The Tendinopathy Continuum
Tendinopathy - what is it?
Incorrect loading (a sharp increase in training frequency, intensity and/or duration without appropriate time between loading sessions for adaptation to take place) results in the development of lower limb tendinopathy (“achilles tendinitis”, “jumper’s knee” etc).
This typically presents in athletes as;
pain at the start of the warm up which recedes once “warmed up”, only to return post exercise.
pain the following morning after intense exercise
tenderness when pressing on the tendon
+/- a thickened tendon (not to be mistaken for swelling)
+/- one or multiple nodules along the tendon
“Tendinitis” is often used incorrectly to describe tendinopathy due to the outdated belief that a traditional inflammatory response contributes to tendon damage. Tendons affected by tendinosis display a range of non-inflammatory abnormalities at a macroscopic level where the collagen fibres are “disorganised”.
Tendons can be thought of as rubbers/erasers. A normal rubber (tendon) will bounce rapidly off the floor when dropped from a height. However, imagine if you collected all the rubber shavings that come off when you erase something and bind them together in sellotape. This represents a tendon experiencing tendinopathy. Try to drop them from the same height and that tendon won’t bounce back at the same speed or height as the normal eraser despite weighing the same.
So, what’s the go with this tendinopathy continuum?
The Tendinopathy continuum is a proposal by tendon authorities Jill Cook and Craig Purdam to describe the way tendons are constantly remodelling and their “health” can range from ‘normal’ to ‘reactive’ to ‘dysrepair’ to ‘degenerative’ and anywhere in between. This highlights the importance of treatment to move your tendon ‘backwards’ along on the continuum and reverse the effects of incorrect loading.
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References:
Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. British Journal of Sports Medicine 2014;48:506-509.
Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009 Jun;43(6):409-16. doi: 10.1136/bjsm.2008.051193. Epub 2008 Sep 23. PMID: 18812414.
Cook JL, Rio E, Purdam CR, et al. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British Journal of Sports Medicine 2016;50:1187-1191.
Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013 Apr;43(4):267-86. doi: 10.1007/s40279-013-0019-z. PMID: 23494258.
Malliaras P, Cook J, Purdam C, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. J Orthop Sports Phys Ther. 2015 Nov;45(11):887-98. doi: 10.2519/jospt.2015.5987. Epub 2015 Sep 21. PMID: 26390269.
Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther. 2018 May;48(5):A1-A38. doi: 10.2519/jospt.2018.0302. PMID: 29712543.
Scott A, Docking S, Vicenzino B, et alSports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012British Journal of Sports Medicine 2013;47:536-544.