What is a tendinopathy? Understanding the basics

: this first episode, what is tendinopathy? Understanding the basics. Welcome to the podcast helping you overcome your proximal hamstring tendinopathy. This podcast is designed to help you understand this condition, learn the most effective evidence-based treatments and of course, bust the widespread misconceptions. My name is Brodie Sharp. I'm an online physiotherapist, recreational athlete. creator of the Run Smarter series and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. So let's give you the right knowledge along with practical takeaways in today's lesson. Episode 1 and the topic is what is tendinopathy. It sounds reasonable that will be our first episode. We're just doing the basics and understanding what is this pathology before we move on to something a bit more technical. But this episode, the majority of this episode will be from my past podcast, the Run Smarter podcast, and more specifically during my talking tendons series that I put in there. So I've got to snip it from that episode and put it into today's episode rather than me recording it all over again. to just repurpose it and then at the end chime in and talk about how this directly applies to you and what else we might need to consider when it comes to proximal hamstring tendinopathy specifically. While you will be listening to this past recording, within that recording, I do mention things to do with season one, which would be how to adapt and stress less is one of my topics. And we will eventually get there. We will talk about certain portions of season one within that podcast, but I have decided to reorder things and restructure things so that today this will be episode one. And I'll just be a little bit more free flowing and get you to understand the concepts, understand different topics in the right order so that it's better for you. So today we're gonna talk about things like the pathology. Well, first of all, we'll talk about the definition of tendinopathy, tendinitis, tendinosis, all that sort of thing, and go through the pathology continuum. We're going to talk about different types of tendinopathy around the body. Um, why do people get a tendinopathy, um, mainly due to like spikes in loading, compression, lack of recovery, we're going to delve into all these things and finish off with some risk factors. And so we're going to listen to that recording now we're going to dive in and then I'll chime in later on. Why have I decided to discuss tendons? Well, it is a very common condition. and applies to several different body parts. And if we learn these key principles when it comes to tendinopathy, the same principles can apply to any tendinopathy you have throughout the lower limb. And I also have booked in Peter Maliaris to be interviewed next week. I understand that some of my interviews don't go according to plan, like last minute, sometimes it changes, sometimes we are busy or our schedules change and it might not be recorded when planned, but I'm crossing my fingers and hopefully that schedule stays there. That way I can bring out these talking tendons 1, 2 and 3 and then we can interview Peter Maliaris for talking tendons number 4 and it'll all come together really nicely. So that's the reason why I started this mini-series and I wanted to first... discuss terminology and there's a couple of different terminologies that are thrown around out there in the running world and that being tendinitis, tendinosis and tendinopathy. And so a tendinopathy, like if you were to look it up on Google, it says it's a disorder that results in pain, swelling and impaired function of the tendon. Tendinosis, on the other hand, describes a bit more of a chronic condition, and it's when there's a bit of degeneration in that matrix in the structure of the tendon. So if a inflamed, impaired, irritated tendon has that condition for a long period of time, the actual cellular matrix and the structure of that tendon can start breaking down. So that's tendinosis. tendinitis, which is a bit more of a obsolete term. Like, itis usually means inflammation, and it's debatable whether most of these tendons that are reactive actually have inflammation presenting there. There's some literature that say there is a little bit, others saying there is none. So it's up for debate, but the term tendinopathy is most commonly used in physiotherapy. today and so that's what we're mainly going to be using moving forward. Jill Cook and Ebony Rio have this tendonopathy or tendon structure continuum and it's kind of like a model where you have certain conditions or certain levels of irritation that the tendon goes through throughout its life cycle if it is undergoing a reaction or if it is overloaded and if you can imagine this continuum starting with a healthy tendon where there's no function impairment and if you're running at a comfortable dosage and all the tendons are happy, you then have a healthy tendon. If you overload that with excessive load, it then becomes a reactive tendon and so this heads down the continuum. So it goes from a normal tendon to a reactive tendon where it becomes painful. further down the continuum you have disrepair which is kind of like this tipping point. Are you going to start recovering that tendon or is it going to move further down that continuum to a degenerative stage? Now the degeneration signifies structured damage and signifies irreversible or very hard to reverse the condition and the health of that tendon. So the further you go down this continuum the more permanent the effects are you could say. The nice thing is if you head down this continuum and you start to have this reactive and even disrepair phase with the right management and loading it adequately you can reverse all of to a healthy tendon. It can revert back to a healthy tendon if it's taken care of. If it heads down to that degeneration phase, yes, there are certain parts of the tendon that are irreversible, that structure damage has occurred, but that's not to say it can start to become a pain-free, fully functioning tendon. What you're doing in that rehab is you are strengthening and building up the function. of the healthy parts of that tendon. So if it goes into that degenerative phase, only a certain