Tendonitis Part 1- No Pain, No Gain?
Introduction
Tendonitis is one of the most common diagnoses that you hear about on a regular basis. It can pop up in the ankle (Achilles Tendonitis), the Knee (Patellar Tendonitis), the shoulder (Biceps Tendonitis, Rotator Cuff Tendonitis), and other places as well. If I were to guess, you’ve had at least two friends in the last year tell you about a “tendonitis” that they’re dealing with! Since these conditions are so common, and often so poorly treated, we’re going to do a series of blogs to spread some knowledge and some good news about tendon issues.
First, what IS Tendonitis??
Tendonitis is actually a subgroup of a larger classification of conditions called Tendinopathy. Let’s define some terms before we move forward.
Tendonitis refers to a flare up in tendon pain that was likely caused by a recent overuse of a tendon. Think about going on a 5-mile run when the farthest that you had gone before was 2 ½ . The tendon wasn’t prepared for double the stress, so it flared up. Often these issues resolve in a couple of days because the tendon calms down, heals up, and recovers quickly.
Tendinosis refers to a condition where you are experiencing pain in a tendon that has been present for a longer time. These are often issues where you can’t point to one particular thing that caused it to flare up. It is much more common for people to seek care for this type of issue, because the pain sticks around for long enough for people to want to get it taken care of.
Tendinopathy is the umbrella term for both of these issues, and others, because it refers to any type of painful tendon issue.
Is Tendinopathy a “No Pain, No Gain” Kind of Thing?
As with most things in life the answer is “it depends”. Ugghhhhh. But, fortunately, in the majority of cases, pushing into a certain level of pain is very acceptable with tendinopathy, and even beneficial to stimulate recovery!
Tendonitis:
Let’s first dive into pain with tendonitis. Remember, with tendonitis you have done something and soon after felt a flare up in pain. If that’s the type of tendon pain you’re dealing with, then we always recommend keeping that tendon gently moving. An example could be going on a long run and developing pain in your Achilles tendon the evening or morning after that run. In this case, it’s best to try to walk and move around as you normally would, as long as the pain stays below a 2 or 3 on a 0-10 scale (10 being the worst pain you could imagine). If you hate 0-10 scales like almost all of my patients do, just keep the pain to what you consider a “mild” level. This allows the tendon to continue to get plenty of blood flow, prevents atrophy and stiffness, and allows the tendon to go about the normal process of healing itself.
You should NOT, if at all possible, stop moving that tendon completely, because that’s when we see tendons that develop extreme intolerance to any stress being put through them. Even if the pain is bad enough where you have to use a brace or boot to walk, you should still be moving your ankle around consistently throughout the day and putting some weight through it in a controlled fashion. Often, if you can keep that tendon moving for a few days without pushing it into higher levels of pain, it will calm down and you’ll be able to go about getting back to running (shorter runs) within 1-3 weeks!
Tendinosis:
Now, let’s talk about the other, more chronic tendinopathies, a.k.a. tendinosis. Remember, these are tendon pains that you’ve been dealing with for a long while, and it’s hard to point to exactly what caused it to start. For these conditions we actually have some good research that tells us that pushing into pain (to a certain extent) does NOT hinder your recovery!
Way back in 2007, some researchers looked at people with Achilles Tendinopathy (pain in the tendon that attaches at the back of the heel), and they had half of the group continue doing whatever physical activity that they wanted to do, as long as their pain didn’t go beyond a 5 on that 0-10 scale mentioned above. The other half had to rest for 6 weeks, not doing any of the physical activities that were causing them pain. Each group received physical therapy treatment for the duration of the study.
What did they find? The group that kept doing their physical activities recovered at the same rate as the group that rested for 6 weeks!
This was an indicator that we don’t have to completely eliminate pain to recover from tendinopathy. In fact, it’s useful to avoid complete rest, because continuing activity (if it’s not overly painful) will help to keep up your fitness, strength, and general quality of life! This “pain-monitoring” model, where we’re ok with pain that’s 5 or below, has been used in lots of studies since 2007 to determine how much activity someone is appropriate for someone with tendinopathy, and it seems to be the best “rule of thumb” we currently have for how much pain to allow while rehabbing tendinopathies. The other guideline that is helpful in these cases is to try to avoid activities that flare up pain that lingers into the next day. If you’re just a bit sore for the remainder of the day, that’s fine, but if it lasts through the night and into the morning that can be a sign that you pushed the tendon too much.
Conclusion:
So, what’s the bottom line here? No pain, no gain?? Not quite, but mild to moderate pain isn’t a sign of damage in these conditions, so as long as you’re acting within the guidelines above, you can feel comfortable to keep moving. No pain, no gain could be changed to: “Just some pain? Continue to train.”
In the next couple of blogs in this series we will dive into some “work-arounds” to keep you training towards your goal while you’re rehabbing a tendon issue, and then some basic principles to apply when progressing rehab exercises to actually solve the problem of tendinopathy. Stay tuned!
References Mentioned:
Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35(6):897-906.
