By Alex Earl, DC DACRB DNSP
This week on the Health Restoration Blog, we are highlighting an important clinical presentation – tendon rehab.. We wanted to provide helpful information regarding one of the most challenging injuries to manage in physical therapy, physical medicine, strength training and overall longevity.
(If you missed last week’s article on ACL Injuries in Soccer you can read it here)
Today’s article focuses primarily on how Dr. Alex Earl uses important (and effective) principles to overcome nagging tendon aches and pains that the traditional medical system is not sufficient at resolving. The reason for this is quite simple, the mainstream medical system is great at prescribing pain meds and anti-inflammatories targeting the symptoms of tendon rehab while we focus on identifying and rectifying the ROOT PROBLEM of tendon rehab.
How can I rehab my tendons?
Tendon rehab can be a daunting journey, often presenting a formidable challenge to those seeking recovery from tendon injuries. Unlike muscles, which boast robust blood supplies aiding in their regeneration, tendons possess a comparatively limited blood flow, rendering them slower to heal and more prone to re-injury.
This inherent characteristic, coupled with the intricate design of tendons for resilience rather than rapid repair, underscores the complexities involved in achieving full recovery. As one of the most frequently asked questions in our chiropractic and rehab practice in Carol Stream, Illinois, the quest to rehab tendons prompts individuals to explore diverse avenues, from conventional treatments to emerging therapies, in pursuit of restoration and renewed function of very painful tendon injuries.
What are the 4 Stages of Tendon Rehab and Healing?
The four stages of tendon healing are inflammation, proliferation, remodeling, and maturation.
- Inflammation: This initial stage begins immediately after injury and involves the body’s natural response to tissue damage. Inflammation helps to clear debris, control bleeding, and initiate the healing process by attracting specialized cells to the injured site.
- Proliferation: During this stage, which typically lasts for several weeks, the body starts to rebuild the damaged tissue. Fibroblasts, specialized cells responsible for producing collagen, migrate to the injury site and begin depositing new collagen fibers to strengthen the tendon.
- Remodeling: In this phase, which can last for several months, the newly formed collagen fibers undergo reorganization to improve their strength and alignment. The tendon gradually gains strength and becomes more resilient to stress.
- Maturation: The final stage involves the ongoing remodeling and maturation of the tendon tissue, which continues for months to years after the injury. During this phase, the tendon continues to adapt to functional demands, achieving optimal strength and flexibility.
Understanding these stages of tendon rehab and healing is crucial for designing effective rehabilitation programs and managing expectations during the recovery process.
In fact, understanding these important phases of recovery is one of the most important bits of education we deliver to our patients with tendon pain. More on that below…
What are the 10 Dos and Don’ts of Tendon Rehab?
The 5 Do’s:
Do #1: Set realistic timelines.
The reason it is important to understand the phases of recovery is that it provides for us (and the patient) a clear, direct path towards recovery with an expected timeline for all tendon rehab:
- Most tendinitis cases will resolve in 3-6 weeks.
- Most tendinopathy cases will resolve in 6-12 weeks.
- Most tendon tears will recover in 6-12 months.
In our chiropractic and physical medicine clinic in Carol Stream, Illinois, we specialize in this rehabilitation timeline, among other things. In our opinion, most rehab chiropractors undertreat complex tendon injuries and leave patient’s frustrated when the issue comes back.
By understanding proper tissue healing time frames, we can better educate patients on the road ahead without feeling like we let down patients if and when the patient returns. Oftentimes, the pain does return, but in our experience, it does not come back nearly as severe as it did in the beginning..
Do #2: Progressively load the tendon.
Tendons LOVE load. Tendon rehab must include loading strategies.
According to researcher, Seth O’Neil, tendinopathy is known as a failed healing response to loading.
Therefore, to change the tendon’s loading response, we must strengthen it through progressive overload. To progressively (but not excessively) overload a tendon, we need to consider how to manipulate the load.
