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Why do tendons become painful and what can we do to restore normal tendon function?

I recently completed the APA sports level 2 course and one particular component which peaked my interest was Tendinopathy. So I know Tendinopathy doesn’t sound so exciting; but painful tendons are often treated poorly and develop into chronic pain conditions.

Peter Caine’s tendon component (based on Jill Cook and Craig Purdam’s tendon model) was very insightful so I thought it would be a great start to our blog posts.

So why do tendons become painful and what can we do to restore normal tendon function?

Tendons are the structures which attach muscle to bone and transfer load from muscle contraction to create joint movement. We often see painful tendons in our clinical which are effecting the patients ability to perform their desired tasks. So why do tendons become painful? Why does tendon pain often become chronic? What can be done to rehabilitate tendons and prevent chronicity?

All of these questions can be answered with one simple factor; LOAD. And Jill Cook and Craig Purdam’s tendon model gives us a good framework to identify and treat painful tendons.

There are 3 types of painful tendons; reactive, degenerative and reactive on degenerative.
If a tendon is intensely loaded above normal; without enough rest, this may develop into a reactive tendinopathy. This happens more in the younger athlete who has recently increased training load, frequency or duration. This may also happen after a period of rest and return to normal exercise. Alternatively, if a tendon is repetitively overloaded for lengthy periods; this may develop into a degenerative tendon. These tendons tend to present in the older patient who has a chronically overloaded tendon and a long history of symptoms. Thirdly, there are reactive on degenerative tendons which tend to present in the older patient as a “flare up” of their normal pain. An example of this may be an older patient who has recently commenced training for the city to surf.
So why is it so important to understand why a tendon has become painful?
Each of the above painful tendons needs to be treated differently so it is important that the correct type of tendon problem is diagnosed to implement effective treatment. Therefore, a detailed history is key in identifying the type of tendon problem and guiding treatment.
For example; a reactive tendon needs rest to settle and a degenerative tendon needs load to improve. If a reactive tendon is treated as a degenerative tendon it will get worse; and vice versa. Tendon pain often becomes chronic and failed treatment occurs often. This is because a thorough understanding of the presenting tendon problem has not been established.

What can be done to manage painful tendons?

  1. HISTORY: Establishing the type of tendon problem
  2. EDUCATION: regarding tendon pain and load modification
  3. AVOID STRETCHING: Often times the first thing prescribed to painful tendons is stretching. Stretching should be avoided as it increases compressive tendon loading and pain
  4. LOAD MANAGEMENT: i.e. appropriately resting a reactive tendon and then reloading and appropriately loading a degenerative one
  5. ADDRESS BIOMECHANICS: addressing movement deficiencies which may be contributing to tendon overload

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