Ultrasound imaging (USI) may be one of the newer forms of imaging, but newer doesn't mean better. USI for abdominal organs and the uterus is valuable, but its value when it comes to musculoskeletal problems is not convincing. A new study in Physical Therapy in Sport entitled “Ultrasound imaging features of the Achilles tendon in dancers. Is there a correlation between the imaging and clinical findings? A cross-sectional study” does not find a correlation.

The study looked at the Achilles tendons of 29 dancers with no pain nor functional problems - 58 tendons total. With USI, 62% of the young women had at least one abnormal tendon. Of the 58 tendons, 26 were abnormal when examined using USI. This study also points to others that do not find a relationship between what USI shows and pain.

How is this applicable? Say one of these dancers with an abnormal tendon starts having pain in her Achilles after the study. It’s easy to assume that the tendon - which was abnormal on USI - is the problem. However, given that it was abnormal without pain, it makes sense that something else could be causing pain - perhaps something that cannot be visualized. For that reason, we should test a person’s musculoskeletal system by moving her musculoskeletal system. Versus imaging, that gives us improved chances to find the true source of the problem. --Laura

Patient complaint: right Achilles pain preventing him from training and competing (sprinting). By taking a thorough history and mechanical exam, it is clear his pain is originating in his low back. When taking his verbal history, what made me suspect his spine - and not his actual Achilles tendon - is the tendon pain variability, his report of intermittent low back and calf "tightness," and his history of other lower extremity issues.

If a tendon itself is the problem it is very unlikely that it “warms up” and pain during a workout subsides. The more you stress a problematic tendon, the worse it usually gets. However, it is likely that a joint moves from a place causing pain to a harmless position as you move (“warm up”).

When we did the mechanical exam he had an obstruction to movement in his right low back and sciatic nerve tension on his right. When he initially did 10 right, single-leg calf raises, the Achilles burned starting with repetition #2. After repeatedly moving his spine into extension with  pressure (about 30 repetitions), this test was much less painful. His homework was therefore spine extension in lying with belt overpressure. After a couple weeks of doing that (10 repetitions every 2 hours), we added spine bending to ensure the injury was fully healed. He was discharged at visit 4 with a prevention and maintenance program. ​ -- Laura

The primary law with tendons is first clinically (not via imaging) ruling out that it’s not a joint problem masquerading as a tendon problem. Joint misalignments (spine and extremities) can cause pain in tendinous areas and inhibit muscles, which unfortunately leads many clinicians to treat innocent tendons. If the “tendon” is taking forever to heal, it’s likely not the tendon. Tendon/muscle pathology comprises a small proportion of problems.

When it’s indeed a tendon, rehabilitation is relatively straightforward. A tendon’s collagen often needs to be remodeled to become functional again. This is accomplished by regularly (several times per day) loading the tendon for a few months. It may never look normal again, however. Causes why the tendon became dysfunctional initially should be addressed, and proper spine and extremity mechanics should be ensured.
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The load a tendon needs is individual-specific. I find the load that creates pain (about 6/10) for 15-20 minutes following the exercise - which may be isometric, concentric, eccentric, or ballistic. Once a load doesn’t meet that criterion, the load is increased so it’s effective. Tendon rehabilitation is largely about 1) ensuring it’s a tendon, 2) educating the patient, and 3) encouraging briefly painful self-management with limited office visits. -- Laura