Pain from tendons is a very common thing for people to experience at some point in their life. This pain can arise for a number of reasons, and can come on suddenly or can slowly develop over time.
In general, tendons are stiff, rope-like structures that connect muscle to bones usually at some bony point that crosses a joint. When a muscle contracts it pulls through a tendon onto the bone and causes the joint to move in one direction or another.
To continue on with the theme of the tendon being like a rope, imagine it being like a piece of yellow braided rope. If that rope gets used day after day, and the amount of force that the rope is trying to manage is greater than its capacity to manage it effectively and safely, one of three things will happen:
- The rope will tear, either fully or partially;
- The fibres that make up the weave of the rope will begin to fray and become brittle;
- The rope will be irritated and not work as well. In tendons, this is when you get inflammation around the tendon
The “-itis” part of tendonitis means that there is inflammation of the tendon. Recent research has taught us that there is no actual inflammation in tendons, rather there is degenerative changes and tears to tendons. This is why we now call it tendinopathy, or there are pathologic changes to tendons.
Whether there is a partial tear or there are frayed fibres, most people keep on asking the muscles and tendons to do the same amount of work with the same loads. The only problem is that there are fewer fibres to deal with the forces going through them.
So, the question is, what do you do with a tendon that is injured? Often people with tendon pain reach for an anti-inflammatory, which in the case of an acute tendon that is painful makes sense. In the long term tendons actually need a “pro” inflammatory rather than an “anti” inflammatory environment to heal. All the while being uncomfortable, stiff, and painful at the start, inflammation is a body’s natural response to bring the required cells, hormones, and chemicals to the injured area to heal. So, why would you take medication or do a treatment that would take this away?
Outside of the initial acute injury we wanted to take some time to go over the general principle of treating tendons, which as you will see, involves a couple of steps to heal them up properly:
- Change the forces going through the affected tendon
- This doesn’t necessarily mean to rest the tendon, but rather increase the strength of the other muscles that help in a particular action. No muscle works alone. If you increase the strength of one muscle, it reduces the work that another muscle has to do;
- To deal with this end of the treatment, being guided by a physiotherapist, an athletic therapist, or a personal trainer who has knowledge in dealing with sports injury rehabilitation can help balance out the loads in a particular part of the body.
- Take the tension out of the tendon
- If the tendon has a lot of tension or stretching stress in it as a result of a muscle being in spasm or being tight all of the time, the tendon is experiencing a lot of undue forces on a daily basis that doesn’t need to be there. This is why it feels so good after a massage, and pain goes down. There is no longer the tension in the tendon or in the muscle that the body is continually fighting.
- Getting a massage or acupuncture, or both, can really help with this. These treatments also help promote blood flow to the affected and injured areas so that those cells and hormones can get to the area to get to work on the healing and restorative process.
- Reorganize the tendon
- When tendons fray after chronically being overused, overloaded and abused, the fibres mat up like a gnarly mass of disorganized strands of fibre. There is no way that a rope that is all frayed and balled up can deal with forces effectively.
- Clinics, like ours, do this by using something called shockwave therapy. It in effect provides a “sound wave massage” to the injured tendon, thereby re-injuring a tendon so that when we apply the next treatment the fibres heal back in an organized fashion. It also works to promote the flow of blood to the area that is shockwaved so that the blood can bring the important nutrients and cells to the area to heal the injured tendon.
- Stress the tendon to become more resilient
- Rehabilitation specialists use a technique called “eccentric loading” to stimulate the release of a chemical called nitrous oxide in the injured tendon. Eccentric loading is effectively having a muscle contracting, while the muscle/tendon unit is stretching out. Essentially, it’s like you have a heavy box in your arms and you are lowering it to the ground. Your biceps are doing work, but the actual length of the biceps from one end to the other is getting longer.
- This is best guided by a physiotherapist who has the knowledge and skill to be able to develop and advise you on the specific exercises required to load the tendons in a way that they can heal.
- Occasionally, in addition to trying to get the body to release nitrous oxide in the injured tendon, we use nitroglycerin patches over the injured tendons to help provide more of that chemical in the local environment.
- Optional, but not essential, medical treatments
- Steroid injections: People will often come in with tendon issues and let us know they take ibuprofen or an anti-inflammatory, and it hasn’t done anything. These medications have to get absorbed by your body, travel around your blood vessels until they find the place where they are supposed to work. The steroid injections put the medication right where it is needed without having to figure out where they are supposed to go. However, while these injections don’t actually do anything to heal the injured or damaged tendon, an important role of these injections is pain control. By improving pain, you can then perform the required exercises that do the actual healing process. Be careful though, getting repeated injections over time, can often do more harm than good. So this is a temporary crutch to help you get on with your rehabilitation.
- Prolotherapy: Over time, as we mentioned above, repeated steroid injections can actually do more harm than good. Using such as prolotherapy can be a safer alternative. This involves the injection of a high concentration of glucose solution around the injured tendon, which stimulates the body to improve the healing, regenerative environment of the injured tendon. Patients can get this treatment once every four to 12 weeks during the rehabilitative process to help along with healing.
- Platelet Rich Plasma (known as PRP): this treatment re-introduces your own concentrated blood platelets, which are rich in growth and healing factors, into the areas of an acute or chronic tendon injury. Often, a could of PRP injections are required to stimulate the tendon enough to work. While the evidence says that it is good for some tendon injuries, it is not the “cure all” that gets portrayed in the media. While we do not yet do this at Reactivate, we have several colleagues at other clinics out of town who can perform this treatment as it requires specialized equipment.
- Your mind and your machine
- The last, but most important, element of rehabilitation is you, your patience, and your compliance. In order for your tendon to heal, you have to be patient.
- These injuries and conditions take time because tendons don’t have very good blood supply to them, and as such they take longer to heal. However, if you are compliant and keep on doing the exercises, with the exercises getting gradually harder over time, you will see a dramatic improvement over a six to 12 week period of continuous and committed effort.
Our team at Reactivate Muskoka can help you out every step of the way with your rehabilitation from tendonitis. We would love to see you, and please feel free to visit www.reactivatemuskoka.com for more information about us or to book an appointment online.
Dr. Trenholm moved to Muskoka in 2003, after completing his residency in Family Medicine, Obstetrics and Emergency Medicine at the Northern Ontario School of Medicine.
After rediscovering his love for being active through the sport of triathlon, he decided to incorporate this personal passion with a professional interest in Sports Medicine. This exciting field of medicine builds on his strong foundation in anatomy and biomechanics that he gained from completing a Masters of Science in Kinesiology at McMaster University.
Dr. Trenholm’s strength is looking at each patient as a unique structure of moving parts, in which movement at one part will affect movements at another. By looking at the human body as a puzzle full of complex movements, Dr. Trenholm works hard to determine a diagnosis of what is going on and put a plan in place of how to best get patients back moving again and enjoying life to its fullest.
Dr. Trenholm is a former national board member of the Canadian Academy of Sport and Exercise Medicine (CASEM), is the Chair of CASEM’s Endurance Sports Medicine special interest group, and is actively involved in research in the field of Sport and Exercise medicine. He actively participates in local and national sporting events providing medical support as a physician, and recently returned from the 2019 Para Pan American Games in Lima, Peru.
A referral from a client’s Primary Care Provider is required to see Dr. Trenholm as his services are covered through OHIP. Alternatively, if clients are already seeing an Allied Health Professional (Physiotherapist, Chiropractor, Massage Therapist, Naturopath, Osteopath), the Allied Health Professional can ask that a consultation request be made by a client’s Primary Care Provider.