Tendon pain is a common complaint seen in the general population but particularly in sports people. It is an injury that can haunt an athlete for months, preventing full performance and in a lot of cases, stopping performance. To make matters worse, once you have suffered from tendon pathology, the chance of you suffering again is increased significantly. The term used for tendon pathology is tendinopathy, this is a generic descriptor of the condition which covers both pain and the underlying pathology. 

Tendinopathy is an overuse injury, which usually occurs as a result of excessive load being placed on the tendon. The tendon reacts to this load and often becomes acutely painful and swollen. At this stage of injury, if we reduced the load on the tendon, the tendon would probably settle down. However, if we continue to excessively load the tendon, we start to see changes in the make-up of the tendon. If this is allowed to continue, degenerative changes are often seen in parts of the tendon structure. Despite all this, the tendon remains a strong structure that should not be feared! The painful Achilles tendinopathy or patellar tendinopathy (commonly seen in runners) may give us the sense that the tendon is no longer strong, we might then scare away from training, but in fact exercise is the best thing for the tendon repair process.  

It is accepted in tendon specific research that tendons have a brilliant ability to adapt, they get stronger and become more resilient in response to exercise. Degenerative changes sound scary and can evoke feelings of ‘being old’ ‘unrepairable’ but we know from numerous studies that pain-free subjects will have similar degenerative changes on scanning. There is a poor correlation between the pain we feel and pathology seen in a tendon. A diagnosis of a degenerative tendon therefore tells us little about someone’s pain or function and cannot predict future issues. The important factor is to treat the presenting symptoms with a focus on the individual’s goals, which could range from being able to walk to the local shops to running a marathon. 

It has been suggested to categorise tendinopathy into two groups; the pain dominant stage (where pain is the main feature and the tendon is more irritable) and the load dominant stage (where progression to full training/performance is hindered but day to day activities are manageable). If pain is the dominant feature, treatment needs to aim to reduce the pain. In this stage reducing the load on the tendon is key, we want to reduce the irritability of the tendon to then be able to build it up again gradually. Volume, intensity and frequency of training are likely to need to be modified. Some aspects of training may need to be put on hold. For example, Achilles tendinopathy tends to flare up if there is excessive dorsiflexion of the ankle (pulling the foot upwards). Reducing hill running, which forces the foot into more dorsiflexion, may be enough to rest the tendon and settle pain. Once pain is settled, we can then be more goal focused and start rehabilitation to improve the load capacity of that tendon, gradually achieving a return to full performance. Throughout the rehabilitation process there needs to be careful, ongoing assessment of strength, muscular control and pain response. Once goals are achieved, it is vitally important to set the individual up on a maintenance programme for good tendon health, as recurrence rates can be high. 

Alternative treatments are available to treat tendinopathy and I am frequently asked about these. Physiotherapy involving an exercise programme is not a quick fix, it takes time, effort and patience. I can understand therefore that other treatments may seem a more appealing, quicker solution. There is some research to support other treatments, such as shockwave therapy and GTN (glyceryl trinitrate) patches but these are advocated if there has been no improvement after 3 months of an appropriate physiotherapy programme. They should also always be used together with an appropriate exercise regime. Steroid injections and a treatment called platelet-rich-plasma therapy (PRP injections) have limited evidence and can affect tendon health, for this reason these treatments should not be routinely offered. Lastly, surgery is sometimes offered to treat tendinopathy. Again, this might seem like a quicker fix but there is limited evidence to show that surgery is superior compared to a physiotherapy loading programme and therefore it is only recommended, generally, if there is limited improvement after 12 months.  

As you can see, tendinopathy is a condition that often takes a long while to treat as unfortunately there are rarely quick fixes. Reducing the load on the tendon early in injury, should help settle the symptoms down but this relies on the individual spotting the signs and making a conscious decision to reduce training levels. Occasionally, during treatment, training needs to stop completely but in a lot of cases training just needs to be modified and managed. Continuing to run can then actually become part of the rehabilitation back to full performance.  

Being a runner myself the last thing I want is to stop running through injury. Running has so many positive effects, in addition to the obvious on physical health. An injury can have a knock-on effect on all aspects of well-being. Obviously, an injury from a direct fall, a twist of the ankle, is easy to explain, there is a direct cause and effect. But what about those injuries, the majority of running injuries, that just develop? The dreaded plantar fasciitis, the stubborn ITB syndrome to name a couple, these can hinder performance for weeks, if not months. What causes these types of injury? Surely if we have a greater insight into why these develop, prevention could be more possible. 

Lots of well-meaning advice is often offered, ‘it’s your trainers’, ‘you shouldn’t run on grass’, ‘you shouldn’t run on the road’.  Professionals can also give conflicting advice causing confusion and frustration. The problem is, we have very limited research/evidence to support a lot of our well-reasoned theories. There is a limited amount of research that exists to support strength, flexibility and alignment to be the cause of an injury and the research we do have is generally of low quality. That is not to say that these factors should not be assessed to formulate a diagnosis and treatment plan but a single finding should not be given too much weight as the cause of injury, it is more likely to be a combination of many factors.

One area that does show some promising results is the strength of the adductor (inner thigh) muscles.  Adductor strength may be a predictive factor for injury. An interesting study done in 2010 showed that adductor strength was reduced prior to injury. Strength was assessed at different stages and was found to be reduced just before injury occurred, compared to the original strength level. This suggests that keeping the adductors strong may play a role in injury prevention, although this has not been investigated. 

Research suggests that errors in our training are likely to contribute heavily towards injury and therefore understanding these could help in injury prevention.  An error might be a sudden change in the amount we put on our body (the load) or training when the body’s ability to run is lowered (the capacity).  If we put too much load or if we change the load we are putting onto our body, for example suddenly increasing our distance or speed, our body’s capacity needs to be able to cope with this change. Equally, the load/training might not need to change but injury might still occur. In this case there might have been a change in the body’s capacity to take the normal training program. For example, a period of illness will reduce the ability to run at the same load, through reduction of fitness, strength, endurance etc. 

Psycho-social factors are a well researched contributing factor for the development of injury. Stress has a well-documented effect on our immune system, lowering our capacity to withstand the load of running and in turn can play a role in injury. Sleep plays an important role in the recovery from a training session. Sleep deprivation, from a waking child for example, or from stress, will hinder the recovery and therefore reduce our body’s capacity to withstand the load during the next run.  

Let us consider an example; a 32-year-old male who is an experienced runner runs up to a max of 10km in training sessions. He is in good medical health. He wants to complete a ½ marathon in 2 months time. He has a young child who has just started to wake again in the night. He is also coming up to a deadline at work and is working long hours to get the work submitted. He therefore can only run at the weekends so thinks, to make the most of it, he will increase the distance of his next run to 15km. He previously had a niggle in his knee after running but this was completely manageable, otherwise, he has been running comfortably and feels like he is getting stronger. Today on his run, after 13km his knee caused him to stop :(  

Here we see that capacity has reduced through stress and lack of sleep. The error in training is pushing the distance too quickly. Normally this might have been fine but with the reduced capacity of the body to withstand the extra load, the niggle in the knee is now a bigger problem.  

Injury is likely to be multifactorial, there is seldom a single risk factor. A 2017 study found exactly this and named training load increase, training intensity increase and decreased sleep to be the biggest risk factors.  It is sensible to conclude that at a time of sleep deprivation, for whatever reason, training load needs to be carefully managed and not increased suddenly. 

Through better understanding of the contributing factors of an injury, a better, more rounded approach to successful rehab can take place. In turn, recovery will be quicker.