Tendinopathy is a very frustrating diagnosis to treat as a physical therapist. However, it is even more frustrating to the patient. There is a lot of ideas out there on tendinopathy and how to treat it but what is more concerning is that many treat with "evidence" without even understanding what the evidence is telling us. The truth is, we don't know everything yet about these conditions. Fortunately, over the last few years, more and more solid research on clinical applications to diagnosis and treatment for tendinopathy has been published.
As a sports therapist that has dealt with triceps tendinopathy myself, I am particularly interested in this subject. Often when clinicians think about tendon issues they think about overuse. Sounds pretty simple right? I mean, we overloaded the tendon. The problem is we must identify what the overload was. What I mean is how was the tendon overloaded? Tendon's are typically overloaded by two mechanisms: energy storage & release and compression. But I doubt many clinicians understand the compression mechanism. To understand the compression mechanism of tendon pathology, see this video. It is a perfect explanation to how this occurs.
So what about classification of tendons? Well as Jill Cook (a tendinopathy research/expert) explains, there are reactive tendons and degenerative tendons. Understanding where the athlete is on the continuum is the key. Knowing where they are can guide your treatment. For example, an athlete who is reactive and in-season would benefit from isometric exercise. The thought behind this is that isometrics help with cortical inhibition. There have been studies to show immediate decrease in pain with isometrics. This is particularly important for the management of in-season athletes because isometrics can be applied before practices/games without loss of muscle strength, which would potentially be the case with isotonics.
Here is a great short 15 minute interview with Jill Cook on reactive tendons and degenerative tendons and how to treat them. In an ideal world you would want to structure your treatment plan like this:
Isometrics to Isotonics to Strength Endurance to Energy Storage and Release to Functional Exercise.
Basic Ideas to remember:
- Tendons are load bearing. Collagen takes the load. When the collagen matrix is disrupted, change in mechanical strength and capacity to take load can change.
- With injury to the tendon, cell proliferation occurs which can lead to proteoglycans causing swelling of the tendon. If overload continues to occur, the number of cells in the tendon will disrupt the matrix leading to neovascularization.
- With rehab, isometrics help with immediate pain relief. Work the entire kinetic chain for best results and improved assistance to tendon.
- Brian Schwabe, PT, DPT, SCS, CSCS