Treating Painful Tendons – Tendinopathy and Its Real Cause

By: Gema Sanchez, PT

tendinopathy, tendinitis, physical therapy
Pain relief and increased strength are a few of the benefits of treating tendinopathy with Physical Therapy.

Pain and tenderness in a tendon, sometimes lasting for many months, is a fairly common occurrence. Many people would still call this tendon pain tendinitis, which means inflammation of the tendon. But when researchers began looking more closely at the structure of chronically painful tendons 20 years ago, they found that many of the painful tendons did not have inflammation. Instead, the tendons showed signs of degeneration without inflammation. These findings indicate that there is much more going on than just inflammation, so the diagnosis of tendonitis was no longer accurate. In an effort to more accurately describe the state of the tendon, a chronic painful tendon is currently diagnosed as tendinopathy, meaning a disorder of the tendon.

Tendinopathy is diagnosed using clinical findings. These include:

  • tenderness/pain with palpation of the involved area
  • pain with activity, stretching and contracting the muscle
  • decreased function
  • gradual onset of stiffness in the tendon
  • sometimes localized swelling and palpable crepitations (a crackling sound or feeling)

An ultrasound or MRI could be used to confirm clinical findings, but these tests are not accurate for diagnosing tendinopathy.

Tendinopathy affects both athletes and non-athletes. The most commonly affected tendons are the Achilles, kneecap, shoulder rotator cuff and elbow extensor tendons. Pain can be debilitating, leading to the inability to perform work and sport activities.

Causes of tendinopathy are not yet fully understood.  It is believed that it occurs due to a combination of intrinsic factors (such as muscle tightness/imbalance/weakness, age, joint hypermobility and systemic disease) and extrinsic factors (such as occupation, physical load and overuse, inadequate equipment and environmental conditions).

Treatment of tendinopathy has influenced and been influenced by the evolving understanding of tendon pathology and healing. Various forms of intervention aimed at decreasing pain and promoting tendon healing have been used. These include: extracorporeal shock wave therapy, low level laser, glyceryl trinitrate patches and injections. Surgical intervention has been shown to be successful in non-responsive cases, but is in general considered a last option.

The most widely used and favored treatment for tendinopathy is eccentric exercise, which has been shown to reduce pain, improve function and normalize tendon structure. Eccentric exercise refers to a specific type of muscle contraction. There are two types of muscle contraction, concentric and eccentric. A concentric muscle contraction is when a muscle contracts while getting shorter. This is what you normally think of as contracting a muscle to move a joint, for example, flexing your biceps to bend your elbow. An eccentric muscle contraction is when a muscles contracts while getting longer. When you are relaxing your elbow back down to straight, the biceps works eccentrically to slow and control the motion.

 In order for an eccentric exercise program to be effective for treating tendinopathy:

  • loading must be customized to the particular tendon involved, taking into account length of tendon, load, and speed
  • exercise program should be as similar as possible to the usual mechanical stressors that the person experiences
  • exercise must be gradually progressed
  • exercise progression must last for at least 12 weeks

Physical therapists have the correct training and knowledge to design, monitor, instruct and progress a customized eccentric exercise program.. They will provide you with a program that stresses the tendon in the right way to promote healing and help you return to your normal work and sport/recreation activities safely and without pain.