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What is Tendonitis (Tendinopathy)

Tendons are subject to many types of injuries.  These are called tendinopathies and are usually due to overuse but vary slightly in there nature depending on the part of the tendon affected. This may be related to age, body type, body weight, nutrition, poor training, excessinve heat or cold.

These types of injuries generally result in inflammation and degeneration or weakening of the tendons, which may eventually lead to tendon rupture.

     1.     Paratenonitis (or paratendonitis) refers to inflammation of the paratenon, or paratendinous sheet located between the tendon and its sheath.

     2.     Tendinosis refers to non-inflammatory injury to the tendon at the cellular level. The degradation is caused by damage to collagen, cells, and the vascular components of the tendon, and is known to lead to rupture.

     3.     Paratenonitis with tendinosis, in which combinations of paratenon inflammation and tendon degeneration are both present.

     4.     Tendinitis which refers to degeneration with inflammation of the tendon sinew.

How is Tendon Structured?

A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone[ and is capable of withstanding tension. Tendons are similar to ligaments and fascia as they are all made of collagen except that ligaments join one bone to another bone, and fascia connect muscles to other muscles. Tendons and muscles work together and can only exert a pulling force.

Tendon length varies in all major groups and from person to person. Tendon length is determined by genetic predisposition, and has not been shown to either increase or decrease in response to environment, unlike muscles which can be shortened by trauma, use imbalances and a lack of recovery and stretching. Tendon length is limits muscle size and potential muscle size. For example, should all other relevant biological factors be equal, a man with a shorter tendons and a longer biceps muscle will have greater potential for muscle mass than a man with a longer tendon and a shorter muscle. Successful bodybuilders will generally have shorter tendons. Conversely, in sports requiring athletes to excel in actions such as running or jumping, it is beneficial to have longer than average Achilles tendon and a shorter calf muscle.

Tendons have a small amount of elasticity, which gives them some ability to function as springs. This allows tendons to passively modulate forces during locomotion, providing additional stability with no active work. It also allows tendons to store and recover energy at high efficiency. For example, during a human stride, the Achilles tendon stretches as the ankle joint dorsiflexes. During the last portion of the stride, as the foot plantar-flexes (pointing the toes down), the stored elastic energy is released. Furthermore, because the tendon stretches, the muscle is able to function with less or even no change in length, allowing the muscle to generate greater force.

How does a damaged tendon heal?

The healing process of a tendinopathy begins with an inflammatory response which can last for three to five days. This is a crucial time during which rest and protection of the injured part is vital in order to prevent any further damage. During the inflammatory reaction the body produces chemicals and cells which remove dead tendon fibres and start the repair process. The repair process consists of three stages:

REGENERATION: New tendon fibres grow from special cells within the tendon.

FORMATION OF SCAR TISSUE: There is bleeding in the gap between the torn tendon fibre ends, and from this blood matrix, or scaffold, is formed to anchor the two ends together.

MATURATION OF THE SCAR TISSUE: The collagen fibres which make up the scar tissue become aligned along lines of external stress and are able to withstand more force


Acute tendinopathy: Follow R.I.C.E protocol. Stop the activity, rest in a comfortable position, preferably lying down and apply ice or a cold pack for 10 minutes every hour for 6 hours to reduce internal bruising to the tendon and its sheath.

An Ice Cup is the easiest way to reduce inflammation of the tendon. Freeze a polystyrene cup of water and then gently rub the affected area with the ice for 5 minutes several times a day.

The associated muscle may tend to spasm for the first two or three days after injury.  Warm compresses can help to ease the spasms. Avoid over-working the muscles for several days but do try to continue with as near to normal activities particularly walking to keep the muscle actively healing.

Massage will help to clear the inflammation form the musclotendinous unit and ease the tenderness but care must be taken not to further bruise the tendon or its sheath.

It is important to keep the region warm to relieve pain and muscle spasm, but preferably using clothing, a pad or pillow avoiding hot water bottles or similar as these tend to cause congestion of the area. Taping or bandaging with elastic cohesive bandages or using a muscle or joint support can help relieve pain and protect the muscle to allow more normal activity to continue.

Rest and, if needed, non-steroidal anti-inflammatory (NSAIDs) drugs e.g. paracetamol, aspirin or ibuprofen should help settle the problem in a week or two.

Mild to moderate tendinopathy: This is usually noticed the next day when there may be significant pain and stiffness on getting up in the morning. A warm shower or bath, especially with Epsom salts will help to ease the stiffness. See the Hydrotherapy page. Again refrain from the offending activity but do keep on the move. Seek advice as to whether to continue with ice or to use alternate hot and cold compresses.

The rehabilitation after this period involves gradually stretching the muscle to elongate the scar tissue and progressively increasing the muscle strength. Your osteopath will use massage and neuro-muscular techniques to improve drainage, blood flow and reduce spasm as well as addressing any causative factors such as local or remote stiffness or dysfunction using mobilisation and remedial exercises.

Protection and Prevention of Tendinopathies

The following measures may have the effect of reducing the chances of sustaining a muscle strain:

Warming up is thought to decrease tendon injuries because the musclo-tendinous unit is more extensible when the tissue temperature has been increased by one or two degrees. A good warm up should last several minutes - starting gently and finishing at full pace activity. Simply starting with lighter activities and building up gradually whether it be housework, gardening, moving building blocks, preparing for playing golf, dancing or practising match activities such as sprinting and passing for rugby. Do not stretch before exercising unless specifically instructed to do so.  There is a lot of recent evidence to show that stretching slightly irritates muscle and therefore leaves it more vulnerable to injury during exercise.

Recovery after training sessions and matches can be enhanced by performing a cool down, which is thought to help muscles get rid of waste products.

Careful stretching of muscles after use or exercise is important to re-order the musclo-tendinous unit and return to its normal length. Tired muscles tend to retain a memory of the repeated contractions they have undergone as part of the exercise or activity and stretching helps to correct this contraction. Tight muscles are also associated with increased risk of strains, and stretching is therefore practised to maintain muscle strength and prevent injury.

Do not overstretch the muscles (remember pain means damage!) - just take the stretch to the point of where you just feel it. Very slight discomfort only, not pain.  Active stretches are helpful if the muscle is very tight.  For these you hold the stretch and slightly contract the muscle at the same time.  Ask your osteopath or physio to teach you.

Maintaining good muscle strength and flexibility may help prevent muscle strains. Muscle strength allows you to carry out activities in a controlled manner and decreases the unco-ordinated movements which can lead to injury. Diet can have an effect on muscle injuries. For instance, it has been found that if a player’s diet is high in carbohydrate in the 48 hours before a match, there will be an adequate supply of the energy which is necessary for muscle contractions. However, if the muscles become short of fuel, fatigue can set in during training or matches. This fatigue can predispose a player to injury. Carbohydrate and fluids can be replenished during training and matches by taking regular sips of a sports drink. This applies to any physical activity.

Common Muscle Tendinopathies

Lateral or Medial Epicondylitis - tennis or Golfer’s Elbow

Achilles tendonitis or paratenoitis

Patella tendonitis

Runner’s Knee - Iliotibial band tendonitis

Repetitive Strain Injuries (RSI) of hand and wrist

Groin Strains - adductor tendonitis