Tips for Tendinopathy
As a physical therapist that specializes in treating runners I see a lot of patients with tendinopathy or tendon injury/pain (you may have also heard it referred to as tendinitis or tendinosis). Most of the time if you follow some simple principles the tendon responds very well to treatment. In my opinion these are really fun injuries to treat because you do not have to cease all activity to get better and you eventually get to challenge people and even improve running performance above pre-injury levels.
There is a multitude of information online from Dr. Google about how to manage these injuries but I have complied a few lesser publicized considerations for your information. As always you should consult your local health care practitioner for specific guidance and this is not formal medical advice. Ok here we go…
1. Make sure the diagnosis is correct.
This is a big one, we all like to use Dr. Google and self diagnose our ailments but this can lead to several weeks or even months of frustration if you miss the boat. Make sure to seek advice from a medical provider you trust that that also has specialty in treating runners.
2. Addition by subtraction.
Once you’ve confirmed you have a tendinopathy you want to make sure you avoid doing the things that will make it more angry or sensitive. This is where the concept of tendon compression comes into play. Here is a video that explains this concept. The classic example is someone with an insertional achilles tendinopathy that has been told to do the eccentric heel drop exercise. Many times people are stretching and compressing the irritated tendon against the bone and it is keeping it extra sensitive. It can be likened to scratching an itch, it might feel good at the time but might be making the problem more sensitive overall.
3. Passive therapies aren’t worth much of your time.
Passive therapies like massage, dry needling, cupping, taping, ultrasound, foam rolling, and so on will do nothing to stimulate tendon adaptation. These things may help with the pain in the same way that rubbing your elbow after hitting your funny bone helps with pain, but we all can understand this is a short term strategy. Points #4 and #5 are where you will make a lasting difference in your condition.
4. Have a framework for exercise. Also understand that pain does not equal damage with tendinopathies.
This is the idea that you can push into pain without causing more damage. It’s helpful to think of the tissues as sensitive versus damaged. I will show patients something like the picture below to give them a framework for exercise. This means that if symptoms are in acceptable levels people can do some of the activities they enjoy like running before the injury is fully rehabilitated. I’ll use a quote from Greg Lehman here “You don’t need fixing before you start doing, doing can be the fixing”. I understand this is a foreign concept with people and that is why I spend a lot of time educating patients on how to monitor pain and progress their activity. This doesn’t mean you can just do whatever you want but ceasing all activity is not necessary either.
5. Load (strengthening) will solve the problem, but it has to be dosed correctly.
Loading the tendon is the best treatment for tendinopathy, but it has to be the correct dosage. Just as you would take a specific amount of medication for an illness you need to find the correct dosage of load. Too little and the tendon won’t adapt, too much and you might make it more sensitive. It is also important to remember the dosage changes as the injury progresses. Again this is why working with a physical therapist through this process in invaluable as they will have progressions to take you through.
6. Don’t stop rehab the once the pain is gone.
Have you ever seen a movie where they don’t finish off the bad guy in a fight and he comes back last second and almost wins? Well thats what can happen with tendinopathies if you do not finish out a course of strengthening. Remember, pain is not our guide for tissue health, I recommend at least another 6-8 weeks of continued strengthening even after symptoms are completely gone. Sometimes for chronic issues it may even take longer.
Hopefully these concepts are helpful and shoot me an email if you have questions. Or if you are a runner/triathlete in the DFW metroplex and are struggling with a tendinopathy feel free to reach out to schedule an evaluation.
-Steve