How does that song go? …Head, shoulders, knees, and toes, knees and toes. And that, ladies and gentlemen, is where you can get a tendon problem: everywhere. A tendon is where a muscle attaches to a bone. This attachment is what allows our muscles to pull on our bones to effectively move our joints. The most common places for tendon issues to occur are in the heel, knee, elbow, and shoulder. Today, we will discuss the difference between “tendinitis” and “tendinopathy” as well as natural methods to manage pain and treat tendinopathies effectively.
What is the difference between tendinitis and tendinopathy?
Typically, you hear people use these words interchangeably, when in actuality, there are some key differences between the two. Tendinitis is an inflammation of a tendon resulting from sudden, acute overload. The pain can typically be isolated to a single traumatic event. On the other hand, tendinopathy (sometimes referred to as tendinosis, which is a subset of tendinopathy) is pain in a tendon due to reversible degeneration of a tendon’s collage due to chronic overuse. The onset of pain is gradual, and there is no “time of injury.” Tendinopathies are common with repetitive motions and lack of adequate rest of the affected tendon .
So which one do I have?
There seems to be widespread confusion about the difference between tendinitis and tendinopathy. In most cases, many injuries diagnosed as a “tendinitis” are actually a “tendinopathy,” especially if there isn’t a specific injury you can remember. For example, tennis elbow is defined as a “tendinitis of the extensor carpi radialis brevis (ECRB),” a muscle of the forearm. However, histological (cell) studies have not found any evidence of inflammation in the tendon of the ECRB, suggesting that tennis elbow is more likely a tendinopathy/tendinosis and not a tendinitis . Given the fact that most tendon issues are generally tendinopathies and not tendinitis, the treatment discussed below will focus on tendinopathies.
So how do I treat my tendinopathy/tendinosis?
The first thing to keep in mind is that chronic tendon issues take a long time to happen. You also are not able to pinpoint exactly when your pain started. Because of this, they are also going to take a long time to resolve, even if you do everything you’re supposed to. Treatment can take 3 to 6 months on average, but can be up to 9 to 12 months for full resolution. Because tendinopathy is related to a disorganization of the collage fibers within the structure of the tendon, it takes a while for those collage fibers to realign and for the body to make new collagen. Similarly, these tendons can also have a pathological growth of blood vessels related to the degeneration. Treating chronic tendinosis for just a few weeks is not going to provide any long-term changes in the tendon structure and likely won’t give you much pain relief [1,2].
Natural ways to treat tendinopathy
The good news is most tendon issues will resolve with conservative care. Remember to expect that no matter what you do, it will still take a long time to treat any sort of tendinopathy issue.
The most well-studied and effective treatment for any tendinopathy is specific eccentric exercise, depending on the body part affected . Similarly, ice (cryotherapy) may be helpful in reducing pain related to a tendon issue. While it won’t “fix” the collagen degeneration, it may counteract the increase in blood vessels in the area of the affected tendon, which may potentially be a cause of tendinopathy [1,6].
Eccentric exercise is defined as the “lowering” or lengthening part of a movement. For example, when you do a bicep curl, you bend your elbow to bring your hand towards your shoulder (a concentric muscle contraction). When you bring the weight back down by “unbending” your elbow, this is the eccentric phase of the exercise. You are lengthening your bicep muscle to prevent your forearm and hand from just falling towards the floor.
The eccentric phase of exercise tends to produce more force through the tendon you’re trying to target, but there is some debate whether or not it is any better than slow resistive training or other types of loading on the tendon .
It is important to note that eccentric training may actually produce some pain in the tendon we’re trying to affect, which is normal. This pain should gradually diminish both during the set and between sessions of the eccentric exercise. In any case, most of the available research focuses on the benefits of eccentric tendon loading, so that is where we will focus in this article for each of the typically affected tendons.
Pain related to Achilles tendinopathy usually presents in the area of the heel cord, above the heel, in the region of the taut band of tissue at the bottom of your calf muscle (mid-substance Achilles tendinopathy). There are some cases where the tendon will be more irritated closer to where it attaches on the heel, but this doesn’t happen as frequently (insertional Achilles tendinopathy). Eccentric strengthening is a first line treatment for Achilles tendinopathy. See Figure 1 below for an illustration and written instructions for appropriate performance of an eccentric calf raise for pain relief of Achilles tendinopathy. Also see Table 1 below for an example of an Achilles eccentric exercise protocol . This set and rep scheme is similar for all types of tendinopathies because there needs to be adequate load to the affected tendon before the collagen fibers will remodel. Studies show more pain relief and normalization of the Achilles tendon after a 12-week strengthening program .
Figure 1. Eccentric calf strengthening. Go up on both of your toes, making sure to keep both of your big toes on the ground. Don’t roll to the outside of the foot as you go up on your toes. Then, shift all of your weight over to your painful side (left side here), making sure to stay up on your toes. Slowly lower your heel back down to the ground.
Table 1. Example of an Achilles tendon eccentric exercise protocol. Adapted from Childress et al (5).