The 3 key variables are:
- Intensity
- Volume
- Frequency
As tendon rehab progresses, we must continue to load it to cope with greater demands. As proposed by Dr Seth O’Neill, to progressively overload a tendon effectively, the rehab pathway should look something like this:
Do #3: Use isometrics BEFORE exercise.
Next up, is isometrics. Isometrics are simply drills in which you hold a given position and keep a muscle and tendon at a specific length. They used to be the go-to move for tendon rehab. I mean, I even utilized isometrics as a kid with Sever’s Disease as a kid and Osgood-Schlatter’s Disease and as a teen.
But here’s the scoop: recent research has thrown a bit of a curveball. Turns out, isometrics as a part of your tendon rehab plan are like that friend who’s sometimes there for you and sometimes not – they might give you a quick breather from the pain, but there’s a catch. You gotta crank them up to at least 80% of your max muscle power to really feel the benefit. Problem is, a lot of folks end up slacking on the intensity, which kinda defeats the purpose.
Now, don’t get me wrong – isometrics aren’t a magic fix for everyone. But hey, they’re worth a shot. Even at that 80% mark, they’re super gentle on your body, and if they give you even a little relief, it’s a win in my book.
Here’s the game plan: toss some isometrics into your “prehab” routine. The research says go for 5 sets of 45 seconds each with a 2-minute break in between – but between you and me, knocking out 3 sets can do the trick too, saving you some time without skimping on the pain relief. It’s a smart move for those moments when the pain’s acting up during your rehab sessions. Plus, it helps keep your tendons on their toes as you work toward full recovery.
Pro Tip: Isometrics are like that unpredictable friend – they might help, they might not.
Do #4: Compress the tendon (LATE stages see below)
Since nearly all human movements involve compression of tendons, it would NOT be wise to simply avoid compressing tendons for the rest of your life.
Therefore, it’s important to begin mild compression strategies in the third stage of care for a severe tendon rehab process.
Bounding and plyometrics are contraindicated early on, but bunny hopes and light jump ropes would be a wise final stage of your tendon rehab journey.
After all, if you plan on jumping again in your sport, then you should have done so already in your tendon rehab plan, right?
You’d hate to be the guy who spends 8+ months recovering from an injury sustained by jumping, only to never jump in rehab, only to then get injured on on your first play back when you jumped for the first time in a loooong time.
Pro Tip: In the latter stages of your tendon rehab plan, begin light compression exercises and drills under medical supervision.
Do #5: “Movement Snacks” throughout the day.
This is a relatively newer concept to most. “Movement Snacks” as coined by my colleague and friend, Chris Johnson, is the idea of breaking up smaller movements throughout the day before bigger movements take place, like in a workout.
Since a snack is a very small meal in between big meals that helps satisfy your hunger – a movement snack is similar — a very small amount of movement to give your body a break from extended periods of inactivity.
The concept of movement snacks is all about tackling the drawbacks of inactivity, especially during those long stretches of sitting. It’s like hitting pause on muscle stiffness, boosting circulation, revving up your energy levels, and getting your productivity back on track.
Pro Tip: Set a timer on your phone for 25 minutes (Pomodoro Technique). When the timer goes off, get up and walk around for 5 minutes before starting the timer again. Repeat throughout your workday!
The 5 Don’ts:
-
Don’t completely rest.
Rest is not always best for tendon rehab. In fact, I would argue that absolute rest is not a wise strategy at all.
Rest might seem like the go-to solution when dealing with tendon issues, but it’s not always the best approach – especially with tendinopathies. So, the first thing we gotta figure out is whether our patient is getting too much or too little action. Here’s the deal: we need to ask ourselves a couple of questions to set up our game plan:
Can we start loading them up right away?
or
Do they need a bit of a break?
(Please Note: we’re talking about relative rest here, not locking them away in a bubble. Relative rest is where it’s at for speeding up that tendon healing process, trust me.)
Usually, when patients come in complaining about tendon pain, it’s right smack in the middle of a flare-up. That’s when dialing down the load is key, at least in the beginning. But here’s the kicker: we can’t just hit pause on all activity for ages; that’s like hitting the snooze button on your tendon’s recovery (not cool).
