Our senior Physiotherapist Abi recently spent a day with Achilles tendon pain guru Seth O’Neill, getting up to date on all the latest research and management of lower limb tendinopathies. Read on to find out more…

What is a tendinopathy?

Tendinopathy is the word used to describe an injury or healing disorder of a tendon. It is usually characterised by pain, swelling and impaired performance or function.

Who does it affect?

It is expected that 57% of the population will experience a lower limb tendinopathy at some point in their life time. In the lower limb, the most common sites for tendinopathy are the foot and ankle (achilles tendinopathy) and the lateral hip (gluteal tendinopathy). The most common groups of people to experience this dysfunction include endurance runners, athletic people over the age of 40 and inactive sedentary people.

Risk factors for developing a tendinopathy can be intrinsic or extrinsic:

Intrinsic	Extrinsic
Increasing age Gender Muscle weakness Tendon structure Increased BMI (Obesity) Diabetes Steroid medication Lower limb biomechanics	Footwear Training surface Training errors – overloading or underloading Sedentary behaviours

 

What causes a tendinopathy to develop?

A tendinopathy occurs when there is an imbalance between the wear or load on the tendon and the repair processes, resulting in a degenerative process. This is often due to a sudden increase in activity levels or when returning to normal activity after prolonged rest.

Here is an example of the amount of load or force that the achilles tendon will experience during a 5km run:

Average time for a 5km run = 30 minutes
Average jogging step cadence = 150 steps per minute
150 x 30 = 4500 steps (2250 per leg)

Average load per stride = 6 x body weight (approx. 4000-5000N)

Calculation for a 70kg person running 5km:
4200N x 2250 steps = 9,450,000N load per leg
This equates to 945,000 kgs of force through each achilles tendon during a 5km run!

Our bodies do an extremely good job of coping with these loads, most of the time! It is easy to see how an extra 1km or 5 minutes of jogging could tip the balance between wear and repair though.

This article by Tim Gabbett explains load tolerance nicely, using beer tolerance as an example!
https://thesports.physio/2016/07/26/whats-beer-got-to-do-with-sports-injuries-a-guest-blog-by-dr-tim-gabbett/

So how do I make a tendinopathy better?

Activity modification is key to helping the repair processes for a tendon. This doesn’t however mean we need to rest completely. Usually by reducing the frequency, intensity (pace), volume (distance) or duration of training we can continue to be active during the rehabilitation phase.
In 2007 Silbernagal developed the ‘Pain monitoring model’ which can be used to help guide training and activity modification. It is based on symptom response to exercise within 24 to 48 hours following activity.

Following exercise symptoms should settle quickly and not worsen the following day. If this is the case, you are exercising at a level that will aid tendon repair.

The type of exercise we do also has a big impact on tendon wear and repair. Heavy strength training that gradually progresses over 12 weeks has been shown to reduce pain and improve function. It is also important to focus on control and quality of movement whilst we are exercising. In order to reduce the chances of developing another tendon issue in the future it is recommended to continue a long-term strength maintenance programme once or twice weekly.

Reducing compression over the tendon will also aid pain relief and tendon repair. This can occur through both active and passive methods. Using the most appropriate exercise for each individual tendinopathy will have a big influence on compression and strength improvements. Stretching however can cause direct compression over the tendon and has been shown to have little positive impact on tendon repair. Passive ways to help reduce tendon compression include the use of heel cushions in shoes for achilles tendinopathy or sleeping with a pillow between the knees for gluteal (lateral hip) tendinopathy.

Is there anything I should avoid?

Poking and prodding a sore tendon will only make it more sensitive.  Often people use pain on touch as a measure of recovery but there is no direct link between pain and function/repair of a tendon.

Ice can be useful to reduce pain and muscle soreness following an increase in activity. If used regularly though it can inhibit muscle and tendon adaptation. This also applies to anti-inflammatory medications like ibuprofen.

Tendon pain often feels tight and makes us want to stretch lots. As discussed earlier, static stretching can cause increased compression of the tendon and therefore increased irritability.

Summary

Tendon pain is common but it doesn’t have to stop us doing everything we enjoy.
Focus on improving the strength of the muscles around the tendon, modifying activity/training as pain allows, allow yourself recovery days and gradually build back up to your normal activity levels.

If you need any advice or guidance regarding a tendon issue, please get in touch and we can arrange an assessment and work towards a specific rehabilitation programme to help you get back to the things you love.