Tendinopathy Explained

Tendinopathy is the term we used to describe a tendon that exhibits signs of structural disorganisation on imaging studies such as ultrasound. The term tendinopathy was coined as a replacement for the more commonly known term- tendinitis. The term tendinits dropped out of favour once it was discovered that clinical presentations of pain in or near a tendon, tend not reveal the presence of inflammatory markers within tendon tissue. In other words tendon problems are generally not inflammatory in nature- so the use of the term tendinitis, which infers the presence of inflammation has been considered inappropriate. Confounding the issue is the fact that while a tendon may itself not be inflamed, the lining on the tendon, known as the tenosynovium, can become inflamed.

So we can have a tendon which shows sign of disorganisation under ultrasound, which would justify the use of the term tendinopathy. And we can have an inflamed lining of the tendon, which we would label as a tenosynovitis. Sounds confusing? Yep- It doesn’t need to be, but unfortunately as science drives knowledge forward, it often leaves a trail of outdated and redundant terms in its wake. And often these terms take a hold in the common vernacular. This is unfortunate and confusing for patients but probably unavoidable.

My hope in writing this piece is that if you have a tendon injury, or if you have pain in or near a tendon, you can better understand the different diagnostic terms that you’re likely to hear if/when you seek out information or treatment. I hope that we can cut through some of the confusion and provide a framework for understanding how to recover from tendon injury, tendon surgery or tendon pain.

Should we call it a tendinopathy or tendinitis?

Technically, it is more correct to use the term tendinopathy for the reasons provided above. But the term tendinitis has been used so widely and for so long that it isn’t likely that it will stop being used. The bottom line is that from your perspective as a patient, it is really only a matter of semantics. I say this because the treatment we carry out for tendon problems is much the same, regardless of whether we call it a tendinitis or a tendinopathy. I suggest that we leave the nomenclature to the researchers and focus on those aspects of symptoms that we can affect in the treatment setting.

Ok, then how do we treat tendon problems?

There are basically three phases of treatment to follow. The first is a “desensitizing phase” where the focus is on activity modification. Essentially, if you’ve got a symptomatic achilles tendon, or tennis elbow, or golfer’s elbow, rotator cuff tendon problems, the main reason there is pain, is that the nerve endings that are plugged into the tendon have become highly sensitized. This means that loading the tendon is more painful than it would normally be.

In order to normalize the sensitivity of the nerve endings within and around the tendon tissue, we need to stop subjecting it to loads that will continue to keep the system sensitized and irritated. Identifying the activities that we need you to back off from can be tricky, and may require a bit of trial and error. We don’t always need to cut activities out altogether, it may be sufficient to simply modify how you perform an activity. Or it may be a matter of modifying how long or how often you carry out the aggravating activity. Manual therapy to the soft tissues and joints near the symptomatic tendon can also help to reduce the sensitivity to loading. So the initial desensitizing phase usually comprises a bout of manual therapy over a couple of weeks in parallel with some modifications to those daily activities that we suspect are maintaining an unnecessarily high state of sensitivity.

What happens after the sensitivity has been normalized?

Usually your symptoms overall will be much less severe. At this stage we begin to expose the tendon to load again with exercise. The idea is to reintroduce load to the tendon gradually, so as not to trigger another increase in sensitivity. The most sensible way to do this is to start with low loads and build up gradually. It’s also important to load your tendon tissues in such a way that they are more likely to respond favourably. Tendons generally respond well to tensile load (like someone pulling on a rope), as opposed to transverse load (like someone stepping on garden hose). Determining which exercises are appropriate for your condition can be tricky. We need to consider the biomechanics of nearby joints and how this plays into the load profile that is placed on a tendon during a given exercise. For some conditions, such as achilles tendon problems, we have some reasonable protocols to follows. For other body regions, getting this part right can take a little experimenting and progress may be slower.

What’s the third phase?

The third phase of tendon rehabilitation is a guided return to pre-injury activities. Essentially, it is the transition from rehab exercises to those occupational or sporting activities that you’ve been avoiding during phases one and two. For some people, returning to these activities is not a problem. For others, there can be flare up of symptoms. If this is the case, we need to respond quickly and discuss longer term options. Is the activity necessary for your sport or occupation? Can we modify how you perform it in the long term? Can we manage how often or for how long you perform it in the long term?

