If you play competitive sports you have felt the inevitable pains that can come with too much activity. Often these pains are felt in our tendons.

Tendons transmit forces between muscle and bones. We don’t yet fully understand tendon pathology (the injury process), but research is providing greater clarity. I believe the following three points are a good place to start:

1. A tendon injury appears to be caused by a combination of high load and high stress during a stretch, shorten cycle. The shorter the cycle and the higher the force the greater the strain on the tendon. We see this in sports like squash, basketball, and running. There can be other causes for tendon pain and it is crucial for a physio to clear other potential diagnosis.
2. Exercise is the only “drug” that promotes collagen growth. The gold standard treatment for tendons is better load management. This includes physical loads, neurological loads, social and psychological loads, and lifestyle loads. Some may argue that PRP (platlet rich plasma) stimulates growth but the mechanisms of how this works are still not fully understood or proven. Although many stakeholds would like PRP to be proven it is still not advisable for tendon rehab (yes I realize every athlete does it but this does not mean it works…far from it). See here, here, and here.
3. Tissue turnover is slow compared to muscle. This can lead to a slower recovery and resolution of pain. Programs that last 12 + weeks are normal and a full resolution may take up to a year.

Like other injuries in the body it is important to remember that pain is not always a good indication of tissue damage. This knowledge is crucial because it encourages patients to stay active even in the face of pain. A patient shouldn’t blindly ignore their pain but they are allowed to “poke the bear.” Furthermore, we must remember that social, psychological, and lifestyle factors can help or hinder the healing process. As the picture below describes, pain is an experience that has many contributing factors.

Different contributors to the pain experience.

For squash players (or most athletes) the most common cause of pain is due to an in-balance of load and recovery. Quite simply, the tendon was inadequately prepared to meet the demands of the sport.

The rehab process:

There are many things to consider in the rehab process. A simple place to start is to identify training pitfalls and measuring baseline load tolerance. In most cases I include both local tendon exercises (ie calf raise) and general full body exercises. A reduction in squash is sometimes advised. In these cases it is imperative for the athlete to find other forms of exercise. A rehab pitfall can occur if an athlete rests too much during a pain episode. This not only reduces the tendon’s capacity to heal it weakens the entire body. When a patient yo yos between rest and activity they are inadequately preparing their tissue for the high demands of their sport. The graphs below show the yo yo effect and the more gradual and preferential return to sport.

Rest periods followed by high level activity is a poor choice for rehab.

A more gradual return with a smart combination of rest, education, activity modification, and strength.

With this in mind an activity ladder and pain scale are useful constructs to guide exercise choice and load progression.

Each tendon and each person needs a unique plan but a typical gradient looks something like this:

From low load to high load:) General to specific.

1. Isometric (activation with no movement)
2. Slow strength ( isotonic or simple strength)
3. Dynamic / energy storage (add more movement and speed)
4. Sport specific / energy storage and release (transition to sport specific and greater speed)

This video displays example progressions and educates using the above diagrams.

A workout like this as an alternative to squash.  This is by no means prescriptive but it paints a picture of what rehab might look like!

During an assessment I will also try to distinguish between different tendon problems:

1. Is it an energy storage or stabilizing tendon – achilles vs hip?
2. Is it acute or chronic – Did this happen suddenly or over time?
3. Is it degenerative or acute – how might age being affecting your tendon?
4. Is it an upper or lower limb – this distinction changes how much pain you work into.

With all this mind I would like to end with two important statements.

1. Adherence to a good loading program is the single best thing you can do for your tendon.
2. During a painful episode I encourage my clients to work harder than their periods of “perfect” health…we have to be smart but we should take the challenge head on and work hard:)

Thanks for reading

Dave Carter

ps – a great picture from PT Erik Meira

Check out his blog: https://thesciencept.com/just-load-it/