Nine High Value Tips for your Tendon Pain: From a Chiropractor’s Perspective

In the interest of clarity, we use tendinopathy, tendon injuries, and tendonpathology interchangeably in this article. Tendinopathy is the current preferred clinical term to encompass all tendon dysfunction including tendinitis and tendinosis.

We know tendon pain is awful. You start to miss your weekly tennis practice or evening runs. You may not be able to turn a door knob or open a sauce jar without help. Tendon injuries can be intrusive to our daily lives. Today we give you nine tips to help you through your journey to a full, functional, and happy life.

1) Pain is the key tendinopathy symptom although tendon injuries can occur even in the absence of pain

We frequently meet new clients who would tell us that their tennis elbow (or any other tendon injury) started last week. Most of the time, this is not true. First, we have to understand that repetitive overload is the mechanism that leads to tendon injuries. This means you cannot suffer from a tendon injury from a particular tennis serve last Friday night.

Second, the tendinopathy stages behave as a continuum across three main phase: reactive, disrepair, and degenerative. Tendon pain only occurs in the reactive stage or the reactive on degenerative stage. This is all very technical but the take home message is that you can have a tendon injury without pain.

So yes, tendon injuries can hurt. No, your tendon injury probably started before last Friday. (I.e. you had the injury prior but experience no pain until the “unfortunate” serve last Friday.)

2) Your pain is very real but not the most important part of recovery

This is probably the most brutal thing we have to tell our clients – Your pain is real, we know it is awful, but pain relief is not the most important part of recovery. You can’t turn the door knobs, you can’t raise your arms, you can’t climb stairs. We know and we don’t mean to discount your pain experience. We are trying to help you get long-term results. We want you to get better, faster.

Good news is we know how to help. We know exercise is the cornerstone of tendon injury treatments for the past three decades. We know exercise is still the best evidence solution to your pain.

The bad news? It’s kinda a little uncomfortable as we guide you through the recovery process. We will 100% work within your load tolerance and pain experience. Remember, for most people there will be some discomfort.

On the bright side? There are pain relief modalities from manual therapy to medication we can try. These provide short-term relief to help you cope interim. We highly, highly suggest you do not become dependent on them because they are unlikely to help in the long run.

3) Tendons are designed for tensile loading

This is probably more useful to athletes but gets a special mention because of the intrinsic beauty of the human design. (It also explains why eccentric exercises, in the next tip, work.) So, tendons love, love, and love loading. It is counterintuitive but it is amazing how nature works. Based on the architecture of the fibrous tissue in tendons, tendons are most adapted to tensile load. What does this mean? Think energy storage and the release of that stored energy. Think of what happens when you jump: As you descend into a squat stance, energy is being stored in your tendons. And when you jump, this energy is released from the tendons. It is the energy storage-energy release mechanism that allows humans to run. New Scientist wrote a brilliant article Achilles Tendon is the Key to Evolution of Human Running back in 2010.

p.s. compressive loads induces tissue damage (at the proximal aspect of the tendon-bone junction)

4) Eccentrics and slow progressive loading are the winners

We use exercise very loosely in my profession/industry but because, really, most things from olympic lifting to stretching somewhat comes under exercise depending on how far you want to stretch it. As you can already imagine, not all exercises are created equal.

Despite many, many musculoskeletal “experts” choosing the more inferior manual therapy option for treatment of tendon pain, exercise is still the most effective treatment. Eccentric-focus exercises dominated the rehabilitation protocols for over two decades however newer research is starting to show progressive loading to be superior to eccentric loading alone. A study in 2015 by Beyer et al. found eccentric exercises and heavy slow resistance (HSR) to be comparably effective in clinical outcomes with HSR delivering better patient satisfaction in the short-term. An older study in 2009 found HSR to induce collagen synthesis (and, in turn, increase mechanical stiffness of tendon) with HSR patients being most satisfied at 6-month follow up.

So, both eccentrics and heavy slow resistance (i.e. weight training) do work. Don’t be surprised if we start to get you lift super, duper heavy – research says it’s better for you!

