Has the pain in your foot or heel left you dazed and confused? You don’t remember directly injuring or straining it. You just know it hurts when you stand on it. What about that problematic tennis elbow?  Good bet it is an overuse injury that snuck up on you. But what created the problem?

Knowing what tendons and fascia are makes it easier to understand how they get injured. The description that follows is a bit technical but easy to understand. The upside, there are new treatments out there you should be aware of in case the need arises.

Tendons, What are they?
Tendons are a tough band of fibrous connective tissue composed of collagen and elastic fibers that usually connects muscle to bone and are capable of stretching, absorbing force and redistributing the energy. Tendons are similar to ligaments and fascia as they are all made of collagen except that ligaments join one bone to another bone, and fascia connect muscles to other muscles or muscle to bone.

Normal healthy tendons are mostly composed of parallel arrays of collagen fibers closely packed together. Normal tendons, are about 30% water, the remainder is composed of about 86% collagen, 2% elastin, 1–5% proteoglycans. The blood supply may be visualized within the endotendon (tissues surrounding the collagen bundles) that runs parallel to collagen fibers, with many branches. The internal tendon does not appear to contain any nerve fibers, but the surrounding tissue known as the epi- and peritendon do contain nerve endings.

Much research has focused on the elastic properties of tendons and their ability to function as springs. This allows tendons to passively modulate forces during walking and running, providing additional stability with no active work. It also allows tendons to store and recover energy at high efficiency. For example, the Achilles tendon stretches as the ankle joint dorsiflexes (moves upward). During the last portion of the stride, as the foot plantar-flexes (pointing the toes down), the stored elastic energy is released.

The Trouble with Tendons
There are various forms of tendon injuries due to overuse. These types of injuries generally result in inflammation and degeneration or weakening of the tendons, which may eventually lead to tendon rupture. Tendinopathies can be caused by a number of factors such as over use, medications i.e. Antibiotic Ciprofloxicin, or direct trauma.

The first category of tendinopathy is paratenonitis, which refers to inflammation of the paratenon, or tissue located between the tendon and its covering. Tendinosis refers to non-inflammatory injury to the tendon at the cellular level. The degradation is caused by damage to collagen, cells, and the vascular components of the tendon, and is known to lead to rupture.

Research has shown that tendinosis typically occurs when there is incomplete healing of a more acute injury, or there has been repetitive insult to the tendon. Basically the tendon becomes more like scar tissue which is not as flexible as healthy tendon, and the blood supply is limited in this tissue.

Other forms of tendinosis that have not led to rupture but also show the degeneration, disorientation, and thinning of the collagen fibrils, such as the case with plantar fasciitis (heel pain) and Achilles enthesopathy (pain in the back of the heel).
Tendinopathies may be caused by several intrinsic factors including age, body weight, nutrition and medications. The extrinsic factors are often related to sports and include excessive forces or loading, poor training techniques, and environmental conditions.

Tendons are capable of healing and recovering from injuries in a process that is controlled by the tenocytes (basic tendon generating cells and their surrounding cells). The three main stages of tendon healing are inflammation, repair or proliferation, and remodeling. The inflammation stage usually lasts for a few days, and the repair or proliferation stage then begins. In this stage, which lasts for about six weeks, the tenocytes are involved in the synthesis of large amounts of collagen and proteoglycans at the site of injury. It is during this stage that the inflammatory process gets disrupted and the tendon/fascia deviates into an incomplete healing state and forms thick scar like tissue with decreased blood supply.

If the healing process is not interrupted then after about six weeks, the remodeling stage begins. The first part of the remodeling stage is consolidation, which lasts from about six to ten weeks after the injury. The final maturation stage occurs after ten weeks, and during this time there is an increase in cross linking of the collagen fibrils, which causes the tissue to become stiffer. Gradually, over a period of about one year, the tissue will turn from fibrous to scar-like.

