Lukas Hinds-Johnson, Berlin State Ballet’s resident physiotherapist and owner of PhysioX Berlin
Tendinosis or Tendinitis?
As a dancer, it's likely you'll experience at least one issue concerning an overworked and/or stressed tendon, and if I had to guess the one I would go with the Achilles tendon. Honorable mentions also go out to iliopsoas, glutes, and the rotator cuff tendons on the shoulder. In researching this topic I realized that the confusion for dancers typically lies in the diagnosis and problem course. For a long time, it was believed that the course of the persistent (chronic) tendon pain was due to inflammation caused by minor trauma and overuse. This was then dubbed the term 'tendinitis' with 'itis' as the medical term for inflammation. As decades passed and more data was collected, researchers and clinicians found more evidence that the driving issue in some cases was not inflammation but instead, a non-inflammatory degeneration. This issue was then defined as tendinosis where the driving issue is not the inflammation but the degeneration. In this case of tendinosis, it may not be beneficial to treat the pain with cortisol injections or nonsteroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen and Diclofenac as they could harm the healing progress and inhibit support of the degeneration long-term.
The Birth of Tendinopathy
Then as more years passed, researchers uncovered more reasons relating to the issue that had to do with the advancement of pain science (refer to our last Physio Talk about Pain Perception). A new player was then introduced, Tendinopathy, the umbrella term referring to all persistent tendon pain related to mechanical loading. Defined by the 2019's International Scientific Tendinopathy Symposium (ICON) Consensus, they define Tendinopathy as any persistent mechanical tendon pain where "pathy" is derived from the Greek word disorder.
So why all the fuss around the terminology? If my tendon hurts and I can't jump or do a tendu, how does knowing the right term help?
From a physiotherapist's perspective, it's important to recognize the treatment for tendinopathy. When tendon injuries are similar problems tend to occur and having the right diagnosis can often make the difference. Whether it's a case of tendinosis or tendinitis despite similar treatments, the intensity, recovery time, and medication will still differ. It's a very fine line and having an active approach like that of a specified program is key to recovery—think something along the lines of 'use or it lose it'. Dancers can also find additional support through manual therapy, stretching, ultrasound, shockwave, Blackroll, massages, and so on. It's important to recognize, however, that these do not replace a specified program.
Additional Support for Tendinopathy
While it's a no-brainer that dancers have to stretch in order to maintain their flexibility, the key here is to not overdo it! I'll cover controversial stretching in another installment.
In the case of massages with the exception of sometimes mobilizing the tissues around the tendon—please leave the tendon alone!
As for friction therapy aka foam rollers, there is also no evidence that supports this for tendinopathy. Simply put, if you were to hit your shin would you poke it? Probably not.
The tendon's resilience and loading capacity decrease with tendinopathy so a good (active) training program is required.
Let's start with tendinosis. In acute cases, the recovery time can vary from 2-3 months with chronic cases taking up to 3-6 months. When your tendon degenerates it takes time to build up again so it's good to give the tendon a rest of 1-2 weeks and reduce any aggravating activity such as tendus, pointe work or jumps while still remaining active. Alternatives include rowing, cycling, etc, which will help keep the metabolism and cardiovascular action (blood supply) going and be sure to also keep your nutrition on a high level. Who said you can't train other parts of your body! Use this time to focus on other parts and/or technique and execution.
An Active Training Program
Stage 1 & 2
This next stage of 1-2 weeks can be about adding in isometric strength training. For example, stay on pointe on in tendu.
Suggestion: 3 sets of 30-60 seconds 3x a week.
You can also refer to the following to help navigate and train when you are experiencing pain.
✖️If you are experiencing severe/persistent pain that worsens after training or a resting period...
Continue with the resting period and/or reduce training temporarily (do not push through!)
Get a further examination from a health professional if it persists
Tip: make sure you get at least 8 hours of sleep while reducing as much external stress as possible + support this through a balanced diet
✔️If the pain disappears/reduces after training or after a resting period...
Continue with your regimen but consider changing the level of intensity
Pair with an added focus on the execution of the exercise (quality over quantity)
This stage is the eccentric training phase of 2-3 weeks. The eccentric muscle action is an overall lengthening of a muscle—as it develops tension and contracts to control motion performed by an outside force. For example, the calf muscle shortens when you rise onto your toes/or demi-pointe but lengthens as to control your descent. This lowering motion is an eccentric contraction.
So, use a barre or your other leg to get onto your toes/demi-pointe, you do not want to have a concentric focus on the affected side, and now slowly descend with the affected side.
Suggestion: 3-4x 20 reps, 3x a week.
In the second week, you can start to add some weights by holding a dumbbell or wearing a rucksack. To make it more fun you can listen to your favorite playlist or use a specific riddim/clock to go up and down. The idea is to not focus on the pain and on something else while you are doing the exercises.
Now you can go up concentrically and down eccentrically (slowly). Remember to have a positive focus throughout the exercises.
Suggestion: 3-4 sets 20-30 reps, 1-2 weeks
In this final stage, you can now start with small jumps and exercises, increasing bit by bit with each session. Progress slowly and do not overdo it too fast. Focus specifically on the landing of your jumps in class.
Suggestion: Start with 1-2 minutes of jump rope and then add 2 mins to every session after.
The main difference between tendinosis and tendinitis is the pain caused by inflammation—in some cases we find degeneration. The acute phase requires 2-3 days and if your doctor finds it necessary you can do an NSAID treatment or in more severe cases, a cortisol injection. Chronic cases can range from 3 weeks to as long as 6 months so it's important to note that cortisol is not a long-term solution as it can contribute to further degeneration of the calf. Focus instead on training the calf.
Though the program stages between tendinitis and tendinosis are basically the same, the key driving issue here is inflammation. Make sure you give the tendon a longer resting period from aggravating activities and focus on longer cardiovascular training to keep the metabolism up. Try to move the foot as much as necessary but also as less as possible.
I hope this helps shed more light on the black hole of tendinopathy and for those in recovery. Remember this is only advice and this does not replace a proper medical examination by a physiotherapist and/or doctor.