Tendinopathy: "Treat the doughnut, not the hole!"

So what does this actually mean? Our knowledge of treating tendinopathies has improved significantly over the past few years, largely owing to the work of Cooke and Purdham. In order to explain their work, they developed their Tendinopathy continuum model. (left) I will try to explain what this means.

Firstly, how far have we come over the past few years? When I was a student and we were studying tendinopathies, particularly an

Achilles tendinopathies (see my earlier blog here)

We were taught about neoplastic vessels and echochoic lesions. It was our understanding that the fibres of the tendons had these structures in, kind of like knots in a rope. The idea of rehabilitation was to eradicate these lesions with eccentric (working under load whilst extending) exercise. Yet, in just several, short years, Cooke and Purdham have turned that theory on it's head with their continuum model! Let's try to make sense of their model.

Normal Tendon

If we examine the area of the diagram surrounding the normal tendon, we see phrases such as optimised load and appropriate modified load and strengthen and adaptation.

This is a tendon in it's normal, healthy state going about its duty supporting your muscles in a normal, day-to-day function that they are used to. By going about our day-to-day tasks for example, walking and carrying shopping bags, our muscles and tendons maintain integrity for that desired load. We therefore manage these tasks without pain.

Reactive Tendon

In this area, we see the phrase excessive load mentioned on more than one occasion. In this area, we are asking the tendon to perform a significant amount more than it is used to. For example, running a significantly longer distance or significantly faster than we are used to, or carrying excessively heavier loads than we are used to. This leads us to pain in the appropriate area. If managed in a timely manner, regaining a normal tendon can be expected. Stress shielding

We can help the tendon by unloading or stress shielding it temporarily. This can be achieved by either wearing a temporary heel raise or an elbow clasp, in the examples we are using. With appropriate, gradual loading exercises, the tendon can strengthen and adapt to the load you intend to put it through.

Degenerative Tendon

Or, "Treat the doughnut, not the hole" (Cooke & Purdham).

Once we hit tendon disrepair and tendon degeneration, we are effectively working on fibres of the tendon that cannot be strengthened, hence trying to eat the hole of the doughnut, you cannot! So, whereas historically, we thought the entire tendon could be rehabilitated and the lesions could be eradicated, largely thanks to Cooke and Purdham, we now as part of the normal ageing process, some aspects of our tendons will go into disrepair and no amount of strengthening will rehabilitate will cause an effect on this. Therefore, people should bear this in mind when they set themselves outstanding goals of running an ultra-marathon in a short period of time! Is the body geared up to accepting the load you intend to put it through? Will the body ever be able to accept the load you are going to put it through?