We’ve all heard of someone who has tendon problems – usually the achilles or patella tendon, or the more common upper limb equivalents: golfers and tennis elbow. And whilst the plantar fascia is more of a thickened fibrous ligament type tissue, it has similar properties to tendon and is just as common as the above conditions which just as frustrating (and slow) healing processes. Anyone who has experienced the above will know that these problems do not last days, or even weeks, but nearly always involve months (and sometimes years) of pain and dysfunction. In the first of this five part series, we’ll take a look at why these tendon problems are never easy to get better.

So what makes tendons such a nasty problem to deal with? Well, the first part of this blog series revolves around the question “Why did I develop this tendon problem?” as it’s only through understanding this component that we can embark on a rehabilitation process.

There are some factors that leave a person susceptible to tendon pain – previous injury (especially previous tendon injury); age; gender; weight gain; reduced ankle mobility and many more. But there’s one that we keep returning to as the most common cause of tendon pain in active people: training error!

There are many different training errors that can occur, but one of the greatest causes of tendon pain is a sudden spike in activity (or what we call “loading”) of the tendon. Whilst many people present to us saying they don’t know how their pain developed, when we delve deep into the history there is often a story of: sudden spikes in training frequency/intensity/duration; too rapid an increase in training; returning to activity after illness or long layoffs; change in loading type (changing method of training/sports); or changes in training technique.

Research indicates that tendons do not respond well to these sudden increases in load, or changes in demand. In fact, we often use a “maximum of 10% increase” rule in terms of guiding progressions in training/rehabilitation in people with tendon pain. Think about this – if you are running 10km relatively pain free following an Achilles injury, this may mean we only want you to progress to 11km (and not to think “I feel great, I’ll increase to 15km!”). Whilst the extra 5km doesn’t sound a great deal (particularly if you were used to running much greater distances), an injured tendon may really flare with this 50% increase in loading.

When we exercise, we are breaking down cells in our tendons, creating a chemical reaction that facilitates a healing process, leading to repair and adaptation of the tendon to that particular load. Tendons (especially painful ones) need a little longer for this reaction and healing process to occur. And as we get older this repair process takes even longer, perhaps explaining why age is such a risk factor in the development of tendon pain. So if we return to training or activity too soon, or place excessive training load on the tendon (before the tendon tissue has repaired and adapted) it may break down further. Not only is training error an issue in terms of excessive activity levels, but training error may also involve returning to training too soon. One of the problems with tendons is that the pain often eases well before the tendon has regained its capacity to absorb and tolerate loading, lulling people into a false sense of security. Therefore pain is not always the best guide when deciding when and how to progress.

To make things even more complex in tendon rehabilitation, complete rest in the rehabilitation phase has also been shown to be almost as ineffective as too much activity (but more of that in one of the next editions).

So the take home message from this first blog is that training error is an extremely common reason behind the development of tendon problems – it’s the old “too much too soon” scenario. And training error not only is a major cause of the development of tendon problems, but it is also applies just as much to exacerbations of pain when people are on the comeback trail. Two critical factors to remember are firstly that tendons do not tolerate sudden increases (more than about 10%) in loading, and secondly, that pain is not the best predictive factor when determining when and how to progress.

In the next blog on tendon pain, we’ll take a look at the relationship between imaging (scans) and tendon rehabilitation prognosis – a really interesting topic!

Anthony Lance

SSPC Physiotherapist

(references will be listed in the final blog).