part of that tendon becomes degenerative. You still have a healthy bulk of that tendon that can still be healthy and can still be really, really strong and resilient. We're almost bypassing all that degenerative part of the tendon and utilizing that healthy part as much as we can, building it up. And as you build that up, you can return to a pain-free, fully functioning tendon. I hope that makes sense. The analogy some people like to use is like a donut. You have the hole within the donut, which can be the degenerative part of the tendon, and then you have around the hole of that donut is the healthy part of the tendon. So we wanna treat the donut, not treat the hole. That is a common analogy by, really don't like people envisioning like they have a hole in their tendon. just my personal preference. If you do have that degenerative phase, yes, you can return back to fully functioning, pain-free, like I said. However, it does leave you more prone to a tendinopathy in the future, if it's not looked after really, really well. So I hope that makes sense. Let's move on to some common sites of a tendinopathy for runners. The first one we have is your Achilles. and that can be broken into a mid-portion Achilles or a insertional Achilles problem. We'll discuss that a little bit down the track. You also have your patellar tendinopathy, which is just under the kneecap. Not very common in runners, unless you're doing a lot of like, heel sprints or a lot of speed work, or if your patellar tendon's quite weak to start with. Patellar tendinopathy is a lot more common in, say, jumpers, like a... volleyball player or a basketballer. We also have a gluteus tendinopathy which is on the outside of the hip, can be quite common, especially later in age, especially for females, they seem to be more prone. And then we have a high hamstring strain, or a high hamstring tendinopathy, which is also quite common, particularly for someone who's developing a lot of speed and a lot of heel work. Some less common tendinopathies that I can think of would be, say, a tibialis posterior, which is on the inside of the ankle, just as that ankle bone, just behind that ankle bone. Your psoas, which is like deep in your hip. and your pes anserinus which is not really common. I have it while I've had it in the past which is unfortunate but it is more the inside of your knee. So those are some common areas and in talking tendons 3 I'm going to be breaking down some specific conditions and how you would go managing and treating what some of the most common areas but for today's episode Tendonopathy 101 I thought I'd just break down some real key concepts that apply to any tendinopathy. This podcast is sponsored by the Run Smarter series. If you want to take your knowledge building to the next level, I have built out a proximal hamstring tendinopathy video course which complements the podcast perfectly. Sometimes it's tough delivering concepts and exercises through an audio format, so the course brings a visual component full of rehab exercise examples, graphs and visual displays to enhance your understanding. Even if you sign up now, you'll have access to all current and future modules that I create. Sign up through my link in the show notes, then download the Run Smarter app, and you'll instantly have unlimited access to all the course resources on any device. And to say thanks for being a podcast listener, I want to give you a VIP offer. There will be a link in the show notes in every episode that will provide you 50% off the course price. Just click on the link and it will automatically apply your 50% discount. So the first thing I want to discuss is, why do we get a tendinopathy? Why do these tendons undergo a reaction, become sore, and if you've learnt anything from previous lessons, you might think, okay, one would be an overload. If we've discussed our adaptation zone in the past, it is when we have exceeded our adaptation load. So that's the first thing I've wrote down. In this, why do we get tendinopathies? I've got three points. The first one being overload. And fits right in with our adaptation model that we've discussed in season one and throughout. If you exceed that capacity, the tendon's gonna undergo a reaction. And this overload can be in regards to one session. Say if you do sprint work, but also do hills on the same day, the those two factors combined can put, like say the Achilles tendon at a significant overload and puts it at risk of undergoing a reaction. So it can be overloaded in one session, but it can also slowly be overloaded over a week or several weeks. And so that's when planning your training structure is really important. So you might go from training three days a week with one or two days recovery in between. The following week do three consecutive days. Maybe you've changed your weekly structure, maybe your work hours have changed, maybe you're on holidays and you've got time to do all these things. So if your routine changes to training on three consecutive days, that might not be enough time for that tendon to recover and it's gonna undergo a reaction over that week. Like I said, for the Achilles, some common training errors would be doing hills or doing a lot of speed work. If you have, if we can consider the patellar tendon, it is jumping usually that gets it. So if you're at the gym and doing say box jumps or if you're doing split lunges or some plyometrics that sort of thing and a hamstring would be a threat again if you do a lot of speed work or if you're running downhill. Really the faster you go the more and more your hamstrings need to kick in. Hamstring tendons can't tolerate that spade. you're putting at risk of undergoing a reaction. So that's the first step of why we get tendinopathy. The second one I want to talk about is compression. So if you can imagine as these tendons attach onto the bone, that's what makes it a tendon. A tendon is the muscle, the muscle belly. As you move down that muscle, it becomes a tendon. As it becomes a tendon, it attaches onto the bone. So it's that anchor point for the muscle. And if you can imagine most of these tendons, as they attach onto the bone, they kind of wrap around a bony prominence that's on the bone. And it's that wrapping around of the bone that can