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96 m a s s a g e & b o d y w o r k m a r c h / a p r i l 2 0 2 0 tendon pathologies generally reproduce pain near the end range of any movement that stretches the muscle-tendon unit. Manual Resistance One of the most effective methods of identifying tendon disorders is with manual resistance. During resisted muscle actions, there is a more significant load on the tendon than during other range- of-motion evaluations. This assessment method is especially helpful for evaluating tendons like those of the upper extremity, which are not weight-bearing. The pain felt from tendon disorders in these various evaluation procedures is usually felt in the tendon itself. Therefore, palpation is also important in evaluating these disorders. Palpating the tendon at the same time as the range-of-motion procedures can increase the load on the tendon and make each testing procedure more sensitive. Remember, the pain level felt in the tendon may not directly correlate with the amount of tissue damage or tendon dysfunction. Sometimes tendon damage can be quite advanced before it becomes symptomatic. On the other hand, we know that even minor, early-stage tendon disorders can be quite painful. Active Lengthening Just with active shortening, active lengthening refers to actions of the muscle (in this case, eccentric contractions). There is a tensile load on the tendon during active lengthening, and this load increases near the very end range of movement as the connective tissue elements in a muscle are also pulled. Therefore, tendon pathology pain is usually greater near the end range of elongation. Passive Shortening Passively shortening a muscle removes the load on the tendon. Therefore, pain from tendon disorders decreases with passive shortening. This principle is vital to consider because recognizing what should not hurt can help establish a pattern that points to a particular tissue involved. Passive Lengthening Just like with active lengthening, tendon tissue is under increasing tensile load as the muscle-tendon unit elongates with passive lengthening (stretching). Therefore, TREATMENT CONSIDERATIONS Massage is a common treatment strategy for overuse tendon disorders, with the most common likely being deep transverse friction (DTF) (Image 4). For years, it was taught that the primary physiological effect of DTF was that it helped align scar tissue after tendon fiber tearing. When research indicated that tendon fiber tearing was not a likely cause for most chronic overuse tendon disorders, that called into question how DTF works. DTF applied to the tendon still appears an effective treatment for tendon disorders, however, especially when combined with other strategies that focus on the entire muscle-tendon unit. So why does it work? One theory that has some initial research support is that the specific pressure and movement applied during DTF stimulates fibroblast activity that encourages collagen repair in the damaged tendon. More research is needed to verify this idea, but it seems plausible. Massage techniques that focus on the entire muscle-tendon unit are also effective at pain management with tendon disorders. Quick reference cheat sheet on tendon disorders. This reference sheet and others are available for free at www.academyofclinicalmassage.com. 3 TENDON Active Shortening Active Lengthening Passive Shortening Passive Lengthening Manual Resistance Tendinosis Generally painful if load is sufficient. May not be painful if there is not enough load on the muscle tendon unit. Usually most painful at the end range of muscle/tendon elongation. May be painful throughout active lengthening if eccentric load on the muscle/tendon is sufficient. Rarely produces pain because load is removed from affected tissues. Pain likely at or near the end range where the tendon is being stretched and tendon is under sufficient tensile load. Very likely to reproduce pain from load applied to the impaired tendon. Tenosynovitis Generally painful if load is sufficient. May not be painful if there is not enough load on the muscle- tendon unit. In some cases friction during movement may cause pain even with small load. Usually most painful at the end range of muscle lengthening. May be painful throughout active lengthening if eccentric load on the muscle/tendon is sufficient or condition is more severe. Rarely produces pain because load is removed from affected tissues. In more advanced cases compression or friction during movement may reproduce pain at some joint positions. Pain likely at or near the end range where the tendon is being stretched and sufficient tensile load is placed on the tendon. If severe, pain may be felt earlier in movement. Very likely to reproduce pain from load applied to the impaired tendon.