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The challenge of managing tendinopathy in competing athletes

Cook, J.L. and Purdam, C.R., 2014. The challenge of managing tendinopathy in competing athletes. British journal of sports medicine, 48(7), pp.506-509.

In today’s letter

• A breakdown of the paper that gathered research findings and clinical expertise to provide a plan for managing tendinopathy in athletes during the season

• Key takeaways:

1. In-season treatment of tendinopathy is challenging due to ongoing stress on the tendon.

2. Pain occurs during load and quickly resolves after the load is removed

3. Effective management requires reducing tendon cell activation and sensitivity (Rest from high-intensity loads - Introduction of heavy slow loads)

• 3 resources to check out to further your knowledge about managing tendons in season

• Meme of the week: Oh the confusing old days 😄 

Aim of study

This paper combines research findings and clinical knowledge to outline a management strategy for tendinopathy in athletes during the season

Did you know?

• Tendinopathy (tendon pathology and pain) is common among athletes, especially during the season when physical demands are high.

Athletes with lower limb tendinopathy experience reduced abilities to:

1. Jump

2. Land

3. Change direction

4. Perform other dynamic movements

Which can hinder full training and competition.

• Treating tendinopathy during the season is challenging as it often responds slowly to interventions, making full recovery unrealistic while athletes continue to place heavy loads on the tendon.

• A common frustration is the expectation within sports and sports medicine for tendinopathies to heal quickly, unlike injuries such as stress fractures, muscle strains, or ligament tears that are given enough recovery time.

• Tendon pain is a key issue during the season, as tendons can have significant pathology without pain, but when pain is present, it limits the athlete's ability to use the tendon for energy storage which affects performance.

• The only long-term solution for tendons that repeatedly fail to handle athletic loads is a rehabilitation program aimed at increasing the tendon’s load absorption capacity, but this often conflicts with ongoing high intensity training & matches

Tendon pain - How and Why?

• Tendon pain is typically well-localised and does not spread beyond the tendon unless there is significant involvement of nearby structures like the bursa or fat pad.

• It’s triggered by physical loading, with higher loads causing greater levels of discomfort.

• This pain has a short latency, occurring only when the tendon is under load, and subsides quickly once the load is removed (e.g., after hopping).

• It is uncommon for tendon pain to occur without physical load or to cause discomfort at night or during rest.

• The exact anatomy, biology, and physiology behind tendon pain are not fully understood, with conflicting evidence on the signalling responsible for pain and their pathways to the central nervous system.

• Research suggests that abnormal tendon cells may produce signalling proteins and receptors for substances like epinephrine, acetylcholine, glutamate, substance P, and TNFα, which can drive local responses affecting vascular and tenocyte behaviour.

• There is disagreement about neural ingrowth in conditions like patellar tendinopathy; most nerves in the tendon are sympathetic, though some may have both sensory and sympathetic functions.

Sensory functions refer to the nervous system's ability to detect and process sensations like pain, temperature, pressure, and touch. These signals are sent from sensory receptors to the brain.

Sympathetic functions are part of the autonomic nervous system responsible for controlling involuntary responses, such as increasing heart rate, dilating pupils, and preparing the body for "fight or flight" during stressful situations. They regulate internal organs and blood vessels.

• Central sensitisation can make the nervous system more sensitive, increasing how much tendon pain is felt. At the same time, the brain's ability to reduce pain signals (called descending inhibition) can also affect how much pain is experienced overall

Load and tendon injury

• Tendons that frequently store and release energy, such as those in athletes who jump or move quickly, are more prone to developing tendinopathy.

• Tension and compression (shear) forces can lead to an overload of the tendon attachment (enthesis), increasing the risk of tendinopathy.

• Factors such as genetic predisposition, gender (men are twice as likely to develop tendinopathy), previous load history, and biomechanical “faulty” movement patterns can also increase the risk of developing tendinopathy.

• Biological tissues adapt to increased load over time by becoming stiffer and producing more matrix proteins, improving load tolerance and energy absorption.

• In response to high load, Type I collagen production in a healthy tendon peaks around 3 days post-exercise, with pathological tendons having a greater response but lower resting levels compared to normal tendons.

Load management in-season

• Tendinopathy develops when there is a mismatch between the load capacity of the tendon and the load placed on it, often due to sudden changes in activity.

• Managing in-season tendon pain should focus on reducing activation and sensitisation of the tendon cells (tenocytes).

• Reducing high loads on the tendon can help improve the cellular response if enough time is given for recovery.

• Elastic energy storage increases cell signalling, and extremely high loads may lead to cell death within the tendon.

• Various types of loads can trigger tendinopathy. Consider the total load placed on the tendon over times, as even small overloads can accumulate and cause pathology.

• A rapid increase in tensile load or excessive tensile force can exacerbate symptoms, so these should be managed carefully.

• Eccentric loading, especially in high training environments, has been shown to aggravate tendinopathy and should be avoided during the season.

• Reducing compressive loads and preventing the combination of compression and tensile forces (tendon shear) is importnat for managing tendon health.

• Limiting outer muscle range loads can decrease tendon compression against the bone (enthesis).

• Introducing loads that reduce pain should happen early, as total removal of tendon load can lead to tendon weakening (catabolism).

• Isometric exercises have been shown to reduce pain by recruiting descending inhibition mechanisms and maintaining tendon stimulus without aggravating symptoms.

• Moderate to heavy loads, performed in mid-to-inner muscle ranges, rarely provoke pain and can be repeated multiple times per day to reduce discomfort and maintain muscle capacity.

• Provocative tests and objective measures like the VISA score should be used to track tendon pain, though VISA scores are better suited for long-term monitoring rather than short-term changes.

The role of medication?

• Medication for managing tendinopathy focuses on reducing pain by inhibiting cell activation and proliferation (For example; ibuprofen, celecoxib, naproxen, and indomethacin)

• These medications may help reduce tenocyte activity and aid in aggrecan deposition, while TNFα inhibition could also contribute.

• Doxycycline, green tea, and omega-3 supplements have been explored as potential treatments, but their effectiveness is inconsistent.

• Corticosteroids, particularly short-acting ones like dexamethasone, can be useful for quickly reducing cell activity in highly reactive tendons.

• While corticosteroid injections have historically been discouraged for tendinopathy, they may be effective if used at the right stage (not in the degenerative phase) and accompanied by good load management and rehabilitation to rebuild tendon capacity.

• Analgesics or anaesthetics may seem like a reasonable option to manage pain, but masking discomfort can lead to worsened tendon damage, as continuing high loads on a pain-free tendon can increase the risk of further injury or rupture.

Other treatments

• Other treatments can help reduce pain, improve function of the muscle-tendon unit, or decrease load on the affected tendon.

• Shock wave therapy can provide temporary pain relief by reducing C fibre activity.

• Supportive options like strapping, bracing, orthotics, and appropriate footwear should be considered, as even small improvements can function for athletes with in-season tendinopathy.

3 resources to check out

1. Managing patellar tendinopathy in season (ARTICLE) - LINK

2. Training tendons - what matters (PODCAST) - LINK

3. Progressing patellar tendon loading (VIDEO) - LINK

Thank you for reading this weeks edition!

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