REST WILL NOT HEAL YOUR TENDINOPATHY
Tendinopathy is one of the most common overuse injuries and its occurrence is related to the volume of load the tendon is exposed to.
Popular forms of tendinopathy include:
- Achilles tendinopathy
- Patellar tendinopathy
- Proximal Hamstring tendinopathy
- Golfer’s elbow
- Tennis elbow
- Rotator Cuff tendinopathy
Tendons are bundles of fibrous connective tissue comprised mostly of type I collagen that attach muscles to bone. The basic function of a tendon is to transmit force from a muscle to its corresponding bone to control movement. When the demand is greater than the tendon’s load capacity, injury can occur. Repetitive stress beyond the tendons load capacity can cause small micro trauma leading to changes within the tissue including disorganized collagen bundles, increased ground substance, cellular death, and formation of new blood vessels and nerve endings.
Rest is often recommended as the first form of treatment for individuals diagnosed with tendinopathy. However, evidence suggests that prolonged rest is the least effective form of treatment. Complete rest may help relieve pain; however, it also leads to decreased mechanical properties of the tendon, muscle weakness, and negatively effects the rest of the kinetic chain. Successful management of tendinopathy requires understanding of load capacity and adaptation.
Load capacity refers to the ability to perform functional movements at the volume and frequency required without exacerbating or causing tissue injury. There is a tissue-based threshold that determines whether the applied load induces an adaptive or maladaptive response. The threshold for load capacity can also be referred to as mechanostat point. There are 4 possible tendon responses depending on degree of mechanical stimulus relative to the mechanostat point.
- Prolonged stress deprivation below the threshold (<1% cyclic strain) can produce a maladaptive response observed by markers suggesting tissue degradation.
- Mechanical stimulus within a certain level above the threshold (2-6% cyclic strain) maintains homeostasis
- Appropriate and progressive loading within a small range above the threshold (6-9% cyclic strain) can create an adaptive response including increase in collagen I mRNA and an inhibition of degradation enzymes.
- Repetitive strains largely above the threshold (>9% cyclic strain) can also produce a maladaptive response including the production of inflammatory cytokines and markers of cell death.
The mechanostat point for each tendon is not absolute, rather it is fluid and influenced by long term load. Progressive loading can cause a positive change in the mechanostat point; the tendon can withstand greater loads that once exceeded the threshold inducing maladaptation. Conversely, prolonged understimulation can lower the tissue-based threshold decreasing the tendon’s load capacity.
The best intervention for treating tendinopathy has yet to be identified due to the complexity of structural changes. However, evidence does suggest that rest is one of the most inferior treatment methods. A meta-analysis published in 2021 looked at 22 randomized controlled trials investigating the effectiveness of treatment in patients with Achilles tendinopathy. At a 3 month and 12 month follow up, the data showed that all interventions including active exercise were superior to rest AKA wait-and-see. The rankings were based on VISA-A scores which is a subjective evaluation tool for patients with Achilles tendinopathy. It is a self-administered questionnaire that evaluates symptoms and their effect on physical activity.
Effective forms of treatment found in the meta-analysis included:
- Exercise + shockwave therapy
- Exercise + night splint therapy
- Exercise + injection therapy
- Exercise + supplement therapy
- Exercise + placebo injection
- Shockwave therapy
- Exercise therapy
- Acupuncture therapy
The conclusion that rest is not effective in treating Achilles tendinopathy can be applied to other areas of the body due to the principles of load capacity and tendon adaptation.
BOTTOM LINE
Rest is not effective in treating tendinopathy. If you suffer from tendinopathy, a physical therapist can help identify appropriate loading strategies while managing your pain and helping you stay ACTIVE.
Written By Hannah Sweitzer
References
- Docking SI, Cook J. How do tendons adapt? Going beyond tissue responses to understand positive adaptation and pathology development: A narrative review. J Musculoskelet Neuronal Interact. 2019;19(3):300-310.
- van der Vlist AC, Winters M, Weir A, et al. Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. Br J Sports Med. 2021;55(5):249-256. doi:10.1136/bjsports-2019-101872
- Xu Y, Murrell GA. The basic science of tendinopathy. Clin Orthop Relat Res. 2008;466(7):1528-1538. doi:10.1007/s11999-008-0286-4