Is stretching making your tendon pain worse?

One of the most frequently recommended treatments for tendon pain is stretching. The thought is that tight muscles place tension on the tendons leading to pain, therefore, stretching will help decrease muscle tone and tendon pain. However, could stretching actually make tendon pain worse? This post will discuss the function of tendons and whether stretching is beneficial. 

The purpose of a tendon is to transmit force between muscles and bones. You can think of tendons as springs between your muscles and bones. With each step, your Achilles tendon transmits force between the bones in your feet and your calf muscles. Your Achilles tendon will also store some of the force generated when your foot first makes contact with the ground and then use it to help push your foot off the ground as you take your next step. The stiffer the spring (tendon), the more efficient this storage-release of force will be. 

The terminology for tendon pain has changed frequently over the previous few decades as our knowledge of the pathology has changed. Tendinitis was the first term used to describe tendon pain because the pathology was thought to be driven by inflammation. Newer research then suggested that degeneration was driving the pathology, not inflammation, so tendinosis became the preferred term. The currently used term to describe tendon pain is tendinopathy. This is because tendon pathology appears to be more of a spectrum from normal to degenerated tendon, with pain occurring at any point. 

While stretching may provide short term relief for tendinopathy, it appears that it may have negative effects on the tendon structure. Research has shown that compression of the tendon against a bone (which occurs with stretching) causes the tendon to alter its collagen structure. The structure of the tendon transitions from type I collagen typically seen in normal tendon to type II collagen which is seen in degenerated tendon. 

The implication of this finding is important for many common conditions. Below are a few examples of common situations that cause tendon compression. 

  • Golfer’s/Tennis elbow pain
    Stretching the wrist flexors or wrist extensors (golfer’s and tennis elbow, respectively), will compress the tendons against for forearm. 
  • Biceps tendon pain
    Stretching the biceps or pec muscles will put the shoulder into extension which will compress the biceps tendon against the head of the arm. Also doing dips or bench press where the elbows go behind your torso can compress the biceps tendon. 
  • Gluteal tendon pain
    Gluteal tendinopathy is a common cause of pain on the outside of the hip. Stretching the gluteals or the iliotibial band will compress the gluteal tendon against the hip. Sitting with one leg crossed over the other is another common position that can cause compression of the gluteal tendon. 
  • Patellar tendon pain
    Stretching the quadricep muscles will cause the knee to flex, compressing the patellar tendon against the knee. Deep squatting and lunges are also positions that can cause compression. 
  • Achilles tendon pain
    Stretching the calf muscles will cause the Achilles tendon to be compressed against the heel bone. Sitting with your toes tucked under your ankle will also compress the Achilles tendon. 
  • Plantar fascia pain
    While technically not a tendinopathy, plantar fasciitis responds similarly to tendinopathies. Stretching the patellar fascia compresses the fascia against the bones in the feet. 

This doesn’t mean that tendons can never be stretched. When dealing painful tendons, there may be more effective treatment options than stretching to decrease the pain and improve the structure of the tendon. Self-myofascial release to the muscles using a foam roller or a lacrosse ball is one option that avoids compression of the tendon against bone. Isometric exercises, which are exercises where you hold still in a certain position, have been shown to decrease the pain of tendinopathies. As isometric exercises are tolerated, a progressive loading program can continue to strengthen the tendon, eventually returning back to your normal activities. 

 

References:
Ark, Mathijs Van, Jill L. Cook, Sean I. Docking, Johannes Zwerver, James E. Gaida, Inge Van Den Akker-Scheek, and Ebonie Rio. "Do Isometric and Isotonic Exercise Programs Reduce Pain in Athletes with Patellar Tendinopathy In-season? A Randomised Clinical Trial." Journal of Science and Medicine in Sport (2015)

Cook, Jl, and C. Purdam. "Is Compressive Load a Factor in the Development of Tendinopathy?" British Journal of Sports Medicine Br J Sports Med 46.3 (2011): 163-68. 

Rio, Ebonie, Dawson Kidgell, Craig Purdam, Jamie Gaida, G. Lorimer Moseley, Alan J. Pearce, and Jill Cook. "Isometric Exercise Induces Analgesia and Reduces Inhibition in Patellar Tendinopathy." British Journal of Sports Medicine Br J Sports Med 49.19 (2015): 1277-283.