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Tendons are very strong structures that attach muscle to bone. When a muscle shortens it excerts a force on the tendon which in turn pulls on the bone and movement is created. It may be usefull to think of tendons as ropes.

Tendon pain is often misdiagnosed as tendonitits or in other words inflamation of the tendon. A more appropriate diagnosis would normally be tendonosis, which is degeneration. Recent histological studies of patients with tendon pain have revealed that there is an absence of inflamitory cells, rather there is evidence of degeneration of the connective tissue. To be more precise patients with tendon pain have a disarrangement of collogen fibers and blood vessels, the collogen fibers are what give the tendon its strength. These fibers become less dense in number and are no longer arranged in the most stucturely appropriatre manner which results in a thicker tendon that over time becomes progressively weaker as well as becoming painfull.

The more traditional treatment of a cortisone injection can lead to further degeneration in the tendon putting it at inceasd risk of rupture. Osteopathic treatment of tendonosis starts with identifying what has caused the problem in the first place. For example for an athlete it may be due to incorrect footwear, or an increase in training too quickly, without allowing the body time to adapt.

An examination of the body as a whole is carried out to assess if there are any biomachanical abnormalites causing an excessive force being transmitted to the injured tendon. These may include restrictions both bony and muscluer or muscle weakness and poor muscle control. You may be asked to perfrom functional tests such as squats. These tests provide information on your ability to control your joints, limbs and axial skeleton. For example weak glute medius muscle (side of the hip) is often associated with hip drop along with the knee rolloing inwards during walking and running. Functional exercises can be prescribed to improve the strength and control of the outer hip. By learning to control unwanted movements your body is better able to distribute stresses.

Examples of muscular restriction elsewhere in the biomechanicl chain may include tight hip flexors or hamstrings. Either of these can effect the postion of the pelvis which in turn can effect walking/running gait. The osteopath will treat these tight muscles and will ofen provide advice on stretching them. Joint restriction may involve back vertibre that have become locked. For a tennis player with tennis elbow this may effect their ability to rotate the spine when hitting the ball. Releasing the restrictions in the spine can free up its movement. In turn the arm does not have to work so hard thus reducing the stresses placed on the elbow.

Often the adjoining muscles are stiff and have lost some of their elacticity. As muscles also act as shock abosorbers, releasing tension with some deep tissue massage helps the area to absorb and dissipate forces away from the injured tendon. If the area is not too painful, then some frictions of the tendon itself may be applied and possibly ultrasound of the area.

The research which is showing the most promising results in the treatment of tendonosis is what has been termed eccentric loading. In other words the patient is asked to perfrom exercises which put high loads through the injured tendon as the muscle is lengthened. Eccentric loading has been demonstreated to decrease pain, restore the cross sectional area of the tendon, increase the density of collogen fibers and restore the arrangement of both the collogen fibers and blood vessels. Eccentric loading of the offending tendon may be prescrbed to help rectify the local changes within the painfull tendon.

Patients will often also report improvement in performance due to more efficient movement. This holisitc approach addreassing all the various contributing factors to the injury aims to fix the underlying cause and not just the symptoms.

Barry McVeigh – Osteopath

References:

Kongsgaard M, Qvortrup k, Larsen J, Aagaard P, Doessing S, Hansen P Kjaer M, & Magnusson P, (2010) Fibril Morphology and Tendon Mechanical Properties in Patellar Tendinopathy: Effects of Heavy Slow Resistance Training. American Journal os Sports Medicine 38 (4): 749-756

Ohberg L, Lorentzon R & H Alfredson (2004) Eccentric Training in Patients with Chronic Achilles Tendinosis: Normalised Tendon Structure and Decreased Thickness at Follow Up. British Journal of Sports Medicine 38: 8-11

Rees J, Wilson A, & Wolman R (2006) Review: Current Concepts in the Management of Tendon Disorders. Rheumatology 45: 508-52