If you’ve been diagnosed with tendinitis, tenosynovitis, tendinopathy, golfer’s elbow, tennis elbow, rotator cuff impingement, runner’s knee or plantar fascitis, your symptoms should respond well to the management approach outlined above. While some of these conditions can require surgical or medical intervention, the need is quite rare. All of these diagnoses are driven, at least in part by sensitized nerve endings in and around the affected tendon tissue. If it doesn’t bring about a resolution of symptoms, tidying up such sensitivity will at least provide a clearer clinical picture to guide a progression to medical or surgical management. For more information give us a call 9665 9667.


Core Stability

The concept of “core” strength and it’s role in back pain and rehabilitative exercise programs emerged from research carried out in the early 1990s. The popularity of core stability training soared as this research made its way into the practice patterns of clinicians and trainers throughout the 1990s and into the 2000s. The message that has long since been propagated is two fold:

  1. that a weak core predisposes one to lower back injury and pain

  2. that the resolution of back pain is contingent upon strengthening of the core

We now know that there is more to back pain than what is implied by these two propositions… things just aren’t that black and white. The utility of the core stability concept is also hampered by inconsistencies in the operational definitions of the “core” across and within health and fitness professions. Some will define “the core” as it was initially described in the research by Paul Hodges. That being the canister formed by the diaphragm, transversus abdominus and the pelvic floor. Others will describe “the core” as including all the trunk muscles, hip and buttocks muscles.

We can’t really say that a “weak core” causes back problems, or that we need to “work on the core” to fix back problems, because we can’t even agree on what we mean when we talk about “the core”. And even if we could agree on a definition, back pain is a really complex phenomenon. Reaching agreement on what constitutes a “weak” versus a “strong” core, and then linking that to one’s back pain in a cause / effect manner is very challenging.

So where to from here? 

The one thing we can be pretty sure about is that exercise helps people with back pain. So I think it makes sense for back pain sufferers to engage in an exercise program of some sort. The specific type of exercise one chooses to engage in really boils down to personal preference. The research is generally equivocal when it comes to asking the question “which type of exercise is the best for back pain?”

I guess we could say that “core exercises” are a type of exercise for back pain. However, since there are varied definitions of what constitutes “the core”, we see different types of programs emerging in the exercise rehabilitation scene. The different types of exercise programs sit on a spectrum ranging from very specific, targeted transversus abdmominus training, to more global trunk, hips and buttocks training.

Specific training of the transversus abdominus

The exercise programs that have been developed to train the transversus abdominus (and other groups such as lumbar multifidus, horizontal fibres of internal oblique) in isolation, perhaps with the assistance of real time ultrasound, provide patients with a novel perspective for understanding the role of motor output in their back pain. I think there is value in the process of learning how to be more aware of what it feels like to contract some groups of muscles near the spine, but not others. People with lower back pain are often very sensitive and reactive to movement or loading of the spine. I suspect that the gentle, small amplitude, low effort movements that characterise specific transversus abdominus training sharpen one’s awareness of movement in the lower back and help restore normal sensitivity to movement in the lower back.

I tend to prescribe this type of exercise to back pain patients who are still in an acute or perhaps just into subacute phase following a recent episode of low back pain. I think it’s important to reiterate though, that I don’t think the benefit lies within “strengthening” of any particular muscle group. Rather, I argue that when this type of thoughtful movement helps with symptoms, it has helped because the movement brought about a reduction in protective tensioning of the trunk musculature. Very often, my focus for the acutely painful lower back patient, is gentle, very low load active movement of the spinal segments in multiple planes, without any particular attention to which muscle is “on” or which is “off”.

As a patient becomes less symptomatic with a course of treatment, or with the natural course of recovery following injury, I like to progress the extent to which we load the spine while a patient attempts to control movement in the lower back or limbs. Again, early in the process, this is more about normalizing the sensitivity of the nerve pathways in and around the lower back than it is with any specific strength gains. It is quite normal for a patient to reports “feeling stronger” from these exercises, but I attribute this experience of “feeling stronger” to a shift out of a “protective” holding pattern.

