Tendons are the weighted ropes of our musculoskeletal system. Primarily designed to transfer load , power and strength from our muscle into our joints , tendons enable us Being the wires that transmit signals throughout our body , nerves are designed to carry messages from our central station to our peripheries. These structures are delicate , complex little things that have an immense impact on how we initiate , perform and maintain our functional abilities. However ,at least once in your lifetime you would have encountered a “dead leg” or perhaps a snuggle with your significant other and suddenly your arm goes numb. These are simple signs of nerve irritations and through this article we will be looking at nerve injuries and everything relating to them.

Whether you’re an athlete or a simple sedentary human , nerve injuries can affect anyone , regardless of age body type or activity levels. Sustaining a nerve injury is a common injury , with a reported incidence rate of 43 million people annually in the US as traumatic nerve injuries account for up to 3% in the emergency room.

By not being able to transmit messages effectively into your peripheries , they give the platform for many secondary complications which in turn reduces your functional ability and well being. Furthermore , due the slow recovery of nerves , their complexity and and many ways to injure them , clinicians often struggle in returning full function to their patients.

Fortunately for you , we are experts at nerve injuries and wrote this article with you in mind! As you sit tight and begin the first step of your journey to greatness we will go through all the particulars relating to your nerve injury as what to expect , how to manage it and what not to do!

Nerves are built up of multiple structures that work in unison to transmit signals from your brain into your peripheries. The main component of a nerve is the neuron. This is made up a cell body and a long slender tube known as the axon which is the main structure responsible for carrying and transmitting signals throughout your body. The axon is incased in a segmented sheath called the myelin which enables signals to be transmitted at a rapid pace from node to node. Diving a bit deeper into the genetic make up of a nerve , you then have some connective tissue structures which provide support , protection and strength for function and repair. These structures are your Endoneurium (Blood supply to your nerve), Perineurim (Forms the blood nerve barrier) and Epineurium (Primary protective layer).

There are multiple ways to sustain a nerve injury be it through an autoimmune disorder , traumatic injury or non – traumatic instances. Lets say you sustain an injury whereby you fall from a tree but as you falling , you fortunately manage to grab onto a branch with one arm. As you reach up and catch onto the branch , there’s a sudden sharp electrical sensation running from your neck into your entire arm and fingers. Due to the immense amount of stretch occurring throughout your arm as you hang from the branch , the force of the stretch itself disrupts the myelin sheath causing inflammation and disruption of the neural pathway , but keeping the axon intact. This is known as a neurapaxia and is the mildest form of a nerve injury.

Keeping with the same mechanism of injury , although this time you fail the grab the branch and end up falling quite hard on an outstretch arm. You feel a sudden onset of sharp excruciating pain and additionally , you’ve sustained a fracture in your arm. The stretching pull going through your nerve as you fail to reach and grab a branch along with the crushing force as you land leads to the nerve body being overly stretched and then suddenly compressed. This can also be typically seen in an motor accident , whereby an external force applied simply disrupts the internal structure and integrity of your nerve and connective tissue , think of the strings of rope being torn apart. This is certainly more severe in nature and will lead to a more intense and severe form of nerve injuries known as Axonotmesis or Neurotmesis.

The internal bleeding , nerve scarring and cellular disruption caused by a more intense injury will directly affect how long it takes to recover and regain neural stimulation along the affected pathway. Furthermore , secondary injuries sustained to the surrounding structures such as a muscular tear , bone bruising or fracture will also add to the healing process as a high grade nerve injury rarely occurs in isolation.

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A tendinopathy can vary in how they present , the type of symptoms they present with and how severe they can be. Pain does not equate to structural or physiological damage , which is important to understand as even the “smallest” tendon injury can present severely and conversely , a “larger” tendon injury can be asymptomatic up until yo’ve completely ruptured it. Lets us simplify and breakdown how severe a tendinopathy can be by isolating it into two categories , namely a mechanical type and pathological type.

A mechanical type of tendiopathy can be thought as the physical site or location of the injured tendon. As tendons transfer mechanical load of a muscle through to a joint , the location of a tendon injury is undeniably important to understand as different locations within the tendon equals different forces coming though it. This ultimately affects how we plan rehabilitation as how a tendon is stressed results in how it reacts.

The three main types of mechanical tendinopathies can range from a tenosynivitis , to a mid-portion tendinopathy to a more tricker insertional tendinopathy. A tenosynivitis refer’s to the inflammation of the sheath that wraps around the tendon , not damage to the tendon fibres itself. A mid-portion tendinopathy refer’s to tensile load coming through incorrectly on the tendon fibres (usually away from bone sites) causing inflammation of the tendon fibres. A insertional tendinopathy is caused by both tensile and compression load causing damage to not only the tendon but where it inserts onto the bone as well.

