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.