What is tendonitis?
Tendons are rope-like collagen proteins bundled together to form fibrils. The primary function of tendons is to transmit forces from muscle to bone for movement. In tendonitis, there is a breakdown of collagen proteins in the tendon. Overloading the tendons, either gradually or suddenly, can cause tendonitis. Ageing and diseases such as obesity and diabetes can also contribute to tendonitis. A tendonitis specialist doctor understands the importance of identifying the factors that have led to tendonitis. This blog outlines why you should use a tendon specialist if you have a tendon problem.
Is tendonitis due to inflammation?
Previously, we thought active inflammation was necessary, a process often referred to as tendinitis. However, we now know that tendons swell with water and then undergo a slow degradation of collagen. This new understanding has led to changes in treatment.
What features are common in tendonitis from a tendonitis specialist doctor?
Generally, people with tendonitis report pain arising from their tendons. Pain often occurs when an activity stresses the tendon, such as running for the Achilles tendons, playing tennis or golf for the elbow tendons, or playing tennis or golf for the knee tendons. Usually, pain ‘warms up’ with activity but often gets worse when you cool down.
Most cases of tendonitis are readily diagnosed based on pain history. Still, examination is helpful to rule out other causes, such as pain arising from muscles, ligaments, or joints. For example, knee pain in a runner may result from a knee cartilage injury rather than patellar tendonitis. Overall, the job of tendon specialists is to get the correct diagnosis the first time.
It is also essential to identify the causes of tendon pain. Often, we see people who have pushed themselves too hard with their training. There has recently been an increase in training intensity, such as the introduction of interval or hill training. In some cases, certain conditions, such as menopause, obesity, and diabetes, increase the risk of tendonitis.
Does a tendonitis specialist doctor always perform a scan?
Tendinosis radiology
Although not essential, tendon specialists use scans such as ultrasound or MRI for complex cases or when cases do not respond to simple treatment. In addition, a routine tendon scan indicates that the pain is most likely unrelated to the tendon.
Typically, ultrasound demonstrates tendon swelling, collagen breakdown, and increased blood flow. Its advantage is that it is inexpensive and is often used in conjunction with a doctor’s appointment, saving time and money. However, we recommend MRI of certain tendons, such as hamstring or hip tendons.
One advantage of MRI in tendonitis is the ability to visualise adjacent structures, such as joints and muscles. For example, an MRI of the hamstring tendon also assesses the status of the hip and sacroiliac joints.
What are the most effective treatments for tendonitis?
Previously, doctors advised patients to take anti-inflammatory tablets such as ibuprofen. They previously believed that acute inflammation played a key role. However, recent evidence suggests that medications like ibuprofen may slow healing. Nevertheless, a short course of ibuprofen can help with acute tendon pain.
More useful is exercise therapy supervised by an experienced physiotherapist.
How does exercise therapy work in tendonitis?
We don’t know exactly. However, exercise works by stimulating collagen proteins in the tendon or increasing muscle strength. Positive effects occur irrespective of the type of exercise. For example, in Achilles tendon pain, concentric loading, which shortens the muscle during contraction, is analogous to eccentric loading, in which the muscle lengthens. An important concept is that the exercise load on lower-limb tendons (e.g., Achilles or patellar) should be heavier but less frequent. On the contrary, exercise should be relatively light but more frequent for upper-limb tendons (e.g., tennis elbow or shoulder tendons).
Exercise also provides graded exposure, so the tendon and person become used to heavier loads over time.
An example of strengthening for the calf:
First, you should reduce or avoid activities that have aggravated your Achilles tendon. For example, suppose you are a runner. In that case, we recommend reducing your running frequency, intensity, and duration until the pain stabilises (see below for the definition of stable tendon pain). Generally, we suggest reducing your running by about 50% and then reassessing.
Next, strengthening exercises help to correct weakness and reduce pain. An important principle is to progress your exercises (add weight) so you keep improving.
Strengthening sessions should be performed every 3rd day and should consist of seated and standing calf raises on a step. In addition, exercises should be performed with a single leg, as recent evidence suggests weakness also occurs on the pain-free side. Aim for three sets of 8-10 repetitions for each exercise. Finally, you should add weight to your body (e.g., 2.5 kg) every week to stimulate strength and muscle development. For the calf, we aim for strength goals: for standing calf raises, we recommend lifting an extra 1/2 x body weight; for seated calf raises, we recommend lifting an extra 1-1.5X body weight.
While we focus on concentric and eccentric (isotonic) exercises, we sometimes use eccentric exercises alone to increase tendon load.
Can you exercise through tendon pain?
Generally yes. Tendon specialists think exercising through pain is ok as long as the pain is stable.
Stable pain is low-level tendon pain that occurs after exercise and lasts less than a day. Some people use numbers—say less than 3/10. Alternatively, unstable pain is high (greater than 3/10), lasts for more than 24 hours, and requires tablets such as ibuprofen.