Using a realistic example of going for a light 5km jog , you begin feeling a sharp dull ache just below your calve muscle at your achilles tendon as you enter the last 2km. It’s not swollen but tender enough for you to start limping and leads to you walking the rest of the way. Once you arrive home , rest and ice seems to shake it off although the following morning , there’s a sudden stiffness and discomfort that you cannot seem to ignore which inevitably only gets worse over the following weeks to come. These are all signs of a tenosynivitis or a mid-portion tendinoapthy. These can be considered a bit easier and quicker for rehabilitation purposes compared to a insertional tendinoapthy.

Within the mechanical type of tendinopathies , we can further our understanding of tendon injuries by assessing the physiological state of the tendon itself. The golden continuum of tendinopathies breaks down the amount of structural damage to the tendon itself. A reactive tendinopathy is first phase in which a tendon responds to an acute load that it was not ready for , this would usually be the case of the tendon itself with the above mentioned example.

As keeping with the 5km jog , you attempt going for a run after resting for a week , although as you start – the pain immediately flare up’s , only this time it’s worse and you cannot even get to the 3km mark. This indicates that the tendon has now structurally worsened into a phase of disrepair whereby the tendon fibres split , the cellular matrix has been infiltrated with nerves and small blood vessels. This leads to pain , swelling and a decrease in functional capacity. As you now attempt to leave it for a while , exercise and continue “stretching” , the next worsening phase of a tendinopathy awaits. A degenerative tendinopathy is confirmed whereby the the tendon matrix is unorganised along with cellular death of the tendon fibres. As you now attempt to run , you are in pain and not effective in your ability to weight bear , generate power or even keep up to 5km anymore.

The next and final phase is a reactive-on-degenerative tendinopathy , which basically translates to an acute flare up of swelling , pain as well as further loss of strength and endurance. This is due to the tendon being stuck and suffering in a chronic state of disrepair , cellular death and tissue disorganisation as you still try to attempt being active. This in turn , leads to the rest of tendon over-loading and eventually rupturing.

With our professional expertise and clinical knowledge we can make the Physiotherapy diagnoses for your tendinopathy a easy , uncomplicated and well understood process. We are skilled enough to calmly guide you through a structured assessment process whereby we can confirm or even rule out tendon injuries.

We are able to isolate and break down the affected tendon and corresponding complications in order to get the best possible clinical presentation of you. Lets have a look at the thorough steps we will guide you through as we identify and confirm or rule out a tendinopathy:

Subjective Assessment

Getting an idea of the events and mechanism of injury leading up to your tendinopathy is our step. This is as important to us as any relevant previous history , medication or chronic conditions you may have gives us a better insight into your path that lead you to us. The better we are able to understand this , the better and easier we are able to plan your rehabilitative journey. Another important aspect of this is to go through your goals and expectations as we strive towards getting you back into the tasks that are important to you within a realistic and objective approach.

Physical Assessment

This is where we assess your physical ability in relation to your tendinopathy. We are able to isolate the tendon , corresponding joint and muscle via a variety of special tests to ensure we get the best clinical picture of your tendinopathy. We are abled and skilled enough to break your musculoskeletal system down by testing your mobility , strength , endurance and functional in relation to your tendinopathy.

Once we able to objectively tick these boxes we are now able to successfully commence your rehabilitative journey. If we suspect any further investigations , we are able to provide you with a referral to get it done. We are proactive in our approach and pride ourselves in taking responsibility as your primary health care provider.

We understand how the body works and know how to mitigate any secondary issues that may arise when having a tendinopathy. Allow us to take on that responsibility while you focus on a structured rehabilitation program to get you back to your best.

Tendons cannot be seen seen on an x-ray, so it will not be effective in diagnosing a tendinopathy. If suspected of any secondary fractures , a x-ray will certainly aid us in assessing the integrity and alignment of any affected joints or bones in relation to your tendinopathy.

Your physiotherapist can refer you to get x-rays taken if necessary.

Primarily considered the first line intervention when dealing with tendinopathies , a US aids us in assessing the thickening , any potential tears as well as confirming the severity of cellular death within the tendon.

We are able to perform a US at our expert practice.

Known as the golden standard of imaging , MRI is expensive and only considered if needed. By revealing all structures , its especially useful to rule out bone stress injuries or complete fibre tears. Not used willing if an Ultrasound has already been done.

If your physiotherapist suspects a MRI is needed , we are able to refer you to the right specialist.

The healing journey of a tendon has the potential to be an extremely complex and lengthy process. Unlike other structures in your body where you can get away with no treatment (such as a simple muscle strain) , even the simplest tendon injury needs to be attended to. Rehabilitation for a tendon needs to be a guided process and not a “wait and see” process. There are numerous factors that needs to be understood effectively and managed in order for your tendon to heal correctly. Lets explore some of these issues as to why your pain is just not resolving , beginning with some of the basic physiological understanding:

The genetic make up of a tendon is extremely different to those of the rest of the body. Tendons are less supplied by blood (4 times less) and it’s ability to take up oxygen (7 times less) than muscle is one of the primary physiological blockades that you’ll face when trying to recover from a tendon injury. As blood carries all the nutrients thats responsible for healing , remodelling and readapting our structures after we’ve been active is one of the main abilities of our bodies. However , when you’ve sustained a tendinopathy the injured tendon by nature , will not have the best chance to recover following injury just due to it’s structural make up alone.

