Tendon problems – why yours is not getting better

What gets tendons better and what doesn’t 

As a Physiotherapist I treat thousands of tendon problems including pain in the Achilles tendon, the patella tendon of the knee, the gluteus medius tendon on the outside of the hip, the hip flexors at the front of the hip, the extensor or flexor tendons in the elbow (tennis and golfers elbow,) hamstring tendon, the peroneal or tibialis posterior tendons of the foot and De Quervains tendon in the thumb/wrist.

Tendons are one of my most favorite things to treat because I know that I can get them better, not just from past experience but, most importantly, from the tonnes of research out there that tells me what will and will not work. Unfortunately I come across lots of cases of people that have seen other health professionals – physio, chiros, osteos, doctors and other so-called ‘specialists’ that have given unsucessful treatments. So in this article I am going to cover the main areas that research (and experience) shows work for treating tendons:

1. Don’t rest it
2. Modify activities 
3. Incrementally load the tendon
4. Don’t stretch the tendon
5. Use anti-inflammatories in specific cases only
6. Get back to cardiovascular exercise as soon as possible
7. Look after your general health – nutrition, sleep, stress management etc

Don’t rest it

The most common mistake I see in the treatment of tendon problems is people being advised complete rest.  Research shows that resting tendons completely will not resolve the problem. Resting may make the pain go away but when you use it again the pain will return – whether this is typing at your desk or returning to your favored sport. In fact your tendons are most vulnerable if you have had a period of time away from loading them – for example when you return to work having been on holiday for a couple of weeks or returning to sport after an illness. 

There is an exception to this rule and this is when the tendon is completely ruptured, in this case rest is required as part of the recovery process (with or without surgery.)

Modification of activities

The fact that complete rest is not good for tendons does not mean that you should plough away at the same intensity of activity that is causing the pain. Instead modification of the painful activity is the key. A decent physiotherapist will work with you to establish all the different activities that need modifying, which can in some cases be a long list and this is why establishing your goals with your physio is so important (if there are any physios reading this we use a scale called the PSFS which is awesome for this purpose.)

Modification of activities can be achieved in a number of ways:

1. Reduction of the same activity. For example in the case of a runner with patella (knee) tendon pain they could change their running to interval running which maintains their cardiovascular goals whilst reducing frequency of impact through the tendon.
2. Changing the way the body is doing the activity (i.e. changing biomechanics) so that the same activity is achieved but in a lightly different way. This causes a change in the load through the tendon and surrounding structures. For example with an wrist or thumb tendon if the wrist is held in neutral whilst being used it can immediately reduce the pain. 
3. Changing equipment to modify the activity for example with a very painful Achilles tendon a heel raise can be inserted and then slowly reduced over the following days/weeks as pain allows. 

Once all modifications have been made these modifications can be slowly adjusted until you have returned to full activity and sports under the guidance of your physio.

Load it

Evidence shows that increasing load through a tendon is the best way for it to recover. This loading needs to be done in all the ways that the tendon needs to function which includes decelerating (‘eccentric’ loading) acceleration (‘concentric’ loading) fast and impact movements. It also needs to be done in the full range of motion through which the tendon moves. For example if you are a basketball player with an Achilles tendon problem then doing heel raises on the flat is not going to get you very far, you are going to need to do them off a step and build up to doing lots of jumping and landing.

In most cases that I see where physio has failed the tendon has not been loaded enough, not the other way around. 

Even when the tendon is very painful and swollen the pain can be reduced by doing static exercises. This is when you hold the tendon in one position while loading it without moving it. This can then be done in different positions.

Don’t stretch it

Everyone loves the feeling of a good stretch but unfortunately stretching has been found to increase tendon problems so you can wipe those stretches off your exercise list and focus on the loading and biomechanics exercises instead.

Anti-inflammatories or not

I have been referring to ‘tendon problems’ rather than tendinitis during this article because this term is no longer considered correct. This is because tendon pain has been shown not to be inflammatory and therefore the term tendinopathy should be used. This is one of the reasons that anti-inflammatories are not the answer for tendon problems.  

In addition to this, inflammation is the first stage of healing so anti-inflammatories should be used with care.

However, if the tendon is swollen, red and painful a course of ibuprophen has been shown to help, just make sure you check with a pharmacist or your GP first.

Cardiovascular exercise

Pain responds well to cardiovascular exercise so as soon as you can get back to some kind of general exercise the better – walking in a pool, cycling, walking, anything that increases your heart and breathing rate.

General health – nutrition, stress, sleep

Tendons are effected by a number of systemic things like hormones so eating healthily, getting enough sleep, rest and working on stress management are all important for the treatment and prevention of tendon problems. 

I hope this has been helpful. There are around one hundred useful exercise videos in the videos section of this website so please take a look. There are also specific articles about a number of tendon problems so please use the search tool on this website to find out more. Please do follow us on twitter, facebook, sign up to our mailing list. If you would like tailored advice, diagnosis and treatment please contact lucy@octopusclinic.com or call 02075838288. 

…and don’t forget to share this with anyone you know with tendon pain. 

I look forward to hearing from you. 

Lucy Macdonald

Chartered Physiotherapist