In Part one, we discussed the 1st stage of tendon injury and what happens when we overload a tendon. What we failed to mention is that with the relative rest the tendon can FULLY recover. Great news.
So, what happens when we fail to test and ‘de-load’ the tendon of the aggravating factors.
In phase 1 we talked of how there is change within the cell of the tendon and how inflammation is absent. When we enter phase 2 the same things occur in the cell but at a higher rate. This causes separation of the collagen fibres in the tendon; which are rather like steel beams providing strength and resilience. So, if the increased proteins being produced causes disruption, you can appreciate when more proteins are produced, how further disorganisation occurs. It all comes down to the attempt to repair but failure due to lack of rest. Which causes further proteins to be produced etc. It’s rather cyclical …. but only to a point.
When we image a tendon in phase 2 it is much easier to see these changes. You can also see increased vascularity (AKA blood supply) and with blood vessels come nerves (or as we call it neural ingrowth). Again, the body’s attempt to heal and repair.
The difficulty of phase 2 is that it is harder to differentiate between elements of phase 1 and 2 – as they really are so similar. So, imaging really is the gold standard. MRI or Ultrasound. Good case history taking will also help.
In a nutshell it’s the frequent overloading during phase 1 with little or no rest.
Age concern.
In the old patient it has been shown to be much more likely that without rest that a patient will enter phase 2. Flexibility reduces in our tendons as we age and with that so does the rate at which they can adapt.
We can still return to relatively normal and improve the tendons strength from phase 2 but the appropriate modified load is essential. As is the athlete’s nemesis; rest. Fear not though – it may just be doing something you do already, with less force or weight, intensity or frequency. It really doesn’t mean lying in with your tendon in plaster.
However, should nothing be done. Be prepared to enter phase 3 where things start to get trickier.
More of that to come shortly.
References:
- Maffulli N, Sharma P, Luscombe KL. Achilles tendinopathy: aetiology and management. Journal of The Royal Society of medicine 2004;97:472–476
- Khan K 2007. New Laboratory Insights into the pathogenesis in tendinopathy
- Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine 2009;43:409–416