Higher load and Higher Intensity Exercises

Typically, when a trainer defines “the core” as including all the trunk, hip and buttocks muscles, their “core” workouts tend to be more intense and involve bigger movements and greater loading than the more specific transversus abdominus protocols. Some examples of exercise that spring to mind include, “planks” or “bridges”. There really aren’t many limitations on a “core exercise” when the definition of the core is so broadly framed… under such a broad definition, one could argue that running is a core exercise.

I think these types of higher load, higher intensity exercises are useful for patients who have moved beyond the subacute phase of an episode of back pain. Once a patient is at this point in their rehabilitation, I think we are able to load the system enough to see some measurable changes in “strength” and functional measures that relate specifically to the patients goals, occupation or recreational activities. Putting in place a plan to systematically increase the intensity, frequency or duration of load on a patient’s lower back is a good idea in my books. The key is to make sure that the load parameters are appropriate for the specific patient.

The Core of the problem

Whether or not all these exercises should be described as “core” exercises is really a matter of semantics. I tend to suspect that those who argue very strongly for a very narrow, or a very broad definition of what constitutes “the core”, usually have a vested interest in having it defined in a particular way. I tend to take a view that the terms core stability, core strength, weak core, etc etc have been so loosely defined and reinvented so broadly and so often, for so long that none of them mean anything in particular.

So I tend to steer away from describing any exercises I prescribe as being specifically directed at “the core”. It doesn’t make sense to propagate confusion and misunderstanding among my patients. It makes far more sense to me to frame any prescribed exercises in terms of the patient’s activity limitations, and the mechanism by which the prescribed exercise is thought to assist that limitation.


Whiplash Injury & Whiplash Associated Disorder

Whiplash is the term used to broadly classify injuries resulting from a sudden acceleration / deceleration of the head and neck. The common example is the whiplash motion of the head in motor vehicle accident. Other common scenarios that involve a whiplash motion of the head and neck include a heavy fall onto one’s buttocks or back, resulting in sudden jerking back motion of the head. Similarly, sports involving high force body collisions can create whiplash scenarios.

If you have suffered a whiplash injury, particularly a high force injury such as a car crash, it is important to have the injury assessed by a doctor or physio. We can assess your condition to determine whether or not it is necessary for you to have diagnostic imaging such as an x-ray carried out. The purpose of the x-ray would be to rule out the presence of a suspected fracture to one of your neck bones. In the event that a fracture is present, you will likely be admitted to hospital for monitoring and treatment. Depending on the severity of the fracture, you could require surgery.

When the assessment reveals that there is no fracture, or no clinical signs of a fracture or other serious structural pathology, conservative (meaning non invasive, non surgical) management is indicated. This is where our role as physios is really important. If you’ve had a whiplash, and we know that there is no structural damage that has occurred to your neck, it is really important to commence a guided and graded return to your normal occupational and recreational activities sooner rather than later.

For most whiplash patients, the early days and weeks are very difficult. Typically the neck is very stiff and painful. There may also be associated symptoms such as pins and needles in your arms. Or you may have a headache, dizziness, nausea, a feeling of fatigue, cloudiness or vagueness. If the whiplash injury was a traumatic event like a car crash, you may also be dealing with flashbacks, anxiety or other changes to your emotional stability. Your sleep may be affected by any of these factors.

In short, whiplash injuries are difficult to recover from. The best way to ensure that your whiplash injury is painful and disabling for only a few months rather than years or decades, is to commence treatment early. An early assessment leads to more timely referrals to appropriate services. In addition to Physio, it’s not uncommon for your GP to include psychologists, social workers and other specialists in the management of a whiplash injury. Early assessment allows for more effective education with respect to the pathophysiology of a whiplash injury and your prognosis. Having an understanding of what is going on, and what is likely to happen at the next step, and the next step really helps whiplash patients get through the acute and subacute phases of the rehabilitation with less risk of developing chronic symptoms.

Generally, the early phases of whiplash management involve lots of education, reassurance, manual therapy and gentle exercise. Following that is a steady progression away from passive treatments such as manual therapy, towards active movement and exercise programs.

If you’re a Coogee or Eastern suburbs local and have had a whiplash injury, why not call us to discuss your treatment options on 9665 9667. You can speak directly with Pat our clinic owner to work out the best course of action for your scenario.


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