Let’s Talk Tendons
On this week's episode of The Dance Docs I am joined by Dr Kathleen Davenport MD to dive a little deeper into those nagging tendon injuries. Helping you to better understand what may lead to a tendon overuse injury, why many clinicians are using the term tendinopathy over tendonitis and discussing what are the current treatment methods being used in the medical community.
What is a tendon
Structure that attaches a muscle to the bone
Not to be confused with ligament which attaches bone to bone
Tendons are non contractile tissue composed of collagen fibers- very strong
Think of this structure more like a rope that can be pulled on to create movement
Not as flexible as a muscle
Helps to absorb shock and limit potential damage to the muscle
Assists in the elastic recoil
Ex: landing from a jump- as the calf muscles/achilles tendon lengthens energy is stored within the tendon to help with the elastic recoil/rebound- initiating plantarflexion power
Tendons have limited blood supply
Can affect healing potential of the tendon
What kinds of tendon injuries do we see as clinicians
Tendonitis or tendinopathy
Itis- an acute injury (recent injury)
Osis- a more chronic injury
Many people use itis/osis interchangeably but they are slightly different
Tenosynovitis- inflammation of the synovium/sheath surrounding the tendons
Partial tear- acute injury or chronic injuries
Think of a Broom- some of the bristles are bent or missing. It still works but not like a new broom
Full thickness tear
Handle of the broom has broken off completely
Often acute on chronic
Many times there is a long term tendinosis going or some underlying pathology
Tendinopathy/Tendinosis vs Tendonitis
Tendonitis means there is an active inflammatory response going on- usually only last 48 hours- pain that continues to persist for days/weeks/years is most likely not due to acute inflammation
Tendinopathy/Tendinosis- Non-rupture injury to the tendon that is exacerbated by mechanical loading
looks at the tissue level and the degeneration of the collagen that forms the tendons.
When tissues in your body are stressed there is usually some micro damage and your body is constantly working to repair the tissue. When the loading occurs at a faster rate than your body can repair this is where the increased breakdown occurs, and we begin to notice pain in the area.
Think of your tendons like house plants- need to give them the appropriate amount of water at the appropriate time for them to thrive
Lack of muscle tone/strength
Muscle belly is not ready to take on the demands of the activity-
Tendons are like a rope- not as pliable as a muscle belly
Do not have as good of a blood supply
What causes Tendinopathy?
Sudden overuse/stress to the tissue ← tendonitis
Nutcracker season
Competition season
New repertoire- stress that the body is not used to
Coming back after time off
Age- more likely to see further degeneration in an older dancer
Change in dance floors/surfaces
Change in footwear-
Pointe shoes that are cut down too low on the sides- FHL tendon issues
vamp is too low or too high
Shoe should support the foot
Weakness in other areas causing overload of tendon
Want to be assessing the dancers full system, not just treating the tendon that is aggravated
Dr. Kats experience in working with dancers with achilles tendinopathy there is usually a weakness in glut med/ poor functioning at the hip
Achilles tendon improved with focusing load at the hip to improve load distribution
Also bilateral tendon issues look into the back
Want to catch these early so that you can limit time off
What is actually happening at the tendon level
Normal Tendon
Tendons that can appropriately handle load
Reactive tendon
Tendon that is irritated, painful, but does not have any significant tearing
May feel thicker to the touch
Degenerative
Partial Tears (part of chronic degeneration)
Weaker tendon
Don’t remodel as easily
Decreased stiffness
Increased cellular turnover
Often seen reactive on degenerative in an older dancer
Not always painful in the degenerative stage
When we look at this closely it consists on a continuum cycle where someone can move between the states
Common areas and tendons affected in dancers
Foot/ankle
Achilles Tendon
FHL
Tibialis Posterior
Knee
Patellar tendonitis
Hip
Psoas
Glut med/min
Proximal hamstring
Shoulder
Rotator cuff
Supraspinatus
Bicep
Thumb and Elbow
Can we treat all tendons the same
NO, there are so many variable
Depends on the load required by that tissue
Tendon treatment is not just tailored to the tendon but to the individual needs. Example: A shoulder tendon in a female classical ballet dancer that requires overhead movement but not lifting is different than a male classical dancer who requires overhead lifting.
Depends on the tissue phase and level of reactivity
Reactive tendons
Tend to respond quicker
Pain relief
Modified loading
Reactive degenerative tendons
Take longer to heal
Pain relief
Loading slower
Treating tendons is not an exact science
Have wot work with the individual in front of you
May have a day when you load the tendon and cause an increase in pain
Recovery is not linear
24 hour rule
When we work its ok to notice or feel the tendon during treatment or activity
When you get up the next morning is it back at your baseline pain level or better?
Then the load was appropriate
If still painful the next day the load was too much and we need to back off
2 pain levels
Your pain can go up 2 pain levels during activity and then need to back off or stop to bring pain back down
Follow the 24 hour rule
Does pain return to baseline or better the following morning
When can I keep dancing with Tendon pain vs when should I stop?
Want to address earlier when it is in a reactive stage and we can focus on managing loads
May need to decrease activity into pain free range/activities
Load tendon appropriately, and increase strength of the muscle
Progress back to full activity
What is the treatment of choice for a medical doctor
Conservative management?
Medications
Anti Inflammatories
Topical or oral
Fix the trigger-activity modification
Physical therapy
Injections if needed
When do we consider an injection for tendon
Cortisone - inflammation, bursitis, tendinitis, short term
Not always available pending tendon requirements/location due to risk of rupture
May do but require time off and immobilizes
Do not want to use to mask pain
Platelet Rich Plasma (PRP)
Placing platelet cells directly to affected area to induce a - healing response
Research is showing good longer term results
Usually requires time off as well as therapy
One downside is that a PRP injection can increase pain short term
Try not to do these during peak season
What is the research like for tendons
Growing, but surprisingly weaker than you would think given that these are extremely common
When might someone consider a surgical approach
Non-healing/failed all conservative approaches
Full thickness tear without ability to compensate
Understand soft tissue surgeries tend to have longer recovery times
Need therapy to gradually load and stress that area
PT approach to Tendinopathy
What was the treatment of choice
Eccentrics, STM, US, estim
What is the current treatment of choice
Varied based on the patient
Level of reactivity
Isometrics
Low load high volume
Heavy slow resistance
How to dose a muscle/tendon for tendinopathy
Coming up in next episode
Bilateral tendonitis is a red flag that there is an issue higher up
B achilles tendon issues usually coming from the back.
Always check the whole kinetic chain on both sides
many times the problem is not where the pain is
Pain just says that something is wrong- your job as a PT/MD is to use your evaluation skills to determine where the initial breakdown is happening.
If you have any questions on this topic or another please contact us at thedancedocs@gmail.com or at www.thedancedocs.com/contact
In Health,
Dr. Kat Bower PT