Tendinopathy

Tendinopathy is a common type of overuse injury and it is the main reason for consultation for a musculoskeletal complaint, corresponding to around 30% of all such consultations with a general practitioner. A tendon with symptoms of tendinopathy is likely to suffer alterations such as color changes, disorganized structures of tendon fibers leading to a friable, fragile and painful tendon. The painful tendon is usuallythicker and larger in size with an increase in stiffness when compared with a normal healthy tendon.  A multifactorial process is responsible for tendinopathy that comprises intrinsic and extrinsic factors. Repetitive movement or excessive load can impose stress in the tendon generating micro traumas leading to intra-tendinous degeneration, partial tears and ultimately rupture if untreated. Damage can also occur on the micro-vasculature leading to deficiency of metabolic activity which is detrimental to molecular and tissue repair (Figure 1). 

Figure 1: Degeneration of a tendon (Tendinopathy).

Tendinopathy is also associated with changes in the expression and activity of various matrix-degrading enzyme resulting in tendon inflammation. Extrinsic factors such as increased frequency, poor technique, footwear, hard, slippery or uneven surfaces may predispose a person to tendinopathy.  Intrinsic factors are those associated with alteration in lower limb function, poor biomechanics, gender, age and also genetics. Usually tendinopathy is more prevalent in males than females. Tendinopathies are clinically characterized by a gradual onset of stiffness in the tendon, activity-related pain, decreased function, sometimes localized swelling and palpable crepitations. Common sites of tendinopathy are the wrist, elbow, shoulder, hip, knee and ankle. 

Treatment: It is important to avoid complete cessation of tendon loading activities, as that will further reduce the load capacity of the tendon. The reduction of high exercise loads, reducing frequency of training (twice a week is tolerable for many tendons) and decreasing volume (reducing time of training) are all useful means of reducing load on the tendon without resorting to complete rest. Classical treatment for tendinopathy includes: rest, ice, NSAID’s, massage, acupuncture, passive physiotherapy and reduction of training load. Althought NSAIDs appear to be effective for pain management, this analgesic effect could lead patients to ignore early symptoms,entailing further damage on the affected tendon.                 

The current most common therapeutic exercise regimen for rehabilitation involves mechanically loading the painful or abnormal tissue with the use of eccentric exercises. This exercise involves lengthening of the muscles while a load is applied to it. This therapy has been shown to decrease pain and normalization of the tendon in those with tendinopathy. Also the combination of static stretches and eccentric training for the affected tendonmay further increase the chances of a rapid recover.