What should I do for tendon pain?

If you’re struggling to keep active and what seems like a painful tendon is shutting you down, then you may want to read what Dr Alastair Jones – a Sports Medicine and Musculoskeletal Physician based in Leeds thinks is important when assessing and treating tendons.

Introduction

A tendon is very tough soft tissue at the tip of muscles which attach muscle to bone. A tendinopathy is a failure of the normal healing response of the tendon and develops after the tendon and surrounding structures has been overused. This is commonly seen in people who have recently altered their daily activities or suddenly increased their training load, for example when preparing for a long-distance race. The tendon fibres become disrupted and some cells die. There is then a disorganised healing response resulting in pain and stiffness. This can sometimes become so severe that it stops exercise or even activities of normal daily life. If left untreated overtime these tendons can become weaker and more susceptible to further injury.

Common Sites

Tendinopathies can occur in any tendon. However, there are some common sites clinicians see frequently in tendons in the shoulder, elbow, ankle, and knee.

Presentation

Patients often report pain at the site of the tendinopathy. This can be severe at first but usually fades to an ache after a few weeks. It is usually worse after exercise and may ease with a little rest. Interestingly patients may well be able to complete their exercise in the early stages of tendinopathy as the pain can reduce during exercise, only to return after stopping or finishing your exercise. Another symptom we see often is a feeling of pain and stiffness at the site in the mornings. When examined by a clinician, patients will often have tenderness around the area and a reduced range of movement of the affected joint. The tendon may be thickened, and the surrounding muscles may have lost definition.

It is crucial the correct diagnosis is made as there are many conditions that may mimic a tendinopathy. This may alter the clinician’s treatment plan. Correct diagnosis is made through careful history taking and a focussed physical examination. A functional assessment must always be performed to look for factors that pre-dispose the patient to develop a tendinopathy at that site. The tendon should be appropriately loaded during the examination and all possible alternative causes should be excluded.

Investigation

A diagnosis of tendinopathy may be made solely from the clinical history and examination findings. Investigations may be used to picture the tendon and confirm the diagnosis. These include Ultrasound and MRI scanning. Commonly these investigations are used to rule out other causes of the patient’s pain. X-Rays can sometimes be useful to rule out a bony cause for the tendon problem, such as spurs.

Treatment

The overarching principle of tendon recovery is appropriately loading the tendon to allow healing and while this is occurring, managing the patient’s exercise volume. With that in mind physiotherapy is vital. The tendon is loaded through a combination of different exercises specific to each patient. These exercises are usually progressed under the guidance of your physiotherapist or Musculoskeletal / Sports Medicine physician until strength in the tendon is increased and the patient can return to their activities in a graded way without symptoms returning. A specialised return to activity program is designed and special equipment such as alter-G treadmills can be used to help the build-up back to normal activity.

In addition to the above it is sometimes necessary to consider medical therapies, largely to help with pain and to assist the physiotherapy programme.

Research into this area is ongoing and the current common therapies include:

Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

The debate of the role of inflammation in tendinopathy rages on (Some researchers believe there to be an inflammatory response, at least in the first instance). A short course of NSAID’s may be prescribed in the first instance when pain is very severe. Long term use of anti-inflammatory drugs is generally to be avoided.

Extracorporeal Shockwave Therapy (ECST)

This is a mechanical therapy that helps to reduce pain at the site of the tendinopathy by affecting the pain receptors and promoting tissue healing. It is delivered by a clinician usually in courses of 3-6 sessions (1 per week) each lasting a couple of minutes.

Steroid Injections

These are used to reduce inflammation and pain. While they show good short-term benefit, they can have negative consequences for the tendon in the mid to long term and so are not widely advised or used now.

Platelet Rich Plasma Injections

This is a procedure in which blood is drawn from the patient and spun down in a centrifuge. The platelet rich plasma floating at the top of the sample is then harvested and injected into and around the tendon. The aim is to promote tendon healing. Usually, two treatments are required.

Dry Needling

In this procedure a needle is inserted into the tendon multiple times in order to encourage bleeding and promote tendon healing. It is done under local anaesthetic.

High Volume Stripping

This procedure disrupts the new blood vessels and nerves that have grown into the tendon during the injury process. The clinician injects normal saline (saltwater solution) into the sheath that surrounds the tendon stripping these structures. This results in reduced pain.

Surgery

A surgical opinion may be considered in cases of severe tendinopathy. It is viewed as a last resort when other treatments have failed. It does not guarantee resolution and symptoms may recur with conservative or surgical approaches.

Conclusion

Tendinopathies usually result from overuse of the tendon and surrounding structures. They often cause pain and loss of function resulting in reduced exercise performance or difficulties with activities of daily life. Careful diagnosis through a thorough history and examination is essential to ensure other conditions are not missed. There are a range of medical treatment options available to supplement the loading and return to activity program usually designed by a physiotherapist.

To find out whether we think your issue is likely to be a tendinopathy and therefore whether a doctor like Alastair can help then simply fill in your clinical details for free on our online form and let us help get you on the road to recovery.