Treating the Donut Not the Hole, Tendon Pain and Function

Research by Sean Docking on Achilles and patellar tendons found that pathological tendons are thicker and contain more normal tendon tissue than normal tendons. The tendon adapts around the lesion, so patients can be reassured, loaded with confidence, and often do not need imaging or injections into the pathology. Jill calls this treating the doughnut, not the hole. Pain is not related to structure: 30 to 50 percent of people with marked pathology never have symptoms. Tendon pain is persistent nociceptive pain that occurs with loading and stops when loading stops, without central sensitization. Nerves sit mainly at the periphery of the tendon, so treatments such as ESWT, sclerosing injections and surgery target nerves rather than pathology. Pain mostly matters because it limits function. Tendons handle energy storage and release, compressive loads near the bone insertion and friction loads against surrounding tissue, and the Achilles is exposed to all three. Rehabilitation has to restore the tendon, the muscle, the kinetic chain and the brain, because good function protects against tendon pain.