Injury Spotlight: The Down Low on Tendinopathies

August 1st, 2020

Quick note: This blog has a bit more technical medical knowledge than my usual blogs but is still written in a way for a pole dancer/aerialist to understand the process of a tendinopathy without prior knowledge. However I would suggest setting some time aside to mentally digest this blog! 

OK! Let’s get started!

So what is a tendon?

FIG 1: BASIC ANATOMY OF A MUSCLE/TENDON

A tendon is fibrous connective tissue that connects muscle to bone. Tendons are thick but elastic in makeup which gives them this impressive strength to transfer large forces between muscles and joints. Each muscle has two tendons (proximal and distal) and the point which the muscle becomes tendon is known as the musculotendinous junction.

Why do we have tendons?

In simple terms, if we didn’t have tendons our muscles would constantly tear from the bone. Our muscles wouldn’t be strong enough on their own to handle the forces transmitted. So the tendons’ main role is to transmit forces from the muscle to the bone and absorbs external forces to prevent injury to the muscle. 

FIG 2: STRUCTURE OF A TENDON

What makes up a tendon?

I won’t geek out too much on the cellular level of a tendon, but for the purpose of this blog it’s important to know that tendons are highly organised structures full of lots of cells, mainly type 1 collagen fibres which are responsible for the tensile strength of the tendon. They also have a very poor blood supply, with only a third of the MTJ being supplied and even less blood supply where the tendon connects into the bone. 

What does this all mean for us??

Well, this is an incredibly complex process to explain and decades of research has been undertaken to understand how tendon injuries heal, but in simple terms the main difference with a muscle and tendon injury is the poor blood supply of a tendon doesn’t support the healing process.

When there is an injury, our soft tissue is expected to go through an inflammatory phase, and then regenerate by laying down new scaffolding/collagen. But if there is minimal blood flow to an area, new fibres aren’t created, rendering the tendon in a weakened state. A weakened tendon then becomes susceptible to further injury which can then develop into a tendinopathy. 

But don’t panic yet! Tendinopathies heal well if we manage them well from the start. 

Tendinopathy

A tendinopathy is an umbrella term used to describe persistent tendon pain and loss of function related to loading (exercise). This terms covers both the pain and pathology that’s commonly associated with overuse and micro trauma of the tendons.

FIG 3: TENDON CONTINUUM, COOK & PURDAM 2009

These injuries can be acute in nature, but generally speaking they tend to sneak up on a patient. Meaning that a patient rarely remembers any specific injury event but might notice a niggle the next time they go to train that just seemingly persists and doesn’t improve over time.  Failed healing of the micro trauma can occur in these tendons which leads to the formation of a tendinopathy. 

Tendon based injuries are incredibly misunderstood and frequently mistreated. In the past, rehab focused on stretching out these injuries and massaging them due to this sense of tightness, however this approach is actually quite detrimental to the tendon. 

Treatment

The tendon must be loaded in a systematic and progressive approach. Early in a tendon injury, the tendon can ‘heal’ itself with load fairly quickly, but for the ones that have sustained considerable damage, we need to build new tendon to compensate for the lack of the old tendon/strength. This process should be guided by a physio to minimise the risk of flare ups. Each area of the body has different suggested strengthening protocols. So the approach that may be suitable for your Achilles or patella may not be as suitable for your shoulder. So basically what I’m trying to say is go see a Physiotherapist to take the guess work out of treatment. 

The Don’ts of Tendons (as taken and adapted from Dr Jill Cook/La Trobe SEMRC)

Let your Physio figure out what you should be doing to help. But in the meantime stay away from these don’ts! Or as I like to call them, the ten tendon commandments.

1. Don’t rest the tendon - Resting will lead to breakdown of the collagen and weaken it further

2. Don’t rely on passive treatments - These may temporarily make your pain feel better, but they will not be helpful in the long term. You need to improve your tendon’s ability to tolerate load, so you should be progressively strengthening under your therapist’s guidance.

3. Don’t use injection therapies as a first line approach - There is currently minimal to no evidence of the efficacy of injections into tendons and potential risk of some injections to break down the tendon further. If you are looking into injections this should not be done under the guidance of a GP but under a specialist sports physician instead.

4. Don’t ignore your pain – Ignoring pain will likely lead to further tendon breakdown.

5. Don’t stretch your tendon (in the early phases) - Once the tendon has gone through a thorough strengthening process and your therapist gives you the all clear, your tendon can then be challenged with tensile loads. But this requires careful monitoring.

6. Don’t massage your tendon - Massage creates greater compressive forces on the tendon and can contribute to further breakdown.

7. Don’t be scared of your scan results - MRIs and ultrasounds may frighten you if you’re not informed. Try and avoid scans if possible as they can be mentally detrimental in the healing process. Regardless of scan results though, there is great evidence that tendinopathies can improve to tolerate loads when correctly strengthened.

8. Don’t be worried about rupturing the tendon - Most people who rupture a tendon don’t usually have tendon pain before. So don’t be scared to load the tendon.

9. Don’t take short cuts - Rehab isn’t easy, but stick to it and the risk of recurrence will be low.

10. Don’t perform high load movements too soon - Listen to your therapist as running, jumping, changing direction too early can worsen your pain and pathology. Starting with low load movements is important in the beginning and your therapist will progress to higher loads when you can tolerate it.

Return to Pole

Pole can usually be modified with this injury to avoid positions that would aggravate the tendon. However, high load positions such as tricks that involve front splits should be avoided until given clearance. The exercise progressions your Physio provides is a stepping stone to return to these tricks so make sure you stick to your rehab closely and don’t return back to tricks before your physio allows. 

Enjoyed this blog?

Gradually over time I’ll aim to cover the main tendon based injuries that pole dancers and aerialists are afflicted by. Make sure you check out my blog on proximal hamstring tendinopathies here that was released last week to see how to address this pain from a front split!

Wanting tailored guidance and rehabilitation for your tendinopathy?

Online telehealth appointments can be booked with the Pole Physio via our ‘Book Online’ page that can be found here. Assessment and tailored rehabilitation are provided in accordance with best practice and evidence-based treatment to help you unleash your 'poletential'. And If you haven’t caught up yet on my front split blogs - make sure you head to the links below to check them out.

Until next time, train safe. 

The Pole Physio

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Related:

• Proximal Hamstring Tendinopathy

Disclaimer: This information and these exercises are not tailored to you as an individual and do not constitute as medical advice. If you have medical or injury concerns, then please individually consult with a medical professional.