Frequently Asked Questions
Tendinopathies Tendonitis Other Tendon Injuries
Tendons are flexible but inelastic cords of strong fibrous collagen tissue that attach muscles to bone. Injuries to these tissues are referred to as tendinopathies (tendinopathy or tendonitis if referring to a single tendon). They are a type of tendon disorder that results in pain, swelling and impaired function. This pain is typically worse with movement.
DeQuervain’s refers to an area of pain on the thumb side of the wrist where a watch band would rest, and is associated with movement of the wrist or thumb. Activities that may reproduce these symptoms include reaching out to grab something with an open thumb and repeated raising and lowering of the thumb. Pain is also experienced when the wrist is bent forward and towards the little finger side of the hand and in side-to-side wrist movements. Holding something heavy or performing a forceful movement will increase the pain.
This condition is quite common in new parents due to lifting baby with thumbs up, combined with an up-and-down movement at the wrist, or holding baby on the hip for sustained periods. DeQuervain’s is also common where activities require strong or repetitive thumb and wrist movements.
The condition can also arise following direct trauma such as falling onto the wrist or thumb, following a sudden twisting force in the area or a direct blow to the side of the wrist.
The tendons are easily seen when doing a thumbs-up sign with your hand as they help lift the thumb up and out. In DeQuervain’s the tendons become more apparent due to swelling as well as pain when performing this movement which is due to thickening of the sheath that holds the tendons onto the bone. This thickening, and associated swelling, tends to tighten or compress the tendons. As a result, movement of the tendon is painful and the pain may travel down into the thumb or up into the forearm.
If lifting your thumb is difficult or painful, or if bending it down towards your little finger hurts, you could have DeQuervain’s. Other conditions that occur around this area may have similar symptoms, but different causes and treatment, so it is wise to seek the advice of your physiotherapist to help you diagnose the condition.
Your physiotherapist will manage your DeQuervain’s by:
- splinting the area to reduce movement of the thumb tendons while you go about your normal activities
- educating you in ways to modify your activities by using your wrist and thumb in different positions, eg when lifting, or holding items for sustained periods
- prescribing rehab exercises of the thumb tendons to help reduce the pain while also strengthening the area – exercises form an important part of the treatment program and can help reduce recurrence of the condition
- treating with massage and other soft tissue techniques to relax the muscles and reduce tension in the area
Gluteal tendinopathy is a common cause of pain at the side of the hip. While this condition is still often referred to as trochanteric bursitis, researchers have now determined that one of the main precursors is a reduction in load tolerance in the tendons of two buttock muscles, the gluteus medius (an important muscle in controlling the hips) and the gluteus minimus.
This may occur in response to rapid increases in training or exercise load, a large force associated with a slip or fall or an increase in body weight. There may not be a particular incident, and instead it may be due to either a gradual weakening of the tendons over time resulting in a lack of stimulus of the gluteal muscles, or secondary to certain postural and movement habits.
Gluteal tendinopathy is more common in women than men with research showing that about 25% of women over the age of 50 suffer from lateral hip pain. Those with gluteal tendinopathy have been shown to have weakness in the gluteal muscles and tendons which if they become weak enough, will fail to cope with everyday loads. When this happens, the nervous system sends a warning in the form of pain.
Your physio will listen to your history and symptoms before performing a number of tests to rule out other potential sources of pain. You may also be referred for radiological investigations such as ultrasound scan or MRI in order to confirm the diagnosis, but it is not necessary to have scans before seeing your physio as most people can be diagnosed without these tests.
Your physio will then be able to help you in a variety of ways, addressing the postural and movement habits that aggravate the condition. You will also be prescribed specific exercises as research has found that this provides the best long-term outcomes for tendon pain. Exercises will aim to improve movement patterns, gradually strengthening the muscles involved and improve the health of your hip. Hands-on techniques such as massage, trigger point releases, heat and dry needling may assist with short term symptomatic pain relief.