cause compression if that tendon is put under load. I hope that makes sense. And a lot of the emerging evidence over the last 10 years now is that putting that tendon under compression, either for a sustained period of time or during. bouts of heavy load puts it at more risk of developing these tendinopathies. An example of what might cause a compression, your high hamstring strains and your high hamstring tendinopathies, that tendon actually attaches onto your sitting bone and if you follow your hamstring all the way up the back of your leg, you can, if you're sitting down, you can appreciate the weight that your body is putting on your sitting bones. your tendon actually wraps around your sitting bone and attaches just onto that sitting bone. So as you sit, if you're sitting on a firm chair or on the floor, the more weight you put on those sitting bones, the more it's actually creating compression for that tendon. A similar thing can be said for your Achilles, if you have an insertional Achilles tendinopathy and you're putting your foot in a lot of dorsiflexion, dorsiflexion being when you point your toes up. that can lead the tendon to undergo more compression. So if you say change your running shoes and your stack height or the height of your heel was say 10 mil and it's now changed to a zero heel drop, so zero mil, it's putting your ankle into more of a dorsiflexion and putting that Achilles into more compression. We'll talk about this concept in terms of management a little bit further down the track, we're not only just talking about your training overloads, we're talking about compression throughout the day as well. So things like the type of shoes you wear, if you're crossing your legs, if you're sitting for long periods of time, if that tendon is stirred up, it's these daily positions and daily tasks that you do that undergoes a bit more compression, can significantly influence your management and your recovery moving forward. The third point I wanted to discuss about why we get these tendinopathies is, basically lack of recovery and reducing the tolerance, the ability for your tendons to tolerate load. And I've discussed this before, and I've discussed this in the stress less episode back in season one. There are certain factors throughout your life that can influence your tendons ability to tolerate load and essentially recover. And these things being sleep, being diet, being stress, even some like supplements and vitamins. I know there's research to say that vitamin C could be a major contributor to the prevention of tendinopathy and promote tendon healing due to its role as like an antioxidant. While vitamin D has been shown to increase collagen structure. So it helps build up that tendon structure. And there's also... Lysine which is an amino acid that plays a major role in collagen synthesis. So all of these vitamins and minerals can actually influence your tendons ability to recover So we want to recap. Why do we get these? One, it's the overload. Hopefully you know a lot about this overload concept From past episodes. Two being the compression. This is kind of a new concept that I've added in haven't really talked about this much But we'll talk about it further down the track and three being the lack of recovery and reducing the load tolerance. These three factors play a huge amount, a huge like significance in why we get tendon pain and contribute to the management and recovery of these tendons. I thought I'd also mention some risk factors for tendinopathies. So there's some research out there, I just had a look at a couple of things and these common factors being one is your age. Usually if you're more advanced in age you could say you're more likely to sustain a tendinopathy and that being just your tendons become less rigid and less able to recoil and respond well to high loads. The other being your BMI which is just pretty much how heavy you are compared to your body type. If you can imagine when you are running, if 6 to 8 times your body weight is going through your Achilles every step you run, the heavier you are, the more tendon load goes through that tendon. Even just as much as putting on 5 extra kilos can be so, so significant when you times that by your body weight. and times it by 6 to 8 times. That's a huge jump. And then if you do that every single step you can see that the accumulative load will put the tendon at threat of exceeding that load capacity. The other being high cholesterol and hypertension seems to be a risk factor for tetanopathies. Diabetes, taking some medication, I know antibiotics and non-steroidal anti-inflammation drugs and statins like all of those seem to be linked with tendinopathies. I know long-term NSAIDs, anti-inflammation tablets, taken over a long period of time can compromise those tendons' ability to tolerate load. Hormonal changes, women approaching menopause can seem to, or seem to have a risk factor for this. And these can usually be flagged if, say, you have bilateral tendinopathy, say if you have Achilles tendinopathy on both sides. We might start to look at things like diabetes and the, if you're taking any medications and if you are going under any hormonal changes, because it does raise a few flags if you are getting it on both sides. Like I discussed in season one, I just want to relay this message as well. we're not heavily relying on biomechanics when you're running. We used to believe that like there's a lot of bowing of tendons and if they're not well aligned, it can be a threat to the tendons, but it's less of an importance now. We're now knowing that there's not a lot of relevance and there's not a lot of links between poor biomechanics and developing these tendinopathies. There are a small percentage of runners who may benefit from gate retraining and altered biomechanics to offload certain tendons in certain conditions, but keep in mind that the three points we discussed before, that load compression and those factors that influence the recovery to tolerate load, far outweigh the significance compared to biomechanics. In my experience, I have had patellar tendinopathy in the past and purely from a lack of pre-season training. I was playing basketball, I was playing quite high level basketball and during the off-season