So what exactly are tendons?
They are the band of connective tissue that connects muscle to bone:
* Plantar fascia
They are non- elastic and store energy which act like a spring.
If we look at all the latest chat on tendons and all the evidence based research then we shouldn’t really be stretching them or treating them but we should be loading them.
I’ll come back to loading later on as this is proven to help actual tendon issues regenerate. What do I think about this? All good and it’s helped me rehab some of my patients and be more focused on the strength side but if I believe this is all we should do then I’ve wasted my last 30 years of work!!
Take this morning’s patient for example; he’s had a grumbling right hamstring tendon for 4 years. This gets worse when he ups his training for half or full marathon or does speed work. No scan so not actually diagnosed as a pathological tendon but clinically that’s what it’s telling us.
Looking at his pelvis this was quite clearly rotated to the right so if you increase speed or mileage on this pelvis there will be increased torsion and compression on the hamstring. Add that to background of rugby and dominant prime movers so the hamstring is massively overloaded. He’s been doing all the loading he’d found on line…. but on a twisted pelvis! See the problem. If we don’t address the cause I don’t feel we will get full resolution of the issue. Especially in runners, where biomechanical overuse issues are huge.
Some key issues that I think we should discuss.
Can I carry on running?
Should I get treatment?
Should I be stretching and Icing?
Do I need to change anything?
How do I prevent tendon issues?
The biggest question we should be asking is what is causing the pain? What is overloading the tendon? Load is one of the key aspects of tendon rehab.
If you can work out what you have done differently to overload it then you can decide where to start with treatment.
Some obvious ones:
* increased mileage or speed to quickly.
* Added in more hills than normal.
Then we need to look at how reactive is the tendon. Does it settle the next day or does it take 2-3 days to settle after training? Obviously the later means you are doing way too much or too hard.
You also need to see whether there are any other structures causing the injury, is the lower back tight, muscles and joints above and below an injury all need checking. It may just be as simple as a couple of days rest a good stretch and foam roller to loosen off all the tight structures. Great if that is the case! Always try first though if things start to grumble as you may avoid having 6 weeks off then.
Once a tendon issue has been diagnosed and you are getting treatment to release any other structures we need to look at loading. Basically you start with what you can do pain free with no reaction the next day, easy eh!
Take the Achilles, if it’s very reactive it may only tolerate 2 foot calf raises off the floor or even static leg press calf work. If allowing you to run steady then it may let you do one leg work. It’s worth comparing both sides, what can the good leg tolerate. Has the core become weak on the bad side, good chance to top this up while not running as much.
Then you need to be able to progress to hopping ideally done weekly for 12 weeks while continuing to build up the running to start giving the spring back in the tendon.
I’ve written out a program for the plantar fascia and you start at a level that works for you. Work through level one to check you can do it but if still running may find level 2 more suitable. If very acute then level 1 is best.
Icing is good along with the rehab if you’ve done too much to settle things down. If the muscle is particularly tight then some foam rolling and a gentle stretch is ok. However too much stretching isn’t good for tendons. If we look at the hamstring tendon this is very often inflamed in people who do loads of stretching, yoga and sitting as well as running and all this aggravates the tendon as it passes over the ischial tuberosity and compresses against this bone. So actually backing of stretching and prolonged sitting help.
Stretching is a bit like scratching an itch, it will temporarily relieve but not get the cause which will fundamentally be a strength issue.
If the tendon is very acute then it’s worth starting with some isometric contractions to load the tendon and this can be reused throughout the rehab as pain relief if you’ve done too much.
For those not sure isometrics are exercises without movement. I.e. static leg press for either the patella of the Achilles depending on whether you extend knee or push with calf.
Only run if settled by the next day and there is nothing more than minimum discomfort. Try easy running on trails to start and see how it copes. Avoid hills and speed initially. Tendons like loading but not overload.
Make sure trainers are good and you change them regularly. The most important factor in any injury not just tendons is making sure the body is prepared and strong enough to do the job you are asking of it. Don’t forget all the extras, prehab core drills they are all there for a reason!
The key with rehabbing tendons in everyone is different and we need to look at each individual case to see what’s happening and what individual exercises are needed. Don’t let these niggles turn into something chronic....