Running Injuries, Pt 1: Tricky Tendons

Since starting at Kinetic Sports Medicine, I have treated A LOT of runners for a lot of different injuries. However, there are two injuries that I see much more often in runners than in any other population… those two being tendinopathies and bone stress injuries. These are commonly overuse injuries and they require very specific forms of treatment and follow-up. In this blog, we are going to take a deeper look at tendinopathies, including what they are, why they happen, what they feel like, how we treat them, and what you can expect if you’re dealing with either of these! 

Let’s start with tendon pain:

So… what even is a tendon? A tendon is the connective tissue that attaches muscle to bone. They allow us to move our limbs and they absorb some of the impact our body takes when we run. 

Tendinopathy is a generic term for clinical conditions associated with overuse in and around tendons. Tendinopathic tendons have an increased rate of matrix remodeling, leading to a mechanically less stable tendon that is more susceptible to damage. This makes up about 50% of injuries to elite endurance runners and is commonly seen at the Achilles tendon, Patellar tendon, Tibialis posterior tendon, and gluteal tendons. 

Curious about what tendinopathy may feel like or how it may present? Here are some common signs & symptoms:

• Pain at site of affected tendon that is local and tender when pushed on
• Load-related pain
• Pain usually present at the beginning of activity that disappears during and reappears when cooling down
• Morning stiffness
• Pain is usually described as “sharp” in the early stages and becomes a “dull ache” after a few weeks
• Inflammation and visible swelling
• Decreased range of motion
• Asymmetrical strength testing (usually due to pain)

After reading that list, maybe now you’re wondering if the injury you’ve been dealing with is in fact a tendinopathy… If so, here are some basic ideas of next steps and how we treat it!

1. Rest is not best!! In order for a tendon to truly heal, it has to be progressively loaded. When you simply rest after an injury like this, you might feel better after a period of time, but as soon as you start activity again (especially the one that was provocative to begin with) your pain will most likely come right back. If a healthcare provider tells you that all you need is ice and rest, RUN…. to our physical therapy clinic and we’ll get you on the right track. 
2. Strengthen surrounding muscles: If you aren’t able to tolerate load of the tendon, there is a lot you can do around tendon rehab that can help your recovery process! When we are injured it’s important to not only focus on the area of concern, but to also strengthen the rest of our bodies so that we are better prepared for when we can tolerate more activity and prevent further injury.
3. Isometric exercises: When you are able to tolerate some load to the tendon causing you pain, one of the first things we prescribe are isometrics, which are long holds in a specific position that puts your tendon in its “happy place”. Our tendons, no matter where they are in our bodies, do not enjoy quick, snappy, jumping movements, which unfortunately makes up the majority of activities athletes do on a daily basis. Instead, tendons like slow, long holds, and heavy resistance. When we’re in a particularly painful state, these isometric exercises can be extremely helpful. Research has shown that performing these exercises for a specific amount of time can actually provide up to 45 minutes of pain relief!
4. Heavy slow resistance training: Like I mentioned before, tendons respond best to heavy, slow loads. One an athlete can tolerate adding load to a movement, this form of strength training gets added to their program. The exercises we prescribe will vary person to person based on the joints we are targeting. We typically prescribe 3-5 sets of 5-8 reps of each exercise, with weights at or above 80% of maximum, and completed 3 times a week. The speed of each rep should be counted at 3 seconds down and 3 seconds up because we want you to be SLOW and CONTROLLED. Programs like this have been greatly associated with increased collagen turnover, which is crucial for a healing tendon.
5. Plyometrics: Plyos involve the repeated, rapid stretching and contracting of muscles, such as jumping. These exercises usually progress last because they are commonly the most provocative activities. The most important part of plyometric training with a tendinopathy is to find a level of difficulty that the athlete can handle without worsening pain, and then progress from there. It is key that we keep trying to challenge the tendon in this regard because, like we mentioned earlier, tendons hate quick, snappy movements (aka plyos). So, once the athlete can perform plyometrics, no matter the intensity, we need to incorporate them to keep building up that tendon’s tolerance for activity.

Now that you have a better idea of how to rehabilitate tendinopathies, here are a few important things to keep in mind…

• Recovery can take up to 6-12 months or longer. If you are working with a PT on an individualized rehab program, you will probably start to feel a lot better in a few short weeks, but this does not mean that you are healed. The structural recovery of tendons takes about 24 weeks. 
• The most effective conservative approach for treatment is a progressive tendon loading program that includes heavy, slow resistance training. Rest is NOT the answer!
• Patience is KEY. In order to get back to doing what you love pain free, the right steps have to be taken and progressions have to be made wisely. Unfortunately, there really isn’t any rushing a tendinopathy. These injuries take time to heal, so listen to your body, do what activity you can, and don’t give up!

If you think you may have some tendon issues or any other underlying pain, contact us to get set up for a free injury screen.

If you are an athlete experiencing tendon pain, download our FREE Return to Running Checklist.

Check out our part two of these running injury blogs about bone stress injuries, otherwise known as stress fractures.