Lower limb tendinopathies

Tendons are strong, thick structures within the body. In the lower limb, they act as springs and allow us to produce powerful, explosive movements such as running and jumping. Lower limb tendinopathies are relatively common in both athletic and non-athletic populations.

Pathophysiology 

When we train, whether it be running, cycling, swimming, weightlifting, etc. the body recovers and adapts by undergoing many cellular processes. These processes allow for physical growth and adaptation. Each person’s fitness, strength, recovery rate, and ability to adapt are very different, and therefore different people may experience injuries at very different activity levels. After a stimulus has been applied to the body, our tendons will undergo cellular processes to adapt to this stimulus. However, if we continue to overload the body without adequate recovery it can be a challenge for our repair cells to keep up with this training stimulus. Our body is smart enough to replace our normal repair cells with an alternative to allow us to continue performing at these volumes, however, the replacement can cause tendon stress, resulting in pain.

Presentation 

Tendinopathies are generally considered an overuse injury. The tendon is not able to adapt and recover to physical demands quickly enough resulting in a localised pain related to high tendon load (e.g. fast movements, running, hopping, jumping). A typical presentation for tendinopathy is pain at the beginning of exercise/activity that warms up with the body – it may then become sore towards the end of your training session. Symptoms will then become more prevalent again over the next 24-48 hours. We think this is due to the protective mechanism of the body, as it is smarter for the body to protect you from overtraining the following 24-48 hours. Other high tendon loads that may provoke symptoms in an irritable tendon include compressive loads (e.g. stretching) and energy storage combined with compression (e.g. uphill running in Achilles or proximal hamstring tendinopathy, as the tendon is technically compression and performing explosive movements).

Treatment

Should I take anti-inflammatories?

Previously known as tendinitis, ‘itis’ standing for inflammation, however, we now know that there is no inflammatory component associated with tendinopathies. Therefore cortisone injections and anti-inflammatory medications are not generally recommended.

Will resting it help? 

Resting a tendon will only result in a weaker tendon, we need to load it through strengthening and graded exposure back into activities. Continued inappropriate loading will cause further tendon stress and ongoing pain, therefore we need to determine the optimal loading program for you.

How about strengthening? 

A progressive loading program allows the tendon to adapt to increased physical demands, thereby enabling you to tolerate increased loads without irritation and tendon pain. As mentioned above, the primary role of lower limb tendons is their springy effect. In an irritable tendon, we may advise you to reduce these types of explosive movements for a short period of time and modify them with slow or isometric movements, which are lower in tendon load. Remember, avoiding high tendon loads forever is not the solution and they should be reintroduced as soon as possible. A progressive loading program in tendon rehabilitation should be individualized to your goals and the activity that you would like to get back to.

Load management

Load management is another key component of tendon rehabilitation. Generally, we are able to keep you training, and it is actually very important to keep you training so that your physical capacity does not decline. We want to find a load that you are able to train at without too much tendon flare-up. We may reduce your normal training volume and intensity OR substitute your training with an activity that is lower in tendon load (e.g. swimming or cycling). It is important to monitor how you feel and how your tendon responds over the next 24-48 hours, as mentioned above, it is over the following day/s that your tendon may be sore, which can make things tricky to monitor. In regards to load management, it is also very important to factor in rest and recovery days during your training week.

Finally, it is important to remember that tendinopathies can take up to 18 months to treat. It is a slow journey but you will come out stronger on the other side. If you are experiencing any tendon pain, contact our physiotherapists to discuss how they can help you.