The aim is to ease off enough to calm things down during the flare-up, then gradually get back into the swing of things with some carefully dosed exposure. This way, the tendon gets a chance to toughen up and bounce back.
Just remember this nugget: Rest might give you a short break, but it’s not the ticket to long-term tendon health.
-
Don’t let pain guide you.
Pain is a terrible guide. It’s not wise to ignore pain, but it is terribly unwise to be guided by it.
The reason for this is that tissue damage does not always equal the severity of pain. That is especially the case in tendon rehab.
Alright, here’s the lowdown: steering clear of pain altogether isn’t the name of the game when it comes to getting those tendons back in action. If we dodge pain like it’s the plague, we might end up babying our tendons too much, which can throw a wrench in the whole healing process, delaying our ticket to full recovery.
That’s where the Pain (and activity) Modification Scale swoops in like a superhero. It’s a nifty visual aid we often whip out in the clinic to give our clients the inside scoop on what kind of pain is A-OK and what’s a red flag. Trust me, it’s a game-changer when it comes to understanding the do’s and don’ts of tendon rehab.
-
Don’t compress the tendon (early stages!)
Alright, let’s break it down in simple terms. Picture this: Healthy tendons are like sturdy ropes, not stretchy rubber bands. When we go overboard with the stretching, we’re basically messing with their job description – which is to handle all those forces like a boss. Now, here’s the kicker: cranky tendons? They’re not fans of getting squished or compressed So, it’s all about avoiding those positions that put too much stretch or pressure on the tendon.
So, ask yourself this:
Where does the tendon feel the stretch and the squeeze?
Take the Achilles tendon, for instance. It gets a stretch when we flex our foot upward, and it can feel the squeeze from those high-top shoes digging into the back of our calf. And guess what? No rubbing or massaging those irritated tendons either – direct pressure is a big no-no to tick off a sensitive tendon.
Just remember: Tendons are not fans of getting compressed or squished.
-
Don’t rely on one method of recovery.
This one is a pet peeve of mine. Too many providers focus all their treatment strategies on just one intervention, when in reality, a complete tendon rehab process takes a multitude of strategies!
You know the provider who is set in his ways and won’t deviate from the facts in front of him??
He’s the type who thinks that one exercise done a million times will heal that tendon (one day).
He’s the type who thinks that passive modalities, such as laser or electric stim and ice will be the key to the healing process in that tendon rehab.
The truth is that proper and complete tendon rehab will take exercise, stretching, loading, soft tissue, needling, shockwave, and BFR.
-
Don’t forget the 24 hour Rule with tendons.
One of my favorite clinical pearls to share with patients is the “24 Hour Rule”. This rule states that it is best to examine your workout after 24 hours.
The reason for this rule is because many people experience discomfort during the workout, immediately after the workout or (in rare cases) the next day.
In tendon rehab, we are not afraid of mild discomfort during a workout, after all Tendons Need Time (TNT) to warm up!
In tendon rehab, we are not afraid of mild discomfort after a workout, after all we are making changes and adaptations to the tendon so it would make sense for there to be some changes felt.
The area where we get worried about overdoing it a bit in a workout, is when there is noticeable tenderness and discomfort greater than 24 hours after a workout.
Do this next!
- Share this Article with a Friend or Family member who has been dealing with a tendon rehab journey. Rest just won’t cut it!
- Text “TENDON” to our office at (630) 765-0575. We will schedule a Complimentary Tendon Rehab Discovery Call as quickly as possible.
- Keep an eye out for next week’s article!
Alex Earl
Latest posts by Alex Earl (see all)
- A Expert Functional Rehab Chiropractor’s Response to Andrew Huberman Back Pain Podcast Episode - May 9, 2024
- 10 Do’s and Don’ts of Tendon Rehab - April 27, 2024
- 6 Epic Myths about ACL Injuries in Soccer - April 25, 2024
