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Tendon Pain- don't be led astray

Professor Jill Cook is at the forefront of tendon research and she has summarised the key principles. Every day I have people coming to me with tendon injuries, and when I ask what they have tried previously, I get so frustrated by the number of clients who have been strung along by healthcare professionals who have taken them down a passive treatment approach, or have been given general advice which in fact worsens symptoms.

If you have a tendon injury, or tendinopathy, do not:

  • Rest completely- use it or lose it. The same applies for tendons. You must find a level of load that can be tolerated and regularly challenge the tendon with this load.

  • Have passive treatments- a pet hate of mine. Treatments that do not encourage the tendon to strengthen and increase its ability to take load, will fail in the long term. Electrotherapy, ice, acupuncture etc will not solve the underlying cause of your pain, even if they seem to mask the pain.

  • Have injection therapies- The best clinical trials have shown that injecting substances is not effective. It should be reserved as a last resort if the tendon does not respond to a rigorous exercise program. Injections increase the risk of rupture, please don’t pursue them as your first option!

  • Ignore your pain- you must not overload the tendon or you risk worsening the issue. Reduce aspects of training that overload, and focus on the level of load that can be tolerated. I usually set a max VAS score of 4/10.

  • Stretch your tendon- tendons do not like compressive loads, and when you stretch a tendon it adds compressive loads. If you have tightness you would gain more benefit from sports massage and strengthening.

  • Massage your tendon- though massaging a muscle can give some benefit, massaging the tendon again is a form of compressive force, and again this is detrimental to tendon health. Your tendon may feel better immediately after but it will reduce its tolerance to load and this is detrimental if done regularly.

  • Be worried about imaging your tendon- Often scan results can create fear avoidance behaviours, especially if they show a degenerative tendon or small tears. There is very good clinical evidence that even, painful pathological tendons withstand loads and this remains the best method of encouraging healing, especially when that load is increased over time.

  • Be worried about rupture- Most people who rupture tendons, have never had any pain. All your pain does, is stop you from loading it, so whilst it’s important not to overdo it, it’s important you don’t avoid pain altogether, and low levels of pain can encourage healing.

  • Take shortcuts- Quite simply, there are no shortcuts for these kind of injuries. Whatever you may have been promised beforehand, from the moment you start the correct for of treatment, you are looking for a 3-6 month process in the worst cases. Long term outcomes are excellent if you follow your programme week by week, and don’t jump ahead or jump ship! Treatments which are promised as quick fixes are just that. You may feel better more quickly, but the underlying pathology of the tendon remains and when you begin to load the tendon the pain is likely to come back.

  • Load incorrectly- this is where your physiotherapist can come in handy. Finding an appropriate level of load which does not over-work or under-work the tendon can be tricky. Using the tendon like a spring, for example like in plyometric activities places high load on the tendon which may be useful in the latter stages of rehab, but will often be detrimental to the tendon health if employed too quickly. It is important to establish what the correct level of load is.

So Professor Jill Cook lays raises lots of excellent points here, but the key thing is that exercise is by far the best, and often the only effective treatment for these kind of stubborn and persistent injuries. Make sure you seek the opinion of a health professional who sticks to the above principles; otherwise you’re wasting your time! Often it will only take a couple of sessions to be set on the right path and then you can manage on your own should you choose to.

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