The stages of healing during a tendinopathy

What is a tendinopathy?

A tendinopathy is a failed healing response for a tendon as the collagen fibres have been disrupted through a spike in load or degenerative changes. A tendinopathy is an injury that is very easily sustained for any athlete. The most at-risk population is the typical ‘weekend warrior’ or recreational athlete. This is because the tendons aren’t getting regular exposure to the load and stress that would lead to them getting stronger.

Now, what does this actually look like in real life, what symptoms might you be experiencing?

Tendinopathies aren’t something that occur overnight  – the tendon will gradually start to tell you that it isn’t happy so by being able to identify what the early signs are will enable you to nip any issues in the bud before they start to get worse.

Typically, the tendon will be stiff and painful in the mornings which will gradually ease as you get moving. For the runners and gym-goers etc., the start and end of the session could well be sore, but the middle section might be completely pain free.

To understand how is best to go about managing these injuries, we must dispel a very common myth, that rest will solve your tendon issue. This is not the case; tendons are reactive which means they respond positively to load. Tendinopathies occur when the tendon is exposed to too much load. Figure 1 below shows the tendon continuum, and this proves exactly that. An unloaded tendon will only lead to degeneration.

So let’s look at what the recovery from a tendinopathy might look like in terms of the ‘stages of healing’.

The inflammation stage

Initially, we encounter the inflammation stage. This is the stage where you gradually start to notice pain and irritation at the tendon and for you runners that is most common either in the Achilles or the Patella’s tendon. The reason as to why this occurs is because the tendon can’t tolerate the load that it is being exposed to, so the collagen fibres (fibres that make up a tendon) get overworked and begin to become overstretched and start to tear.

Personally, I believe that when the tendon has entered this stage of healing, we therapists can have the greatest effect on our patients. This is because we start effectively managing your load. We can find that ‘happy medium’ by which the tendon is still being put under load so it continues to get stronger and thicker and by using the principle of progressive overload.

By intervening at this early stage, it means that we don’t have to take you away from doing the activities that you love the most to optimise your recovery. A short period of adapted load, mixed with the correct exercises will get you back in no time at all.

In these real early stages, as part of getting you back to your to pre-injury state, we would reduce either the frequency or duration of your sessions, in the short term, so you can give that tendon a chance to get stronger and repair so then you will be able to get back on the road to achieving your goals.

Failure to effectively intervene at this stage will mean the tendon will degenerate and the symptoms will get more intense. My best advice, nip these sorts of issues in the bud early on before they become problematic.

How to avoid degenerative tendinopathy

Looking at the Tendon Continuum in the image below, in order to come off the red path down to degenerative tendinopathy and move onto the green, back towards a healthy tendon we need to ensure that there is an appropriately modified load.

By reducing the amount of load that’s going through that tendon, were going to give the body a chance to lay down more collagen fibres to repair the micro-trauma that we have created by exercising. Failure to do so will lead to further collagen fibre disruption and therefore resulting in the tendinopathy getting worse.

Appropriate loading

So, what does appropriate loading look like? Well, that is specific to you as an individual and unfortunately, there is no formula that allows us to tell you exactly how many miles you should run in order to optimally load the irritated tendon.

As an example of how we would approach these sorts of injuries here at the IAC, let us assume we have an athlete running 4 x 5km per week which takes them approximately 30 minutes per run. We would suggest that you take the number of runs per week down to 3 and slow the pace down to 35 minutes per run.

If the route involves hills or descents then we may suggest that it would be better to run on a flatter circuit so there is less stress going onto that tendon. We would combine this intervention with exercises called isometrics, which I’m going to discuss next.

What other ways can us therapists intervene in your treatment to either help reduce pain and improve tendon function? We can prescribe a whole variety of exercises to you. The most effective way of reducing pain and improving function in the early stages of tendon pathology is isometrics.

Isometrics

Isometrics are a type of muscle contraction, where the muscle doesn’t change length. You might typically hold one of these types of contractions for 30-45 seconds and perform 4 sets with 90 seconds rest in between. Now, without getting too sciencey, isometrics are the body’s natural pain killer for tendons, they use the ‘pain-gate theory’ to inhibit a pain response and therefore allows us to load that tendon, optimally, to facilitate tendon regeneration.

The proliferation phase

In the middle to later stages of rehabilitation, we might use common exercises that you have always done but we will adapt them to include working to a tempo. This increases the time that the tendon is under tension and therefore stimulating a stronger cellular response (this helps us heal a tendon a little quicker).

The maturation phase

In the latter stages, we might use that very same exercise but adapt it, so the movement is more explosive. By doing this we are asking the tendon to absorb and dissipate a lot more energy, which encourages the final changes that you’d want the tendon to make so it is bulletproof to any load, any time.

The take-home message

The take-home message from this blog is to make sure that if you pick up a tendon issue, act on it before it becomes overly problematic. Whether you think you’re starting to develop a tendinopathy, or would like to build a programme to prevent a tendon issue from stopping you in the future, book a session now with one of our highly skilled practitioners to start your unique journey.