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Tendon Pathology

So what is a tendon?

A tendon is the continuation of the connective tissues that surround the contractile cells of the muscles, and attach the muscle to its bony insertion. The achilles tendon for instance, is a continuation of the muscles cells from Gastrocnemius and Soleus muscles in the calf, to the back of the heel (calcaneus) where it attaches. The active role of any tendon is transfer the force of a muscular contraction to the bone to create movement, whilst the passive role of the tendon is provide proprioceptive information (position of the body in space) as well as elastic storage and energy release. This is particularly true for tendons of the lower limb such as the patella or achilles tendon.

Tendons are made up of quite different tissue to muscle and bone. Muscle and bone are both highly innervated (large nerve supply) and have a rich source of blood. Tendons however, have a very limited blood supply and thus can take longer for recovery from serious injury.

Types of tendon injuries:

Whilst the scientific debate continues to rage on as to what it is in the tendon that causes pain, what we do know is that different types or areas of tendon injuries present, act and respond differently to activity.

Many people would have heard of 'tendinitis.' What this refers to is the tendon (tendin) being inflammed (itis). Through biopsy studies, what we have learnt is that very few tendon conditions are actually driven by inflammation. More commonly what we see, is that the tissue and proteins that make up the tendon, begin to change in response to load, whether that be excessive load or completely unloading a tendon. Many imaging techniques such as MRI, ultrasound and x-rays were unable to detect this change in tissue and protein structure, and thus further complicated the diagnostic process. Recently a new imaging technique, ultrasound tissue characterization (UTC) (link to RSM Page), was able to demonstrate the internal structure of lower limb tendons and actually showed that the tendon was responding to load when they became sore, rather than becoming inflamed.

Figure 1. Ultrasound Tissue Characterisation of the Patella Tendons in a pathological situation.

The above image (Figure 1) is an example of a UTC image performed at Recover Sports Medicine. The way that a UTC is analyzed can be somewhat simplified to that of a traffic light, green is good, red is not so good. Green pixels represent healthy (aligned) tendon tissue, blue indicates less healthy (wavy or less continuous) tendon tissue, red represents unhealthy (disorganised) tendon tissue and black tissue is often considered as degenerative tendon tissue. The above example shows a focal area of red (disorganised) tissue in the patella tendon indicating that the tendon is currently struggling to tolerate the loads being demanded by the patient. UTC can be a fantastic imaging choice to determine the stage of the tendon injury, and to help ensure that it is in fact the tendon that is the cause of the patients discomfort.

This type of injury is described as a 'tendinopathy,' that is, there is pathology within the tendon tissue.

Frustratingly for physiotherapists, this type of injury can go unchecked for long periods of time. Early in the process of tendinopathy, tendons become stiff and sore at the start of exercise but then improve and pain can 'go away' during exercise. Whilst patients feel that the tendon is ok because it warms up, continual loading of the tissue can cause the tendon structure to worsen.

Other types of tendon injuries include:

  • Paratendinitis: Inflammation of the covering of the tendon
  • Tendon Rupture: Complete or partial tears of the tendon
  • Enthesopathies: Injury to the portion of the tendon that connects directly into the bone

Tendinopathies, paratendinitis, ruptures and enthesopathies all respond differently to load on the tendon and have very different management structures and reasons why they become sore or painful. It takes skill in diagnosis and management of the various conditions and we must always first ensure we understand why the tendon is being loaded differently. Load is critical to tendon health; if a tendon is completely unloaded, such as if a person is using crutches for an extended period of time, the unloaded tendon may deteriorate in structure. If a tendon becomes 'overloaded', the cells of the tendon begin to produce different proteins and begin to change shape, leading to disorganised tissue within the tendon (pathology). Due to this reliance on load, treatment of tendons must focus on finding the correct amount of load to place the tendon under to stimulate a healthy tendon response, without exceeding the limit of what the tendon can comfortably withstand. Often tendons are a victim in the chain, that is, they are unduly loaded due to poor biomechanics or weakness of surrounding muscles.

There are currently many types of rehabilitation processes and medical interventions available to sufferers of tendon pain. Unfortunately most passive interventions, particularly injections of steroids and blood injections have poor evidence supporting their use, and recent literature actually suggests that they can be harmful to the tendon in some instances. Current treatment modalities must aim to correct the biomechanical insufficiencies that lead to increased loading, review the patients history of injury as well as past training loads, current loads and future requirements of the persons sport, hobby or recreational pursuit. If health care practitioners do not address the above factors in tendon injury, patients are unlikely see improvements in tendon health. Patients suffering tendon pain need to understand that tendons take time to improve, much longer than muscles and bones, and are very sensitive to change in loads, be wary of therapists and organisations offering a quick fix for tendon problems.

Jay Anderson
Physiotherapist
Recover Sports Medicine



If you have any questions regarding this post, or wish to book in to see our Senior Physiotherapists, please call us on 1300 858 774 or email contact@recoversportsmed.com.au

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