Patellar tendinopathy is an irritation of the tendon that connects your knee cap (patella) to your shin bone (tibia). Symptoms of patellar tendinopathy can be present for years after initial pain onset. You probably already guessed that the main treatment for patellar tendinopathy is eccentric loading exercises of the quad [5,6]. You can do this with either your feet off the ground (open-chain exercise) or on the ground (closed-chain exercise). See Figures 2 and 3 below for more details. The goal would be to repeat these exercises for at least 12-15 reps 3 times several times per day.
Figure 2. Example of an open-chain knee extension exercise with a focus on the eccentric phase. Kick your foot up into the air so your knee is straight (concentric phase). Slowly lower your foot down (eccentric phase). This should be challenging, so add weight or resistance bands as you need to.
Figure 3. Example of a closed-kinetic chain quad exercise with an eccentric focus. Standing on the same leg as your sore knee, slowly lower your right heel down to the next step trying to keep your hips level and your knee behind the top part of your shoelaces. If you have trouble keeping your balance, hold on to a railing with the hand opposite the knee that’s affected. If we assume this person’s sore knee is their left, you would try to hold on to something with your right hand.
In some cases, a patellar counterforce strap (Cho-par strap or brace) can be used as an adjunct to treatment in order to manage pain while continuing to do eccentric exercise to remodel the tendon. The research on the effectiveness of this strap is mixed, with some studies having poor results and some showing overall symptom improvement .
Tennis elbow (lateral epicondylitis)
Tennis elbow is typically described as pain on the outside of the elbow, especially with lifting, gripping, pushing, pulling, or resistive turning, like in the case of a tight doorknob. The irritated muscles are usually the ones in your forearm that help bring the top of your wrist back towards you (common extensor wad, more specifically the extensor carpi radialis brevis). See Figure 4 for an example of eccentric wrist strengthening.
Figure 4. Eccentric wrist extension strength. Have the wrist and hand of your affected side placed off the edge of a table or counter. With a weight (soup can, jar of sauce, small dumbbell) in your affected side, use your unaffected side to help bring your wrist back (concentric phase). If you can, you can do this motion without the help of your other hand. Then slowly, without any assist, lower your hand back down. The goal would be to repeat this for at least 12-15 reps 3 times several times per day.
In a study conducted on 92 patients with lateral epicondylitis, the group randomized to eccentric strengthening showed a significant improvement in pain, strength, and function compared to the group who did not receive eccentric strengthening .
Rotator cuff (supraspinatus) tendinopathy
People with rotator cuff tendinopathy, specifically of the supraspinatus tendon, which is the tendon located on the top of the shoulder that is most susceptible to being “pinched,” complain of shoulder pain on the top and side of the shoulder, sometimes traveling into the upper outside of the arm. Pain usually increases with raising their arm and/or overhead reaching activities. See Figure 5 for an example of an eccentric exercise that targets the supraspinatus.
Figure 5. Shoulder abduction with theraband. Lift arm out to the side while keeping your shoulders out of your ears (concentric phase). Lift as high as you can before your shoulders start to creep up into your ears. Slowly lower your arm back down trying to keep your shoulder blades still (eccentric phase).
So I did these exercises: why do I still have pain?
It is again important to reiterate that recovering from a tendinopathy will not happen overnight. It takes at least 3 months of consistent and specific exercise to affect the tendon and keep you painfree. While it is definitely possible you will start to notice gradual improvements before the 3 month mark, it is likely that if you stop the exercises, your pain will almost immediately return.
Another thing to consider is that generally, when you have an overuse injury, the location of your pain may not necessarily be where the problem is. There could be underlying motion, strength, endurance issues as well as poor control around the joints near where the tendons are affected. While the consistent eccentric exercise will definitely make the irritated tendons feel better, if you don’t address the other impairments, it is likely the tendon involved will continue to be overloaded and become painful again. This will likely be the case if you’re trying to return to a higher level exercise activity, like running, jumping, throwing, or lifting.
It is important to see your physician prior to diagnosing any tendon issue or starting an exercise or strength training program. Additionally, if you try some eccentrics and still can’t seem to get your pain under control and return to your normal activities, it may be helpful to consult with a physical therapist or other rehabilitation professional in order to determine what else may be causing your tendon to get sore.
Tendinopathies are very common overuse injuries. They typically occur with a gradual onset and most of the time, you won’t be able to recall a specific mechanism of injury. This is in direct contrast to a tendinitis where a sudden and acute injury may cause sudden damage and therefore, inflammation to the tendon. The most common tendinopathies are Achilles tendinopathy, patellar tendinopathy, lateral epicondylitis, and rotator cuff tendinopathy.
Tendinopathies respond very well to conservative treatment and may be managed with appropriately dosed eccentric exercise. This may need to be in combination with ice and other types of stretching and exercises to address other issues that are causing you to place too much stress on your sore tendon. Sometimes, this might require the help of a physical therapist or other health care professional. The mainstay treatment for tendinopathies is exercise, so you can ensure that your treatment for your tendon condition will likely be completely natural.