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The 4 Crucial Stages of Tendon Health- “ITIS” VS. “OSIS”

Have you ever battled against a terrible chronic tendon pain? Are you ready for it to be healed? The science of tendon care has progressed significantly! In the passionate study of the latest and greatest, we have found some clinical gems we would like to share regarding tendon pain.

 

TENDON TISSUE COMPOSITION: HEALTHY AND DEGENERATIVE

Tendons consist of dense regular connective tissue fascicles encased in dense irregular connective tissue sheaths. Healthy tendons are composed mostly of parallel arrays of collagen fibers closely packed together.  Degenerative tendons are highly viable tissue that are hyper-cellular.  Degenerative tendons are mechanically indolent so they cannot transmit load for sport or ADLs.

TENDINOSIS: A NON-INFLAMMATORY DISORDER

The pathology of tendinopathies is based on examination of surgical specimens and has been well described. Studies of the Achilles, patellar, lateral elbow, medial elbow, and rotator cuff tendons demonstrate that tissue appeared exceptionally consistent. Abnormal tissue examined at surgery shows the tendon to be dull- appearing, slightly brown, and soft. Normal tendon tissue is white, glistening, and firm.

Tendinitis really is a rare condition.  Distinguishing tendinosis from the rare tendinitis can be clinically challenging. Due to the fact that tendinosis is far more likely, it may be of most benefit to the patient to act initially as if tendinosis were the provisional diagnosis.

4 STAGES OF TENDON HEALTH

Of the four stages of tendon health, three are clinically relevant (2,3,4).

  1. Normal tissue that is reactive – this tissue is inflamed and is known as a true tendinitis. These resolve with the P.O.L.I.C.E. application and require no clinical intervention.
  2. Abnormal degenerative tissue that is non-reactive – this tissue is a pain free tendinosis. These require clinical intervention to regain functional abilities and avoid rupture.
  3. Abnormal degenerative tissue that is reactive  – this tissue is a painful, inflamed tendinosis. In other words, this is an “itis” on top of an “osis”.  These require clinical intervention to regain functional abilities and avoid rupture just like the pain free tendonosis do, but with regressive loads.
  4. Tendon rupture – To get back to full function, one would need proper surgical consultation to determine best intervention.

COMMON MISCONCEPTIONS ABOUT TENDINOPATHIES

 

PHYSICAL THERAPY PRINCIPLES

Rest is catabolic to the tendon and will turn the tendon to “mush” with excessive rest. Some of the other catabolic affects of rest include that musculotendinous strength drops, kinetic chain function deteriorates and motor drive changes for the worse.  Optimal load is the key to restoration of function.

The dominant factor to healing tendinosis issues is to get full restoration of painfree function through appropriate regression and progression of loads to the tendon.  Pain in tendons destroys kinetic chain function.  We change pain by improving function.  If we improve function through the strength of the tendon, improve the kinetic chain and increase motor unit recruitment, we almost always see an improvement in pain.

Tendon pain is aggravated by load and eased by unloading, but remember that rest of the tendon is catabolic.  Therefore, we must apply minimum effective dose to the tendon while avoiding max overload of the tendon.  These therapeutic loading techniques are built into our tendinopathy protocols.  We implement four phases to recovery with appropriate use of modalities and IASTM.  The phases are simplified for purposes of this article:

  • Phase 1 – Isometrics to reduce pain (used for reactive conditions).  3-4 times a day with 40-60 second holds.  Take away destabilization for this phase.  This also assists in reducing pain before performances due to reducing stronger cortical inhibition.
  • Phase 2 – Isotonic Strength can be utilized with pain settled in morning and reduced from peak pain levels. Integrate higher levels of kinetic chain function.
  • Phase 3 – Energy storage for tendon power.  Good strength and low to no pain must be present to begin this phase.  Plyometric loading and advanced kinetic chain function becomes crucial in this phase.
  • Phase 4 – Sports Specific / Elastic function for explosive performance and energy transmission.

It is nearly impossible to rupture normal tendon tissue. When a tendon ruptures that was asymptomatic, that is an indication that the tendon was asymptomatically degenerative. in fact, 66% of all ruptured tendons were asymptomatic when they ruptured. Therefore, degenerative tendons, whether symptomatic or not, require appropriate remodeling and strengthening through the above phases.

CLINICAL IMPLICATIONS

The following points are pivotal to skilled tendon management:

  • Unload the tendon from high loads
  • Therapeutic exercises to reduce pain
  • Kinetic chain intervention
  • Address co-morbidities
  • Very small incremental load changes because tendons are sensitive to change
  • Instrument Assisted Soft Tissue Mobilization (IASTM)
  • Painful Eccentrics
  • Modalities and drugs for anti-inflammatory AND vasoconstrictive benefits

TAKE HOME POINTS

  1. INFLAMMATORY CELLS ARE ABSENT IN PATIENTS WHO HAVE CHRONIC OVERUSE TENDINOPATHIES.
  2. THERE ARE 4 BASIC STAGES OF TENDON HEALTH.

    a. Normal, healthy tissue that is reactive

    b. Abnormal, degenerative tissue that is non-reactive

    c. Abnormal, degenerative tissue that is reactive

    d. Tendon rupture

  3. CLINICAL EDUCATION IS NECESSARY TO GIVE PATIENT REALISTIC EXPECTATIONS FOR RETURN TO ACTIVITIES.  MOST TENDINOPATHIES WILL REQUIRE 2-3 MONTHS OF STRENGTHENING, REMODELING AND TRAINING TO RETURN TO FULL FUNCTION.
  4. 80% OF PATIENTS WITH TRUE TENDINOPATHIES WILL BE ABLE TO FULLY RETURN TO ACTIVITIES WITH APPROPRIATE INTERVENTION.
  5. ACKNOWLEDGEMENT THAT OVERUSE TENDINOPATHIES ARE DUE TO TENDINOSIS, AS DISTINCT FROM TENDINITIS LEADS TO MODIFICATION OF PATIENT MANAGEMENT IN AT LEAST SEVEN AREAS.

    a. Imaging

    b. Patient education

    c. Biomechancial reloading

    d. Anti-inflammatory strategies

    e. Load-decreasing devices

    f. Interaction with the physical therapist and physician

    g. Appropriate strengthening

  6. REST IS CATABOLIC TO THE TENDON