The Do’s and Don’ts of Tendon Injury

Tendon injuries are one of the top overuse injuries in distance runners. Tendons are thick bundles of collagen fibers that attach muscles to bones and play a critical role in providing tensile support, as well as storing and releasing energy. They are your body’s springs. The most common injury is tendonitis, which is more frequently referred to as tendinopathy. The terminology has changed in recent years since tendon injuries are not always associated with inflammation, but rather micro tear of collagen fibers, degeneration of the tendon, and dysfunction.

The most common tendon injuries for distance runners include:

1. Achilles (pain behind the heel/ankle)

2. Posterior Tibialis (pain in the arch of the foot or inside of ankle)

3. Peroneal Tendon (pain on the outside of the foot or outside of the ankle)

4. Patellar Tendon (pain in the front of the knee)

5. Hip Flexor, Psoas or TFL (pain in front of the hip)

6. Glute (pain on the outside of the hip)

While this seems like a long list, if you catch the early signs & symptoms of tendinopathy EARLY, the treatment approach and training modification is similar for all.

Early Signs & Symptoms: Pain can be acute or gradually increasing over time. In the early phase, pain decreases after warm up. This is called the “tendon warm up effect” where pain decreases after 15-20 minutes. Pain is usually sharp and worsened 1-2 hours post activity and 24 hours after. Swelling, pain, and stiffness is common post activity.

Understanding the phases of tendon healing is critical for determining which rehab exercises to do and whether or not you should continue running. Most people can run once pain subsides with a modified training load. This means temporarily reducing total milage, hills, speedwork, etc.

In the inflammatory phase of rehab, if pain is >5/10 after running and with daily activities (walking, stairs), rest or cross train for 2-5 days until pain levels/swelling are improved and controlled. Find activities that are pain free (walking, biking, swimming).

Should I run with a tendon injury?

• You’re out of the acute phase of injury and your pain levels throughout the day are < 3/10

• Pain during running does not worsen >3/10

• Pain post-run (1-2 hours) should not worsen

• Pain 24 hours after running should not worsen and you should return to baseline

• You have a rehab routine and understand the cause of your injury

Do’s:

1. Load the tendon: tendons respond very well to load. Prolonged rest does not promote tendon healing. The key is to find the right amount of load to promote healing, but not aggravate.

2. Progress your exercises: tendons take a very long time to fully heal. Even if you’re running at full capacity, your tendon may take 1-2 years to have the same tensile strength as the healthy side. Continue to progress your exercises because tendons adapt to their load. This means, you shouldn’t be doing bodyweight calf raises or eccentric heel drops for 6 month. You need to add weight.

3. Be consistent: have rehab routine and stick to it. You don’t always see drastic improvements every week with tendon rehab, but it’s a compound improvement over time. It also prevents setbacks.

4. Work with a PT to strengthen other muscle groups! I.E. lower leg tendon injuries have better long term outcomes when you strengthen the hips/core!

Don’ts:

1. Don’t continue running if your pain is worsening and interfering with daily activities (walking, stairs, etc). Hint: If you’re thinking about it constantly and it’s stressing you out, you’re better off taking a few days off.

2. If it hurts, don’t do it. Often times, runners focus on strength training and rehab too much when they can’t run. If single leg exercises or plyometrics cause pain >3/10, don’t do it.

3. Don’t ignore the pain. Go see a medical professional that understands running injuries to help you understand your phase of injury and what you should be doing.