This is a blog post for everyone, experts in the field and people without previous health-related knowledge. My aim is always to write in a way everyone can understand, because I think that patients should have a clear idea of what’s wrong with them, why and what the injured structure is about.
To make the different tendinopathy treatments understandable, I thought it would be good to introduce some ideas that will be very useful for you when you read about this subject in future blog posts. I wanted to write this post so that you know the different stages of tendinopathy. Historically, we have referred to tendinopathies as “tendinitis” (itis = inflammation), but as I have already explained in previous posts (see the post Achilles tendinopathy, the article Terminology for Achilles tendon related disorders by C.N. van Dijk et al. and Time to abandon the “tendinitis” myth by K.M. Khan et al.), it is known that tendons haven´t got inflammatory cells, so we should use the word tendinopathy.
What is tendinopathy?
Tendinopathy is an injury caused generally by tendon overuse. Basically, it occurs when you overload your tendon, when you stress it more than it is used to handling. Let´s explain this with an example. I’m sure you have a friend or acquaintance who talks a lot. The first time you talked to him, you were not used to such a thing and after 20 minutes you got a massive headache (due to lack of training). After some time of friendship, you get used to him and are able to survive two hours of talking until you start feeling headache (due to overuse or overtraining). Note that in this example “headache” would be “tendinopathy”, for those who had a very long day and their neurons do not work properly.
Tendinopathy can be related to age, work (repetitive, mainly), sport played (example, sudden increase in the intensity of training in runners can cause Achilles tendinitis), obesity, possible diseases you might have (example, diabetes, as bloodstream will be poorer than normal).
The main idea to understand this injury is the fact that tendons are continuously breaking down/building new tissue (always trying to get a perfect balance) and have a very poor blood flow (therefore, few “soldiers” to fight the injury [reparative cells]), which leads to injury if you stress the tendon and give no time to reach the right balance “destruction/creation” of tissue.
Stages of tendinopathy
I am going to show you a model with the different stages of tendinopathy, which is essential to know to be able to carry out the right rehabilitation. I’ll explain in simple words (understandable for everyone) the model described by two “clever guys”, JL Cook and CR Purdam, in the article Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.
This study divides the tendinitis into three phases:
It occurs in response to a tensile or compressive tendon overload. It appears after a quick increase in an activity which you are not used to or, even, a direct trauma. I’ll make it clear with two examples: Ruud, Dutch runner who is used to running 5 km every other day and always in a Dutch city (choose the one you like the most, I have not seen a flatter country in my entire life, I would bet that the highest hill they have would be the one you made of sand on the beach- yes, the Nederlands has beaches and they are pretty good) and one day he went running to the Austrian Alps and got Achilles tendinopathy as a result. Another example can be falling on your knees, which could cause compression of the patellar tendon and, therefore, tendinopathy. In both cases, the tendon will thicken and become stiffer, as a way of reducing stress or adapting to overloading. As I have said to you several times in this blog, there is no presence of inflammation, although there are cellular changes. This stage is reversible as long as the overload is reduced enough or you give your tendon a rest. The way to reverse tendinopathy in reactive phase in the above-mentioned examples would be Ruud going back to running in the Nederlands and forget about the Alps for a while or giving the Achilles tendon a rest, and then increasing mileage gradually to give time his tendon to adapt to the new loading scenario. As for the second example, pay more attention to what you are doing and you won´t fall off again.
It is similar to the reactive tendinopathy, but in this case the changes at the cellular level are more important. You reach this stage when the tendon overloading continues and you do not give it the necessary rest or decrease the afore-mentioned loading. In addition, it is thought that there may be an increase in vascularity. Our Dutch friend Ruud is still in the Alps, running uphill without resting, thinking that his Achilles tendon pain will disappear after some time. However, what he is doing is worsening the situation.
The structural changes of the tendon are considerable after a chronic overload of the tendon. The tendon has degenerated and is now in a stage where its ability to reverse the changes is very small. Ruud, you did too much, you felt that your lungs were working well, you felt strong enought to climb Montblanc on single leg, but now, you have got a nice pain and a thickened Achilles tendon that will hardly allow you to continue with your runs once you’re back in the Nederlands.
Loading will set the direction of the arrow on this “continuum”, either towards the degenerative phase or the reactive one.
What you should have in mind is that these stages are not isolated, but a “continuum”. Distinguishing the phases is important to establish the appropriate treatment. Now, you’re thinking “yes, all this sounds great, but how can I distinguish the phases, should I ask the tendon?” Try, you never know, you might get an answer. As this is unlikely, I would like you to read this sort of summary from the “smart guys”. This summary says that if you come across a n old person with a nodular thickened tendon, he/she is likely to have a degenerated tendon; on the contrary, a young athlete after an acute overload is likely to have a reactive tendinopathy.
Comments are welcome, either to add something or to let me know how wrong I am.
If you have any questions, do not hesitate to contact me on The Physical Therapy, Physiotherapy Clinic based in Southampton, and I will be happy to help you.