Navigating Tendonitis with Mondo Sports Therapy
Mondo Sports Therapy will be giving a presentation on Saturday, September 8 at 8:45am at Gazelles HQ about sports injuries, prevention and treatment. Join us!
[Update] Thanks to everyone who attended the seminar! As mentioned, Katie and Pieter have provided a list of basic strength training exercises for runners. The exercises are available to members on our Seminar Resources page.
Tendonitis, a term you have undoubtedly heard if you have been around the running scene for more than a few weeks, can make or break a runner’s season. Perhaps you have heard that word dropped by a fellow runner, coach or even been told that you, yourself, have the dreaded affliction, but what exactly does it mean?
The word tendonitis indicates inflammation in a tendon. “-itis” is a suffix meaning inflammation and back before the 2000s, this is what we thought tendon injuries were a result of, and therefore we call it “tendonitis.” Recently however, there has been a surge of research performed on tendons and this research has changed not only the way we treat tendon injuries, but has also changed how we refer to them. The term “tendonitis” has been replaced with the term “tendinopathy” meaning that the tendon has a pathology. This change in nomenclature is due to research showing there is not a classical inflammatory response within the tendon, and that the main problem is the breakdown of the collagen fibers that make up the tendon. Tendons break down if the load applied to the tendon is too large for the tendon tissue to absorb. Essentially, the load bearing capacity of the tendon is compromised. There are other tendon injuries, like a tenosynovitis (which is a fancy term for inflammation of the surrounding synovial fluid that envelops the tendon…but we are not going to talk about that specific ailment today).
In runners, the most susceptible areas for developing tendinopathy include the gluteus medius (outer hip), the hamstring insertion (right at the crease between your buttock and posterior thigh) and the Achilles (your heel cord). Believe it or not, patellar tendon injuries are not common in distance runners as these tend to be seen in the younger jumpers and explosive athletes. So knee pain in a distance runner tends to be due to something else, not the tendon.
Tendons are fantastic structures that attach our muscle tissue to bone. Their function is to perform energy storage and release and they are very load dependent structures, so when overloaded, they let you know right away.
So, what do you do if you start to have pain in a tendon!? Contrary to popular belief, rest and ice are not the way to go here! Like I mentioned above, tendons are load dependent structures so if you remove all load then you are actually only delaying the process of returning to your desired level of function. Yes, the pain will decrease if you take time off but you are not addressing the underlying problem so the pain will inevitably return once you get back to training. And that does not give you permission to ignore your pain and keep training, because that will make matters worse too. You will need to MODIFY your loading. You need to decrease some of the load that has made your tendon angry and find the appropriate load so that it can tolerate your training demands without flaring up. Sometimes this might mean just taking out hills or speed work and at other times, it might mean getting on an Alter-G and adding a proper tendon loading program. There are lots of things that can cause a tendon to flare up, from changing training surfaces to increased volume, to adding in speed work, plyometrics or hills. None of these are bad activities but if you already have a vulnerable tendon and add one of these into your training program, it could overload your tendon and without the correct approach, you could be in for a long road of nursing an angry tendon.
What about eccentrics!? The eccentric loading program was extremely popular back in the 1990s and early 2000s when a Swedish orthopedic surgeon, Hakan Alfredson, was doing everything he could to tear his super irritated Achilles tendon so that one of his colleagues would surgically repair it and get him out of his misery. Frustrated, Dr. Alfredson decided to deliberately aggravate his injury with a series of aggressive eccentric jumping exercises in an effort to rupture it so that they would have to repair it. But to his surprise, instead of getting worse, his Achilles improved. The foundation of eccentric exercises to rehab irritable Achilles tendons was developed and people ran with it. Now Alfredson is not wholly wrong in his approach. He had a very irritated, degenerative tendon and the load he placed on it via his eccentric heel drops was a good therapeutic dose for his specific tendon injury. That is not the case for every tendon though and over the past few decades, lots of studies have found that eccentrics are not the Holy Grail of tendon healing. So, to answer the what about eccentrics question, yes, they are fine in some cases, but not all.
So, what should you do if you suspect that you have a tendon injury? You should first and foremost consult a knowledgeable physical therapist, someone that loves tendons (hi, me!!). Make sure that they have a lot of experience in monitoring tendon injuries in highly active people like yourself. They cannot only address the underlying biomechanical fault that caused the tendon to be a stress riser in the first place and guide you to the right loading program, appropriate progression of exercises and can teach you how to monitor your own tendon. They can also teach you some basic things to avoid that are unknowingly irritating your tendon.
Depending on each individual’s fitness and activity level, we may use isometrics, loaded isometrics, isotonics, eccentrics or plyometrics to address the specific tendon injury in front of us. There is no “one-size fits all” and if someone tries to sell you that then I would recommend you find someone else to help you with your rehabilitation.
The main thing to remember is that tendons do heal. However, the healing process is slow, with the majority of problems taking an average of 4 months to completely settle down. This does not mean that you cannot run at all in that time frame! It just means that if someone promises you a quick fix then they do not know enough about tendon pathology and histology.
What does not help?
Passive treatments like ultrasound, heat, ice, laser.
Any injection into the tendon. This includes dry needling. You can needle the muscle but not the tendon.
Stretching – really, stretching can compress the tendon and tendons do not like compression.
Massaging or cross friction or scraping to the tendon. This does not increase blood supply to the tendon and only compresses the tendon and as I just mentioned, irritable tendons hate compression!
Extra corporal shockwave therapy- this is controversial but evidence is mixed and this is a very painful process and not more effective than a proper tendon loading regime.
Caution: Steroid injections can most certainly help BUT, they need to be administered with the greatest of care. They will decrease the complaints of pain, but will also significantly weaken the tendon structure so make sure you understand the risks and rewards before jumping straight into a steroid shot.
We hope this helps give you some understanding of tendon injuries. Again, we love this topic and are passionate about keeping our active patients active so please reach out for help if you are struggling with some aches or pains. We do not promise quick fixes because we cannot change the tissue repair time but we do promise quality care by top-notch physical therapists who are up to date on current approaches in tissue healing.
Mondo Sports Therapy sends physical therapists to Gazelle workouts during the week to provide free injury assessments/evaluations. Take advantage of this amazing part of your membership and visit with Mondo at the following times:
Wednesday 5:30-7:00am at Gazelles HQ with Cody McGrath
Friday (open to the public) from 12-1pm at Gazelles HQ with Pieter Kroon and/or Katie Gwyn
The PTs only evaluate and provide advice, they can not treat you without a physician's referral.