Tendons can be notoriously annoying to heal. They are white tissue, so like ligaments and cartilage they heal slowly due to relative lack of blood flow, unlike muscles that heal relatively quickly because they have much more blood flow. Many of the strategies we have used for years have recently been shown to inhibit tendon healing, unintentionally, due to tendons requiring different guidelines.
Jill Cook is a physiotherapist who has specialized in musculoskeletal research, particularly in tendons with her primary interest being connective tissue function, injury, and healing. She has a list of 10 guidelines to help maximize a person’s recovery and conditioning of a tendon to regain optimal health.
Resting completely decreases the ability of the tendon to take on load - they need to be used. Instead we need to reduce loads on the tendon to the level it can tolerate with minimal pain and then slowly increase it.
Current research shows that treatments that do not address the need to increase the ability of the tendon to take on load are not usually helpful in the long term.
Current research indicates that injections of substances into a tendon have not been shown to be effective in good clinical trials. Do not use them unless the tendon has not responded to an exercise based program.
Pain is a way of telling you that the load is too much for current healing and that we need to reduce the aspects of training that are overloading the tendon.
Though it may seem counterintuitive, we know that stretching a tendon to end range adds a compressive loads that we know is detrimental to the tendon.
A painful tendon is one that is telling you that it is overloaded and irritated. While very light massage can assist in relaxation and blood flow, deeper massage can further insult the tendon, increasing pain and tearing apart newly healing fibers.
There is evidence that the pathological tendon can tolerate loads, especially when you gradually increase the loads. MRI or US findings often have false positives and tendons that look deteriorated can still handle functional loads.
Pain is protective of your tendon and it causes you to decrease the force you’re putting on it, protecting from rupture. Most people who rupture a tendon have never had pain before despite the tendon having pathology in it and do not have that protective effect.
The tendon needs to build its strength and capacity. Things that are promised as cures often give short term improvement but the pain comes back.
The highest load on your tendon is when you use it like a spring (jumping, sprinting, etc.) Other loads are low load for a tendon and do not fully rehabilitate the tendon, although they can have a beneficial effect on the muscles. To get full function we have to use high loads towards the end of therapy.
All tendons heal slowly - there are no verified safe shortcuts to building tissue tolerance and strength. Lack of patience combined with lack of appropriate loading are the most common reasons we see people return to clinic with “chronic” tendon injuries, although the other points are just as important.
Due to the slow healing process and tendency to overload a tendon during that healing process, a thorough evaluation of both the tissue and the forces one puts on that tissue through how they move is critical to designing an effective treatment plan to lead to tendon recovery. Not all tendon injuries are the same...and quite frankly most vary significantly in how chronic they are, how degraded (or not!) the tissue is, and how much force we can safely put on the tendon without causing repeat or further damage. If you have questions, contact us for a free phone consult!
