FRANCISCO QUINONES, DPT
What is tendinopathy?
Good question and the truth we don’t know exactly what happens to the tendon that makes it painful. We used to think there was an accumulation of microtears in the tendon (from overuse) but we know now this is not the case. For some reason the cells that lay down tendon material seem to go a bit haywire and just start laying down proteins in a haphazard way which changes the tendon stiffness and structure in a part of the tendon.
What causes tendinopathy?
This one we do know, loading a tendon in a way that exceeds it’s normal capacity. Every tissue in our body has a certain capacity both from it’s inherent properties and from the ways we use it (i.e. the ways we have asked it to adapt in the past through exercise or work).
What is a tendon?
Right, let me back up. The tendon is what anchors our muscles to our bones. It is designed mainly to transmit tension (or pulling) loads to the bone and gives the muscle an anchor from which it can contract to perform work.
How do I know if the pain I have is a tendinopathy?
Well you can’t really. There is a reason why we (Physical Therapists) go to school for 7-9 yrs, but, in general if you have a tendinopathy, the pattern should be that your pain occurs when you use the aggravated tendon and is not painful when you don’t. So your pain shouldn’t be showing up when you're resting (although it may ache after exercise) and the more you use it the more it hurts.
So I should rest it right?
No. There is no benefit from long term rest because the tendon will adapt to this too. You can think of all the tissues in our body as constantly adapting, both up and down based on what we do with them. With a tendinopathy the capacity of the tendon has already taken a big hit and the last thing we want to do is have the tendon adapt (down) further toward having a lower capacity. In some (more painful cases) it may help to rest it up to 72 hrs after injury but after this it is time to start the hard work of changing the tendon back to it’s prior capacity.
So how do I get it to change back?
Right. First we need to identify just how much (load) the tendon currently tolerates and we can do this by using your pain as a guide. During exercise we think that pain between 0-3/10 is perfectly safe. pain between 3-5/10 as being on the upper end of ok and anything more than this as being too much. I know everyone hates the pain rating scale but people are actually pretty good at getting these numbers right. If this doesn’t work at all for you than just think of it as it’s ok if the pain is there with exercise whispering at you but you don’t want it yelling at you and you shouldn’t have to reach for Alieve when you are done. Think of that light pain as your tendon telling you this is my capacity right now. Every exercise session then is just a matter of meeting it there every time and doing this consistently (every other day or every third day). This means you may need to go slightly up or down with weight or reps with each exercise on a given day but overall, you should be gradually going up to meet it where it’s at. If this is happening, then you are on your way as it is already adapting to doing more. Pain overall will improve gradually too but it tends to trail behind how much the tendon tolerates.
So It should take a couple of weeks then?
No. Unfortunately the research is clear here to that the road to fixing a tendinopathy is a long one. 12-16 weeks is the current timeline we think it takes to make a permanent change in the tendon. The road to getting it pain-free may be up to six month or more. This doesn’t mean that the pain will still be the same six month later, it will be quite a bit better but may still occasionally show up (with exercise or work).
Can I speed this up if I do exercise every day instead of every other day?
No. There is some research that shows we need to give the tendon at least 24hrs between loading sessions to give it time to adapt for the better. But, you can certainly do other exercises that don’t overload & provoke the tendon like low impact cardio or exercises targeting the non-affected parts of your body.
How do I know if I need the help of a Physical Therapist?
Well if you are able to exercise and keep the pain below a 3/10 and it is gradually getting better than you are probably on your way. But, if you are struggling to figure out what to do and how to load it and getting mixed results or it is getting worse than it would probably be worth your time to have someone with training help you figure out how to navigate this injury. I like to use the analogy of bowling where I just act as the bumper guards for my patients so that they can be successful. Ultimately the work has to be done by you either way but the road back from a tendinopathy can be confusing and anxiety ridden so it may help to have a guide.
By Kristina Pattison, DPT, OCS, CSCS
Photo by Seth Orme: Jenna Lyons and Kristina Pattison at the 2020 Runners Edge Run Up For Air fundraiser for Climate Smart Missoula
With upcoming races on the calendar, it can be tempting to increase miles quickly this time of year. But gradually building a solid base of running volume is the best way to prevent the dreaded overuse injuries that often plague runners later in the year. When Planning a Race Season and developing Phases of a Running Program it is important to consider both the principles of overload and rest for a safe build up for the year.
It’s important to understand the physiological implications of increased volume over the course of a training season. Increased miles equates to increased forces absorbed by the body as you’re pounding around on the pavement or trails. With each step the body absorbs 2-3 times your body weight while running. These forces are attenuated mostly by soft tissues of the body--muscles, tendons, ligaments. But also cartilage and bone can take a beating as well as the body fatigues, so the goal is to keep your active shock absorbers--muscles--doing the work to offload less compliant tissues like cartilage that is susceptible to irreversible degeneration. This takes time and gradual adaptation. Remember that as you progress miles, it’s been found that increases of less than 10% per week is associated with decreased incidence of injury in runners.
Also, consider that the day you rest is the day your body heals and responds to overload by becoming stronger and more adept at absorbing shock. The soreness you feel when starting a program is considered to be due to healing associated with micro-tears in weaker muscle fibers. As these fibers heal they become stronger and better adapted to withstand that higher amount of stress during future bouts of exercise. When designing training a training program, most coaches will incorporate at least one full day of rest into the week, and vary the intensity of days so there is at least one easy run between each of your harder, longer, or more intense efforts.
Strategically incorporating increases in volume paired with appropriate rest days allows your body to naturally adapt to increased miles and speed so you can reach you race goals without setbacks associated with injuries.
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