didn't really do much and then got straight back into tryouts and pre-season training which is really hard work. They grind you to the ground because that's when you need to improve on your fitness a lot. and then throughout the season, so all just skills and drills and plays and that sort of stuff. And so my tendon couldn't handle it. I had a sudden spike after having a couple of months off of doing hardly anything, going into these hard sessions and looking back on it now, it was an obvious overload. And yeah, I was struggling with that tendinopathy for most of that season. I was also very unlucky as I discussed at the start of the episode to have a persistent Hesanserina's tendinopathy. It still comes and goes here and there, but as long as I manage my load very carefully and plan it all out, it seems to stay away. I've also, in the past, had a high hamstring tendinopathy doing my first season of triathlons. I was going from running a marathon, so really high mileage, but kind of slow. to then trying a triathlon which is a lot shorter, so a lot faster, you're incorporating a lot of sprints, but it's also the combination of going really hard on the bike and then getting off and trying to run as fast as you can for 4-10kms. So it's those, that's speed work, even though my body was tolerating a marathon distance really well, it's still introducing that speed work was enough for my hamstring to undergo that tendon reaction. So we're bringing this episode to a close, let me just do a little bit of a recap. So tendonitis, the terminology, we're not using that so much anymore so we can take that out of our vocabulary and put in this tendinopathy and use this tendon structure continuum. So we have that reactive tendon that goes to disrepair and then degenerative. you can restore the healthy parts of that degenerative tendon to fully restore. But if you catch it before it gets into that degenerative stage and work its way back up that reactive phase to a normal healthy tendon is obviously a lot better for you. We have those three components of why we get a tendinopathy, that being overload, so training errors, doing too much too soon, too fast. change in shoes, change in terrain, all those factors. The second being compression. So depending on the tendon, it could be things like sitting, crossing legs, changing your shoes, sleeping on say your hip and compressing that tendon, all those sort of things throughout the day. And then the third being that lack of recovery, that reduced ability to tolerate load and being all the factors such as poor sleep, poor diet, increases amount of stress. and a couple of those vitamins and minerals that I was talking about. And as another takeaway, we're not heavily relying on biomechanics as a cause of your tendinopathy. It can be a part, it can be 10%, and some gait retraining can be really beneficial for a small percentage of people, but the points and discussions talked about before account for every tendon and is... 80 to 90 percent of what you need to focus on when it comes to a tendinopathy. Okay, how does this recording apply to proximal hair string tendinopathy specifically? First of all, I want to touch on the talk about tendon degeneration and the longer you've had it for the more irreversible damage, I guess you could say is done. I know this sparks a lot of fear and anxiety when it comes to chronic tendinopathies. but I can reassure you that there will be plenty of the healthy tendon portion that we can start building on structure and start rehabbing the healthy portions of the tendon. We can get you to pain-free and symptom-free full functioning like I mentioned in the recording, but it goes to show that we're always having to manage this particular condition. If you've had it for a long period of time, if you've had it for several years, I have multiple tendons right now that I've had a tendinopathy for several years, and I still need to make sure that I'm on top of my game. I need to make sure that once I'm symptom free and I'm back to running, cycling the full amount, I make sure that my rehab is still in check because I'm constantly managing it because there will be certain portions of that tendon that is irreversible. That way I need to make sure that if I'm loading it correctly, If I do have, I make sure that I try and avoid spikes in training as much as I can. And during my downtime, I'm still keeping my tendons quite strong with strength and conditioning, which we'll talk about later on in this podcast. Um, when it took, when we talk about the, uh, hamstring tendon with what causes, uh, tendon issues, we're talking about spikes in load. So we're looking at things like speed. Um, so increasing your running speed can put a lot of tension on that hamstring tendon. we're looking at things like running uphill, we're looking at things like, if we're delving into compression, we're looking at if you're a cyclist and either if you're sitting on the bone and causing, on the sitting bone and causing pressure that way, or if you're tucked in a real aerodynamic, speedy kind of posture when you're cycling, that can cause a lot of compression on the tendon. And also sitting, we know that sitting is an aggravating factor for proximal hamstring tendinopathy. and sitting actually causes compression. And then the third part being lack of recovery. So we need to make sure that if we do compress the tendon, if we do put it through speed work, if we do put it through volumes of sitting, we wanna make sure that the tendon is strong enough to tolerate that. So coming up next on our next episode, we're going to take these basic concepts and we're gonna start talking about proximal hamstring tendinopathy specifically. We're gonna talk about like what it is, what it's... what causes it, what are the symptoms, what are some tests we can do, what could be a potential other diagnosis, what are some specific risk factors, and yeah, we'll just dive into that specifically. So now we understand the basics, let's hone in a little bit more on this hamstring tendon and build up your knowledge that way. Okay guys, take care. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast, hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future, and remember to stay safe. Knowledge is power.