Most of us do not use the whole tendon so when there is an injury to fibres of a tendon we can facilitate other fibres in the tendon to take over and, even, come out with a better functioning tendon. This approach has been nick named “treat the donut not the hole’, i.e., the Donut Theory.
When you train a structure, it is widely recommended to match the exercise to the function and behaviour of this structure and to include exercises that mimic the variety of ability and operative role unique to this structure. We know that a tendon is able to transfer force, store and release energy, and that it needs to have strength, stiffness and elasticity. A good example of this was shown with Hanlon SL et al (2021) research showed that patients with Achilles tendinopathy could be divided in to three groups and that for each group a different intervention programme was more suitable and would likely be more effective.
It is important, when advising corrective exercises to consider the stages of healing and to treat the tendon with the stage of healing in mind. In the reactive stage (the first stage of injury to a tendon), the load must be reduced. In the following two phases of healing for a tendon; Tendon Disrepair and then Degenerative Tendinopathy, the load is gradually increased.
The type of exercise is crucial; eccentric exercise is the gold standard of treatment for a tendinopathy (Canosa-Carro L et al 2021). Eccentric exercise means that the muscle lengthens with the resistance being greater than the force the muscle is producing, e.g., weight is slowly lowered in a controlled, smooth manner. Recent research has shown that twelve weeks of heavy slow resistance exercise was success to improve the tendon’s function.
Most clinicians would advise those suffering with tendinopathy to cease concentric exercise, i.e., the muscle tension rises to meet the resistance, then remains stable as the muscle shortens. (With concentric exercise the muscle shortens as tension is produced.) However, Breda SJ et al (2021) found a trend towards a higher return to sports rate with a progressive tendon loading programme of exercise. This approach can be considered if a programme of prescribed eccentric exercises has failed to resolve the tendinopathy.
Currently, much is being said about the healing benefit of isometric exercise, i.e., when the muscle produces a force without a major change in muscle length and joint movement. Cook J et al (2019) have found that pain reduction can be achieved by isometric exercise of a challenging weight (70% of maximal voluntary contraction of 45 seconds hold, repeated 5 times).
However, any form of exercise is effective (Clifford C et al 2020) and useful even when the injury has been longstanding. (Breda SJ (2021). The goal of current clinical management is to personalise treatment approaches to adapt them not only to the specific structure but also to the many different needs of the population. (Canosa-Carro L et al 2021).
Time frame for recovery:
Expect to do 12- 24 weeks of an exercise programme for good results. Some tendons take 6 - 12 months to recover and some longer than a year. The load and weekly increase percentage of increase of load is about 10% per week. Be reassured that exercising will help and not harm for a tendon seldom ruptures when there is pain present.
It is not thought to be true that aging prevents the recovery of tendons. Evidence supports the recovery of the mechanical properties’ tendons with aging.
Surgery can be considered, however, “the extent to which tendon structural changes are reversible in response to non-surgical and surgical treatments is still being debated (Hanlon et al 2021).
Take care not to be discouraged with the slow time frame of recovery for tendons; the tendon response to loading is slow and is not normalised until sometime after 6 - 12 months after injury. Half of the patients with random controlled studies are still symptomatic after a year, presenting limitations in their daily live activities. However, being disciplined and consistent with an exercise programme, a programme that is customised for the individual, the chances of a quicker and more effective the recovery are increased.
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.