Tendon injuries in endurance sports - a matter of overuse?
Areas with a high prevalence injury in our endurance athlete population include the plantar fascia, achilles tendon and patellar tendon. With plantar fasciopathy (or plantar fasciitis as it’s more commonly known), becoming classed as tendinopathy-type mechanism of injury, and a group of injuries that we see a lot of in clinic amongst our running and cyclist population, it's not a single bit of a surprise that these are classed as the main injuries in this demographic. Commonly referred to as an 'overuse' injury, I find it more helpful to reframe our poor tendon injuries and explain it as instead of having 'overused' this tendon, it is generally an issue of under preparation. Here's why.. Tendon injuries (namely, tendinopathies) arise when the requirement of work we're asking them to do exceed their current capacity. Tendon's are wonderful, tensile structures and are the portion of a muscular unit that joins our muscle to bone. For this, they need to be robust and physiologically have a reduced blood flow compared to our muscle bellies. This serves to allow them to be more tensile, elastic and store energy for activity but, the disadvantage here is that they are slower to adapt to load than their fleshy muscular counterparts. Mechanism of injury
So, when we go from no running, to 10km/session or cycling once per week to 500km in 4 days (hello, yes, me in 2019 giving myself 3 of these injuries at once) - our tendons (and other structures but let's just discuss the tendons today) struggle to keep up with what we're asking them to do because they are under-prepared for the load you're giving them to take up and here's where pain may kick in. It might not be an instantaneous pain presentation in each and every circumstance. You might be able to keep up with the demands of doing a half marathon without any pre-training, as a one off (please don't do this) but then if you were to repeat the feat or even on 'just' a 5km run following this, it's where the pain may flare. This is where your training history is key.
So, you've got a tendinopathy - rest?
This is where the 'overuse' classification has underserved this injury group. If it were overuse, rest would solve the issue. However, tendons require improvement in tolerance to load which we can achieve with activity modification and guided rehab - both directly to the injured area but also should be assessed by a healthcare professional to look further up the chain to determine what may have led to this in the first place and work together on preventing future episodes. Depending on the location of injury, how long it's been there and it's severity, will largely determine when you can return to sport. There's a period of negotiation with tendons where we'll work to keep it happy on balance with loading. Pain doesn't necessarily mean damage but will be indicating how irritable those tissues are - and how much or how little we can push loading. Some of the golden rules I give people to help guide their own load and recovery outside of the clinic room:
• Generally in lower limb tendinopathies I ideally want you to be able to walk with no pain before we load it at higher impact
• Pain levels need to not spike above 4/10 during the activity or rehab, the hour following activity or the next morning. For example - you return to a low dose of running, it remains at a 2/10 throughout and the following hour all stays pretty stable. But, if the next morning it spikes to a 6/10 then that indicates that the tissues are still too irritable to the load and we may need to scale things back
and the big one! ..
• Pain does not equal damage in tendinopathy. It shows us the sensitivity of structures and will serve as a guide to get you back to function! Language is hugely important here as leaving a message of 'overuse' suggests you can't use something that much, ever. But with the right amount of gradual loading, strength work and addressing predisposing factors (or the ones that are within our control!) - you'll be able to use it up to, and beyond the point of capacity that led to issues in the first place.
Emilie is an Osteopath, Strength and Conditioning coach and Sports Massage therapist at Balanced Osteopathy. She is our resident expert on cycling injuries and available for appointments on Mondays, Tuesdays, Wednesdays and Thursdays.
