For those with a tendon injury, the athlete or non-athlete, an injury to a tendon is frustrating and begs the question ‘how did this happen?’ When, where and how are all questions that are elusive to the tendinopathy sufferer and can puzzle the treating physiotherapist.
In my first article on the new and current understanding of tendon, the structure and function of the tendon was discussed. The state of flux that a tendon exists in is known as the “Continuum Theory of Tendon Health and Performance” (Cook et al 2009). This theory has the concept of ‘load’ as the key component of tendon health and performance. The tendon needs to have mechanical loading of sport and daily activities for maintenance of its structure. A healthy structure of a tendon directly contribute to the body’s capability to handle sport and daily activities. Therefore, the ability for a tendon to handle load is not fixed but dependent on the training or regular work that a tendon is subjected to.
The below factors are what can cause an injury to a tendon.
1. Overload
An injury to a tendon occurs when there is overload of force, i.e., the amount of force received by a tendon is beyond the tendon’s capacity to manage. The force may be a shear force, a tensile force, or too much compression.
Shear force is a force acting in a direction that's parallel to a surface. An example is the pressure of air flow over an airplane wing. The word ‘shear’ indicates that such a force can cut through the surface or object under strain.
Tensile force develops when there is a stretch shorten cycle such as with jumping or falling onto the tendon.
Compression force is when a force presses inward on to the tendon and caused it to become compacted and thereby limits its abilities.
The worst strain on a tendon is compression with a tensile force (Canosa-Carro et al 2022)
A diagram of the different kinds of forces
Masci L (2020)
2. Anti-inflammatory medication
Some inflammation is needed for the development of an increased load that a tendon can manage. Anti-inflammatories taken during exercise prevent any collagen synthesis from being made. Magnusson et al (2019) state that ‘a rise in inflammatory mediators is important for collagen turnover and for tendon adaptation to exercise’.
3. Insufficient rest time between workouts
Tendons take 36 hours to recover form exercise. It is therefore important to give a day’s rest between workouts of areas of the body.
4. Antibiotics
Fluoroquinolones are broad-spectrum antibiotics used to treat bacterial infections. This antibiotic is often prescribed for urological, gastrointestinal, respiratory, sexually transmitted, skin and soft tissue infections. It has been shown that consumption of fluoroquinolones is related to the development of tendinopathy and tendon rupture.
5. Corticosteroids
If corticosteroids are taken concomitantly with fluoroquinolones, then the risk of tendon injury dramatically increases. In one study 50% of tendon rupture patients had had recent use of corticosteroids.
6. Statins
Statins are used for lowering cholesterol in the blood stream, and these have been associated with tendonitis and tendon rupture.
7. Aging
Research on the effect of aging on tendon health is inconclusive. Magnusson et al (2019) writes that given that there is limited research data on older human’s tendons, that it is difficult to firmly conclude anything about the effect of age on tendons. However, it may be that the change in tendons of older people is because of the related inactivity associated with aging rather than the aging process itself.
Physiotherapists ask about a person’s medical history and current prescribed medication as this information gives clues as to how the injury to the tendon may have occurred. This may not help the presenting injury but is important in preventing future tendon injuries. An analysis of a person’s sport, work and hobbies provides information of the different kinds of forces that this person’s body is working with. Checking a person’s work set up or the suitability of a chair for a person is called an ergonomic assessment. A functional sports assessment may be done in the physiotherapy practice by recreating the forces similar to that a person is subjected to in their chosen sport. However, video clips or a visit to the person’s sport’s facility can be beneficial.
References
1. Breda SJ et al (2021) Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. J Sports Med, Vol 55, 501–509.
2. Bullock GS et al (2021) Clinical Prediction Models in Sports Medicine: A Guide for Clinicians and Researchers J Ortho & Sports Physical Therapy, Vol 51, No 10, 517- 526
3. Canosa-Carro L et al (2021) Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Accessed 28/03/2023
4. Clifford C et al (2020) Effectiveness of isometric exercise in the management of tendinopathy: a systematic review and meta-analysis of randomised trials.
5. BMJ Open Sp Ex Med 5:e000760. doi:10.1136/bmjsem-2020-000760 file:///C:/Users/User/Documents/OMTPG/Tendonopathy/Tendinopathy%20article%201.pdf Accessed 28/03/2023
6. Cook J et al (2009) Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 43:409-416
7. Cook et al (2016) Revisiting the continuum model of tendon pathology: what is its merit in clinical practice. Br J Sports Med 50:1187-1191
8. Cook J et al (2019) Managing Difficult In -Season Tendinopathies. Aspetar Sports Medicine and Science in Athletes Targeted Topic pg 268-271 www.aspetar.com/journal Accessed 28/03/2023
9. De Vos et al (2021) Dutch multidiscipline guideline on Achilles tendinopathy Br J Sports Med 55,1125-1134 https://bjsm.bmj.com/content/55/20/ accessed 24/06/2023
10. Hanlon S L et al (2021) Beyond the Diagnosis: Using Patient Characteristics and Domains of Tendon Health to Identify Latent Subgroups of Achilles Tendinopathy J Ortho & Sports Physical Therapy, Vol 51, No 9, 440-448
11. Jones LE et al (2014) The Pain and Movement Reasoning Model: Introduction to a simple tool for integrated pain assessment Manual Therapy Vol 19, Issue 3, Pages 270-276
12. Magnusson SP et al (2019) The impact of loading, unloading, ageing and injury on the human tendon J Physiol 597.5, 1283-1298
13. Masci L (2023) Tendon Neuroplastic Training: More effective rehab for tendonitis https://sportdoctorlondon.com/tendon-neuroplastic-training-more-effective-rehab-for-tendonitis/ Accessed 22/04/23
14. Masci L (2020) How to treat tendonitis from a tendonitis specialist https://sportdoctorlondon.com/tendonitis-specialist/ Accessed 22/04/23
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