Should your tendon or fascia fall a fate that include tendinopathies (chronic poorly formed tendon), here are some new options.

Platelet Rich Plasma (PRP)
The treating doctor, takes blood from the patient and then the blood is placed in a centerfuge, spinning the blood so it will separate in to the plasma , the buffy coat (white blood cells) and the platelets ( the essential cells that make up the blood). Drawing off the buffy coat and the platelets we have concentrated growth factors, stem cells, and white blood cells. There are five growth factors that have been shown to be significantly unregulated and active during tendon healing: insulin-like growth factor 1 (IGF-I), platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), basic fibroblast growth factor (BFGF), and transforming growth factor beta (TGF-β). These growth factors all have different roles during the healing process.

The doctor then takes the concentrate of the patient’s blood and injects it into the injured tendon. The research reveals that by doing this the treatment floods the injured tissue with growth factors, and re initiating the inflammatory state. That sets  the stage for the tendon/fascia to heal more normally and under improved conditions.  These improved conditions are to avoid non steroidal medications such as ibuprofen, naproxyn, and aspirin. The patient is instructed to do appropriate stretching. It has been shown that controlled movement of the tendons after 7-10 days following an acute injury or re initiation of the inflammatory state can help to promote the synthesis of collagen by the tenocytes. This leads to increased tensile strength and diameter of the healed tendons and fewer adhesions than tendons that are immobilized. It has been shown that immobilization of the tendons after injury often has a negative effect on healing. The success rate of this treatment modality is in the range of 75-80% over the course of 6-12 weeks.

Extracoporeal Shockwave Therapy (ESWT)
Several other treatment methods show similar effects on the tissue. Extracoporeal shockwave therapy (ESWT), induces the cell within the injured tissue to breakdown and release growth factors as with the PRP starting the inflammatory state again. ESWT does this by generating a shockwave into the injured tissue. There are different methods that the shockwave is generated. In high energy machines it is an acoustic (sound wave ) that is generated of very high intensity. In low energy machines it is typically a ballistic shockwave generated by air pressure. The success rate of this treatment modality is in the same range as PRP 75-80% over the course of 6-12 weeks.

Cold Laser
Another method of stimulating the tendon/fascia to heal is with cold laser. These are lasers in the 800 nanometer to 950 nanometer range of near infrared laser energy. The light energy focused by the laser can penetrate the skin to a depth of several millimeters depending on the wattage of the laser. The photons (light energy) stimulate the cells in the tendon or fascia to speed up there activity, essentially creating an inflammatory reaction and growth factors are generated into the tissue.  This is a new method of treatment and there is not enough research to give an accurate success rate. Reports currently available show resolution of pain and improved function at 4-6 weeks with 3 treatments per week for 2-3 weeks.

Radio Frequency Coblation
Radio Frequency (RF) Coblation is one more modality that has proven to be very successful in treating tendon and fascia injuries. RF Coblation is a method of creating a low temperature plasma field (electrical field slightly higher in temperature than the body), this plasma field when it comes in contact with the injured tissue, breaks the tissue down, releasing hydrogen, oxygen, water and all of the growth factors held in each cell. The released growth factors then flood the injured tissue. Like ESWT and PRP, this initiates the inflammatory cycle and healing begins once again. The success rate of this treatment is in the same range as PRP and ESWT 75-80 percent over the course of 6-12 weeks.

There is no longer any reason anyone should suffer with a tendon injury such as Achilles or fascial injury (plantar fasciitis). There are new treatments available that provide methods to return the injured tissue to a healthy pain free functioning, collagen flowing state.

— Bruce Werber
Bruce Werber DPM, FACFAS is the founder of In Motion Foot and Ankle Specialists, Scottsdale, Ariz. He is an Associate Professor Midwestern University. He is the author of numerous articles in regional and national medical journals as well as the book A Comprehensive Guide to the Foot and Ankle which you can receive free. For more info visit www.inmotionfootandankle.com