05 Jul To Rest or not rest – Tendons
Written By Megan Hunter
Let’s talk tendons. I have to admit I procrastinated on writing about tendons in this blog series as are they are bit of a beast. So much so that several Physiotherapists in Australia specialise in predominately treating and researching all things tendon – and as a side note have really punched their weight for tendon knowledge around the world.
What I am about to dive into is an explanation of how I have conceptualised tendons in my head to help simplify a complex process. I hope you find it helpful in understanding tendon injuries but take with a grain of salt as I am only scratching the surface.
As a fundamental structure, tendons attach muscle belly to bone. However, they aren’t just a passive connection they provide a mechanical contribution to movement. I think about tendons like a rubber band. Elastic and springy, tendons are designed with specific fibres, proteins and water to store energy (like stretching a rubber band) and release energy (like the band recoiling) to contribute to movement.
Tendons sustain an injury via three main mechanisms; 1) acute overload – one load larger than the tissues capacity is applied to the tendon causing a rupture of differing degrees (full, partial etc), 2) chronic overload e.g. a large increase in load all of a sudden. Remember that in a lot of structures loading results in “micro-strain” and if left to recover this is helpful for the tissue to adapt but if loaded too much too soon can result in “breaking down” over “building-up”. And finally 3) compression. There are parts of the body where tendons can be compressed against the bone and we have found in recent years that they are particularly sensitive to that – especially if the tendon is loaded in a compressed position.
Back to the rubber band – no matter which mechanism has caused the “injury”, changes to the fibres, proteins and water content of the tendon as a result of the injury mean the tendon loses some its ability to stretch and recoil like our normal rubber band. Outside ruptures, which are obviously treated differently, chronic overload and compression type tendon injuries tend to be grumbly, last of a long time and be quite painful.
When I started this blog series about rest, it is the tendon clients I was thinking about in regards to “I rested for a bit but when I went back it still hurts”. Rest is definitely not best for tendons. Even if rest helps settle the pain it is often right there, annoying you, when you go back to activity. We think this is in part because rest does nothing to restore the tendon’s normal rubber band like mechanical properties. This has to happen through load. While tendons are incredibly complex, there are usually some simple places we can start in regards to recovery. One of the biggest mistakes people make is not allowing enough time to build up painful activities. It may take a while and test your patience but a lot of tendons respond well to reducing load below the level that aggravates the tendon and GRADUALLY building up. This beginning load is different for every single person and every single tendon but is guided by pain during, after and within 24hrs following loading. If the pain increases during any of these times, then the activity likely too much and needs to be reduced.
The other common mistake is not having enough respect for how much/what type of load a normal healthy tendon cope with. In running the Achilles tendon can be coping with force equivalent to 6-8 times body weight. The rate of loading is also important, with higher rates associated with higher levels of pain. Studies have now begun to explore the recommendation of being able to single leg calf raise or single leg press (depending on whether it is an Achilles or patella tendon issues) 1.5 x body weight before introducing jumping/hopping/running back into rehab. How many of you have achieved that before starting back into the aggravating activity again?
With compression type tendon injuries – a simple recommendation is to stop compressing the tendon although this is easier said than done. With Gluteus Medius/minimums tendon pain (at the side of the hip) avoiding hitching the hip when standing and crossing your legs can help in reducing sustained compression of the tendon onto the greater trochanter. For the peroneal tendons around the ankle this might involve avoiding calf stretching/excessive dorsiflexion positions where the tendon may be compressed against the lateral malleolus. After a very long post – we can conclude that rest is not best for tendons. Modifications to positions and loads may need to be made BUT the only way to get out rubber band back it to load it!
Cook, J L, & Purdam, C R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409-416.
Cook, J L, Rio, E, Purdam, C R, & Docking, S I. (2016). Revisiting the continuum model of tendon pathology: What is its merit in clinical practice and research? British Journal of Sports Medicine, 50(19), 1187-1191.
Malliaras, Peter, Cook, Jill, Purdam, Craig, & Rio, Ebonie. (2015). Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. The Journal of Orthopaedic and Sports Physical Therapy, 45(11), 887-898.