Generally, you should aim to rehab and train with stable pain. Moreover, unstable pain means you have done too much for the tendon to handle.
What about using a metronome with tendon exercises?
Preliminary evidence suggests that chronic tendon pain leads to brain-driven muscle inhibition. We think that using a metronome improves muscle drive by reducing muscle inhibition. We refer to this activity as tendon neuroplastic training.
Does a tendonitis specialist use other treatments?
While exercise is the most effective treatment, tendon specialists use other interventions to enhance exercise outcomes.
First, GTN patches have become popular for tendonitis. They are a viable, noninvasive alternative with favourable outcomes. We use patches to reduce pain in tendinopathy. We apply patches to the skin on the swollen tendon. They are left on for most of the day but must be removed at night. Generally, we use patches for 1-2 months.
Second, Shockwave therapy directs sound waves to the affected tendon. The sound waves stimulate the body’s healing capacity and stun the pain-generating nerves. Evidence suggests that shockwave therapy is effective for hamstring, gluteal, and Achilles tendinopathy.
Third, tendonitis injections reduce tendon pain. A recent review of different injections used in tendinopathy, co-authored by Dr Masci, suggests no clear favourites. However, there is concern that cortisone injections may harm tendons, including in cases of tennis elbow. PRP injections are becoming more popular for some tendons, although evidence is lacking for most tendons. Other options include percutaneous needle tenotomy and sclerosants.
Finally, surgery should be used only when all other treatments have failed. A recent review of surgical interventions for tendinopathy suggests that, despite surgical risks such as infection and wound complications, outcomes are no different from those of physiotherapy. An alternative to tendon surgery is tendon scraping. This less invasive option has shown promising results for some tendons.
Tenex procedure for tendonitis
The Tenex procedure is a novel treatment for tendonitis. It uses ultrasonic energy to remove damaged tendon tissue while preserving the healthy part. Unlike surgery, it is minimally invasive and performed with a local anaesthetic. Thus, it replaces the need for more invasive and riskier surgery. It is a good option for upper- and lower-limb tendonitis that has failed other treatments.
Frequently asked questions to a tendonitis specialist doctor
Which diseases cause tendonitis?
Generally, excessive exercise or sport that is well above the tendon’s capacity causes tendinitis. However, more recently, it has been shown that certain medical conditions can increase the risk of tendonitis. Examples include diabetes, obesity, high cholesterol, gout and inflammatory arthritis such as psoriatic arthritis. Another example specific to Achilles pain is the presence of a large plantaris tendon close to the Achilles tendon. One of the advantages of seeing a tendon specialist doctor is to sort out other possible causes.
Can I run with Achilles tendonitis?
Yes, but we recommend correcting calf weakness before returning to running. Running needs to be slow and progressive over weeks. Moreover, you should run on the days you’re strengthening the calf (e.g., on calf-strengthening days 1, 4, and 6, and on running days 2 and 5 in a week). Additionally, you should increase your running only if the pain remains stable (see above).
Can Yoga cause tendonitis?
As a general rule, you should avoid direct stretching of sore tendons. Previously, we said that Yoga makes your tendon pain worse. However, we know that Yoga can be modified to reduce tendon load. An example is a Yoga butt injury, where exercises can be modified to help and not hinder tendonitis.
What are the best shoes for Achilles tendonitis?
In general, we recommend a stable shoe for flat feet and a cushioned shoe for high arches. More importantly, we recommend avoiding tight-fitting shoes or those that apply pressure to the tendon. Direct pressure on the tendon—also called frictional load—can worsen tendonitis pain.
A heel raise may also reduce the load on the Achilles tendon. This treatment is beneficial for insertional Achilles tendonitis, as the heel lift minimises the pressure exerted by the calcaneus on the Achilles tendon.
Is there a psychological component to tendon pain?
Yes. We know that people with anxiety and depression find it more challenging to manage their tendon pain, similar to other chronic pain states. Why is this still up for debate? Nonetheless, treating people’s anxiety regarding their tendon pain is essential in the overall context of treatment.
Tendon neuroplastic training: Is there a better way to improve tendon rehab?
Yes. Tendon neuroplastic training is a new rehabilitation principle for upper- and lower-limb tendonitis. Using a metronome during strength training can improve muscle contraction control. Recent evidence suggests that improving strength and muscle control may accelerate tendon rehab.
Final Word from Sportdoctorlondon: a Tendonitis Specialist Doctor
Tendonitis is a complex problem to treat. Most people with tendonitis have an unrealistic expectation of a ‘quick fix.’ Tendonitis generally does not resolve quickly. Overall, exercise is effective in most cases, and occasionally other treatments, such as shockwave therapy and GTN patches, are beneficial. Finally, we should consider injections or surgery only if all other treatments have failed. If you have tendon pain, consult a tendonitis specialist doctor.
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