5) Sometimes you need to take a step back

It’s not always just about pushing for weight and getting you to move more and move fast. Best management also comes with education, load management, and the good-old exercise-based rehabilitation program.

Remember we mentioned (at the very beginning) repetitive overloading is the mechanism for tendon injury? The key to a successful recovery, therefore, lies in the ability to manage the loads acting on your tendon without aggravating your tendonitis symptoms while at the same time build tolerance and load capacity. Does that make sense? In short, we want to make your tendon “stronger” – carefully – without making your condition worse.

N.B. Complete rest is not going to help

6) Recovery can take months and it is common to experience some discomfort

The four stages of recovery can be briefly broken down to:

1. Isometric exercise for pain management
2. Heavy slow resistance training to build endurance, muscle strength, and tendon stiffness while eccentric-focussed exercise helps with increasing neuroplasticity
3. Energy storage and increase in speed exercises
4. Energy storage and release or return to sport exercises.

In short, give us some time. It may not seem obvious to you but the list of considerations are long and we promise we get you there. We ask for your patience and understanding. We know it’s hard work. We know it get exhausting. But bear with us! We have a plan to get you to where you want to be!

7) Pain-relief modalities may be used as an adjunct

Treatments like ice, stretching, acupuncture, deep frictional massage, have been shown to have little efficacy. Stretching is now believed to worsen compression and deep frictional massage can provoke pain with no gains in tendon function and should thus be avoided.

Enough said. I think it’s clear enough. What I’d like to talk a little about though is electro- or electrophysical therapies. Do they work?

Extracorporeal shockwave therapy: Seems to work for short-term pain relief but the number of studies supporting its efficacy is still small. There is no superiority between focused vs. radial shockwave therapy. For best results, go for 2000 impulses per session at thrice a week at highest tolerated flux density. Trust me – it adds up and that is expensive. A shockwave treatment in Singapore alone starts at $85 to $220 (depending on where you go to) before consultation fees are included. p.s. shockwave is still recommended as an adjunctive for pain relief (i.e. exercise is still the golden ticket).

Ultrasound/laser: Seems to work also for short-term pain relief but again more studies and higher quality studies are needed.

The general consensus is that they do work to a limited extend. However, the quality and quantity of research supporting their efficacy for chronic tendonitis is poor. It is unlikely for them to work better than exercise treatment because of the nature of the treatment. Therefore, passive treatments (inclusive of electrotherapy) are at best adjunct therapies to be used in combination with an exercise program.

8) Complete rest is the best way to failed recovery

Almost an oxymoron but it is largely true.

Rest usually does help with your symptom alleviation. Most people feel immediately better with rest. However, return to sports or your daily lifestyle will trigger the pain all over again. Why? Because rest decrease muscle power, it decreases the mechanical properties of the tendon itself, it also negatively affects the kinetic chain and how you move.

In the case of rest, the downside outstrips the benefits.

In short, do not cease all activities with tendon injuries. If required, seek professional help. A chiropractor can help you to identify the load volumes and types that may initiate pain. From there, a exercise program can be developed for you to help you return to your desired lifestyle with minimal symptom aggravation.

If your choice of provider suggest complete rest, please do seek second opinion.

9) Surgery is not always the superior option

A 2018 study looking at 313 patients published in Lancet found that surgery was not clinically better than no treatment. An older study in 2012 found that 80% of the cohort of patients waiting for surgery who chose to undergo a structured exercise program did not need surgery after.

A critical review published in 2001 looking at outcome of surgery for chronic Achilles tendinopathy found that as the quality of the study improves, the the report success rates decreases!

Our take is that surgery is a last resort type situation. As far as best evidence care is concerned, exercise rules. But if conservative care fails you, there is certainly medication, procedures, and surgeries for your consideration.

Take home message?

So there you go! The nine high value tips for your tendon pain.

This entry is largely based off the paper published this month in Best Practice & Research Clinical Rheumatology titled Current trends in tendinopathy management.

The take home message? Lots of things will make your Achilles or supraspinatus tendinopathy feel better in the short-term but exercise is – at this point in time as we know it – your only long-term pain solution.