Top Strategies to Rehabilitate Tendons

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.

1. Do not rest completely
   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.

2. Do not rely on passive treatments
   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.

3. Do not have injection therapies as a primary intervention
   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.

4. Do not ignore your pain
   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.

5. Do not stretch your 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.

6. Do not deep massage your 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.

7. Do not be worried about the images of your tendon
   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.

8. Do not be worried about rupture
   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 depite the tendon having pathology in it and do not have that protective effect.

9. Do not take short cuts with rehabilitation
   The tendon needs to build its strength and capaticy. Things that are promised as cures often give short term improvement but the pain comes back.

10. Do not misunderstand what loads are high for your tendon
    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.