth factors in the fluid are thought to assist with tendon healing. Initial results appear to be promising, but again, a well guided exercise program is needed.

Others treatments such as glyceryl trinitrate patches and surgery: It is becoming more common to see glyceryl trinitrate (GTN) patches used. They may assist in blood flow and thus in tendon healing and perhaps also in pain relief. Surgery is always a last resort and results vary.

You can be confident in encouraging your client to continue to exercise with tendon issues. Recent research has demonstrated that in the case of Achilles and patella tendonopathy it is best to walk and/or cycle daily rather than have complete rest. As a general rule in the gym the volume of weights lifted by clients should be halved, they should ice after loading and they must allow sufficient recovery time in between loading sessions. As always when dealing with clients with pain or injury, it is advisable to consult with your local physiotherapist or sports physician if you are unsure.

Adam Floyd, BSc (Physio) BPE (Hons)
Adam is a Perth-based physiotherapist and exercise physiologist and runs the GymED series of seminars for fitness professionals. He produces a monthly injury management e-newsletter for fitness professionals which you can register for at www.adamfloyd.com.au