The tendon is the portion of the muscle that attaches directly to the bone. It is less elastic than the muscle tissue and has significantly less blood flow as well.
In a healthy tendon, the fibers are aligned well and have a good mix of collagen that allows it to fulfill its function.
In an injured tendon, this alignment becomes more disorganized and tiny blood vessels try to penetrate into the tendon to provide nutrients and blood flow for the repair/healing process. (These small blood vessels are thought to be quite sensitive and a possible explanation for some of the chronic pain that comes from tendon injuries).
Normally, the tendon and most of the tissues in our body are going through a regular amount of both breakdown and repair (think like the top layers of our skin that are replaced by fresh skin on a regular basis).
When a tendon is unable to keep up with the regular breakdown of our tissues, it can lead to tendon injury. There are number of risk factors that are considered, such as:
- Advanced age
But you also need to consider the internal factors as well. This includes:
- a lack of oxygen and nutrients and
- the ongoing presence of inflammation,
Both of which adds stress to the system.
One theory is that while your body is trying to keep everything equal, these factors can push our tendons towards a tipping point - the rate of breakdown is greater than the rate of repair.
The tipping point is where you see a decrease in the function of the tendon.
This tipping point helps to explain how your rotator cuff or hip pain can develop gradually or spontaneously without doing anything different or special in your day.
The tendon did the best it could, until it couldn’t cope any further. And that’s when you first recognize the symptoms.
Love it or hate it, this is one of the first-line interventions that can provide changes to the tendon with almost no downside. What you may be happy to know is that there is no exact type of exercise that is better than the rest.
The most important factors appear to be
- keeping up with exercise long enough for tissues to change/grow and
- do something that is challenging enough to make the body work hard enough.
When compared to various surgeries and injection of medications, exercise does just as well in the long term. Exercise can be painful to perform at first, but this is not associated with any long term downsides that we know of.
Another powerful, but difficult to change part of your life. Avoiding diabetes and high cholesterol complications can be very important for tissue health. If this is well managed, it should be something that can be worked around.
Supplements are hard to recommend specifically. But you may hear of such things as
- Vitamin C
- Vitamin D
- Glucosamine and Chondroitin sulfate
According to research it is too soon to tell in a complex environment if these will have the desired effect.
Because the deepest parts of the tendon do not have much blood flow, taking medication by mouth seems to have a poor effect overall.
Injection treatments are encouraging, but require more study before they could be recommended for all cases.
Modalities like ultrasound, low level laser therapy (LLLT), and various other devices seem to be able to provide short term relief for some people, but more research is required to know how they best fit into the picture on a more general level.
It seems likely that this type of treatment needs to be used in combination with other aspects of care to get the best result.
We have just scratched the surface regarding active care of tendons.
There will be a following post in the future that goes deeper into the exercise models that currently exist for tendon rehabilitation.
If you have any questions or comments about today’s post please feel free to contact the office directly.
- Snedeker, J., Foolen, J. Tendon injury and repair - A perspective on the basic mechanisms of tendon disease and future clinical therapy. Acta Biomaterialia 63 (2017) 18-36.
- Escrichie-Escuder, A., Casana, J., Cuesta-Vargas, A. Progression criteria in loading exercise programmes in lower limb tendinopathy: a protocol for a systematic review and meta-analysis. BMJ Open 2019. Doi: 10.1136/bmjopen-2019-032940.
- Rio, E., et al. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med. 2016;50:209-215.
- Dean, B., Dakin, S., Millar, N., Carr, A. Review: Emerging concepts in the pathogenesis of tendinopathy. The Surgeon 15 (2017) 349-354.
- Van der Vlist, A., et al. Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. Br J Sports Med 2020;0:1-8. doi:10.1136/bjsports-2019-101872.
- Demeules, F., et al. Efficacy of exercise therapy in workers with rotator cuff tendinopathy: a systematic review. J Occup Health 2016;58: 389-403.
- Lociacono, C., et al. Tendinopathy: Pathophysiology, Therapeutic Options, and Role of Nutraceutics. A Narrative Literature Review. Medicina (2019) 55, 447.
- Lipman, K., et al. Tendinopathy: injury, repair, and current exploration. Drug Design, Development and Therapy. 2018;12 591-603.
- Larsson, R., Berhhardsson, S., Nordeman, L. Effects of eccentric exercise in patients with subacromial impingement syndrome: a systematic review and meta-analysis. BMC Musculoskeletal Disorders (2019) 20:446.