Tibialis posterior tendinopathy is a condition considered to be caused by excessive load beyond the tendon’s capacity, with compression of the tendon at the ankle linked to pathology in both the tendon and its sheath.
When the tibialis posterior tendon is overloaded, this results in pain and discomfort where the tendon wraps under the bony knob (medial malleolus) on the inside of the ankle. If there is associated tenosynovitis (irritation of the sheath that wraps around the tenosynovitis, you may feel a subtle crackling or squeaking (known as crepitus) as you move your foot.
Exact causes are not known although some consider rolling in of the foot (pronation) is an important contributor. The condition is most commonly seen in those over the age of 40 and is rare in the younger population.
Your physio will diagnose this condition based on your description of pain and possible creakiness, looking and feeling for swelling and assessing the strength and function of the muscles around your ankle. You may be asked to perform single or double-leg heel raises which may be painful or difficult to do if you have this condition. Scans and X-rays are not usually indicated.
Your physio will inform you of their diagnosis and proposed management plan. Physio management is aimed at reducing the symptoms, including exercises to improve the strength of the tibialis posterior muscle and associated muscles in your calf and foot. These exercises will also improve the capacity of the tendon. Orthotics may be helpful as they will support the foot, but a heel raise or shoes with heels may be helpful as they decrease the compression and therefore the pain.
If your physio suspects an associated irritation and inflammation of the covering of the tendon (tenosynovitis) they may refer you to your GP for a course of non-steroidal anti-inflammatory medication.
This tendon connects the muscles of the calf (gastrocnemius and soleus) to the back of the heel bone (calcaneum). It acts like a spring and allows us to run and jump with ease. If the tendon’s capacity is exceeded, tendinopathy may develop.
Achilles tendinopathy describes pain and dysfunction in the achilles tendon, usually as a result of excessive loading or activity, either due to a sudden increase in training load or resuming an exercise program following a period of being relatively sedentary.
In the early stages, Achilles tendinopathy is caused by increased numbers of cells in the tendon attempting to adjust to the excessive load and it is this cellular reaction that causes pain only when the tendon is loaded (not at rest). In chronic cases the cellular reaction may lead to structural disorganisation of fibres in a small part of the tendon.
There are a number of contributing factors that can lead to the development of this condition, including:
- compression of the tendon (as when performing calf stretches) is also an important factor in the development of pain
- obesity (causes systemic changes in circulating cytokines – immune proteins)
- type 2 diabetes
- fluoroquinolone antibiotics and statin medications
- genetic factors
- poor function of leg muscles
You will likely have very localised pain where the Achilles attaches to the heel or between the heel bone and the muscle (mid portion of the tendon). This pain is specific and not vague in nature and occurs with loading activities such as running, jumping and during sporting activities.
It can affect both young and older distance runners and is characterised by stiffness and pain first thing in the morning and is not usually painful at rest. The tendon may also look and feel thicker which is the result of the tendon attempting to adapt by creating more tendon tissue.
Your physio will diagnose and differentiate the condition after carefully taking your history, noting any reported changes to your activity and loading. Tests will be performed, such as leg raises or hopping, to assess your tendon’s response to load and the strength of your leg will be assessed as a whole. Scans are not indicated if there is a clear diagnosis.
Your physio treatment plan will be tailored to your individual findings, with initial treatment focusing on reducing your pain. This will require you to modify and temporarily reduce any high load activities such as running or jumping, and avoiding positions where the tendon is compressed (when the foot is bent upwards such as occurs when doing a calf stretch). Isometric exercises (holding without movement) are likely to be prescribed.
Exercises will then form the main element of your treatment program once your pain is more settled. This will include heavy and slow strengthening of the whole leg based on the deficits that your physio has assessed. Exercises will need to become more challenging and gym equipment or weights may be introduced to achieve the best outcomes.
As you become stronger and your pain is settled, higher load activities will be slowly introduced. Finally, when your physio is happy that your tendon capacity is sufficient, you will be gradually eased back into your desired physical activities.