Tendinitis is a common condition effecting the Achilles, patellar, hamstring, bicipital, and wrist extensor tendons. Although these are common conditions, there is a lot of misinformation regarding what causes tendinitis and what treatments are effective. This blog post will cover what really causes tendinitis, does pain mean damage, and whether you should rest or stretch for tendinitis.
1. Tendinitis is caused by inflammation
While inflammation can be involved in tendon pain, its role is smaller than once thought. The primary driver of tendon pain appears to be mechanical overloading and any inflammation is the result of overloading. As a result, the term tendinitis is outdated because it no longer reflects the pathology of tendon pain. Instead, tendinopathy is the preferred term when describing tendon pain.
This may seem like a trivial terminology issue, but it has some major implications on how tendinopathies should be treated. The treatment of tendinitis used to consist of NSAIDs (aspirin or ibuprofen) and corticosteroid injections to reduce the inflammation in the tendon. This approach can be beneficial in the beginning, but has been shown to weaken the tendon leading to a higher reoccurrence rate. The treatment for tendinopathy focuses on increasing the tendon’s resiliency to loading.
2. Pain equals damage
Unfortunately, the association between pain and tendon damage is relatively poor. Tendons that appear normal on imaging can be debilitatingly painful while severely degenerated tendons can be pain-free.
The reason this occurs is because pain is a protective mechanism to alert you of danger or the potential of danger. For example, think about the pain of a paper cut compared to a bruise that you didn’t notice on your arm. The paper cut represents a relatively small amount of tissue damage but it is quite painful, while the bruise represents tissue damage but there was no pain.
3. Rest is best for tendinitis
In the initial stages, reducing the load on the tendon may be necessary to allow it to calm down. However, prolonged resting of the tendon can cause stress-shielding which causes the tendon to become weaker. In fact, the changes in the tendon structure with stress-shielding can be similar to those changes with chronic overload.
Another problem with resting for too long then returning to the same activity level is that it spikes the load on the tendon, which increases the likelihood of re-injuring the tendon.
4. Stretching the muscles will help tendinitis
While tight muscles may contribute to tendon pain, traditional stretching can actually cause more harm than good. Compressing the tendon against the bone can cause more irritation of leading to structural changes in the tendon.
To address the muscles during a painful episode, using a foam roller or lacrosse ball to massage the area can be a better option as it can relax the muscles while avoiding compressing the tendon.
5. Loading is bad for tendinitis
Tendons are designed to transfer force between bones and muscles, so loading isn’t bad for tendons by any means. The problem with tendon pain is that the load placed on the tendon has exceeded its ability to tolerate the load. The goal with tendon pain would then be to find a tolerable amount of load and build up the capacity of the tendon from there. Initially, isometric exercises can be used to load the tendon during acute pain episodes. Isometric exercises, exercises where you contract the muscle but don’t move the joint, have actually been shown to reduce the pain of tendinopathies. The load on the tendon can then progressively increase until it can tolerate the load of whatever you want to do.
To summarize, tendinopathy is an overload syndrome which is not driven by inflammation. Start a rehabilitation program by finding an appropriate amount of loading for the tendon and begin strengthening the tendon to load. While flare ups may occur during the rehabilitation program, rest assured that pain does not mean you are causing tissue damage. Although dealing with a tendinopathy can be a frustrating experience, overcoming the pain and discomfort is possible.
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