Furthermore , a tendon is made up a complex arranged fibres that when stressed , form a strong “scaffold” to tolerate the load coming through it. Now when your tendon is sprained , these Collagen fibres will disorganise themselves as they are “hurt”. This would not be an issue if we had enough repairing cells in the tendon to aid the breakdown of these injured fibres as to make new ones again , however these “ambulance” cells account for only 5% of the total tendon matrix. When struggling with a tendinopthy , this is imperative to know as rehabilitation aims to readapt and remodel 95% of the fibres with 5% of cells that are able to , hence rehabilitation can take up to 24 months!

Scar tissue formation and disorganised fibrous tissue is what you can expect in a untreated tendinopathy. This is a massive roadblock in your healing journey as when your injured tendon attempts to heal without proper guidance, the regenerating fibres will not grow correctly , but in a way that is not aligned with your natural tendon fibre formation. These usually manifest in a painful mass of scar tissue and bumps along your tendon which not only prevents functional recovery but also becomes a source of chronic pain and joint stiffness. Evidence shows that when you load an injured tendon , its the sensory nerve endings within the matrix of the tendon causing pain , not the actual tendon itself.

We are experts at preventing and setting you on a path to correct these complications before they become permanent. Do not let it worsen or restrict you from the basic daily activities that you should be able to do. Have us guide you through this journey with care , passion and clinical mastery.

Complications arising from a tendinopathy are extremely common in clinical practice. We have experience and skill in identifying any shortfalls in your recovery and more importantly , find out why you still have tendon pain , even though you may have “recovered” already. These misconceptions and shortfalls about tendon recovery is popular amongst individuals who do not seek the correct intervention or have simply just not had the best care given. Below are some of the issues we see in clinical practice , which ultimately delays your rehabilitation progress. Focus is almost always paid to secondary complications have now taken a front seat , thus meaning more time needs to be spent on these issues before getting to the actual tendinopathy itself.

Misdiagnoses can lead to more damage than good. Understanding the difference and being able to differentiate between a nociceptive , tendon or muscle pain is clinically the first step that needs to be correctly identified. Often we see individuals whom have been misdiagnosed with the “confirmed” diagnoses of a muscle strain or a stiff joint. This leads to further complications later in their recovery and more importantly , delays the prognosis even more. After doing weeks of rehabilitation , they try to integrate back into training , only for the symptoms to flare up again. If a tendon injury has not been correctly identified , it will never heal on it’s own.

Muscle wasting or atrophy as well as secondary muscle tears are all too common when sustaining a tendinopathy. As tendons transmit force from a muscle to your joint , when they’re injured – all that force is not being transmitted correctly. This leads to an overload on the corresponding muscle and eventually leads to a muscle tear. Muscle wasting is found in individuals who waited too long for the correct treatment.

Chronic pain is often seen as a consequence of ill treated tendon injuries. Complex regional pain syndrome (CRPS) is a popular type of syndrome we see in individuals , whereby the amount of joint stiffness , neuropathic pain and swelling is disproportionate to the initial injury. This is usually accompanied by loss of sensation , motor control and limited functional abilities.

Within our domain , we are absolute professionals and experts as we strive ourselves on our ability when it comes to the clinical assessment and treatment protocols we use to treat a tendinopathy. We are confident , systematic and use a guided approach to establish the extent of your tendon injury and any secondary issues it has caused on the surrounding structures. We can ensure that you get the best treatment and care while we use an array of different modalities and techniques to aid you through your rehabilitative journey.

We begin by assessing and confirming the extent of your tendinopathy. This is achieved by carefully undergoing our thorough assessment protocols whereby we not only focus on your tendon in isolation but also on the associated joint and muscle. Once we’re able to assess the severity and get a clinical diagnoses we can then proceed on a plan of action. Primarily this is focused on accelerating the fibre regeneration of the tendon as well as gradually increasing the load tolerance by improving the tensile strength of the tendon itself. We would also want to decrease any inflammation surrounding the tissue as well as improving muscular interfaces and joint mobility.

We are experts in our field and have extensive experience in achieving a better improved functional outcome based on your objectives. We are able to make us of a variety of refreshing and clinically sound treatment protocols. Allow us to get you back to where you need to be , in the most timely manner possible.

Following a peripheral nerve injury , research shows that the average rate of nerve regeneration is about 1 to 3mm per day. This can be equated to about 2.5cm a month! This is not a lot of growth and therefore the total recovery time for more severe injuries is directly related to the distance the nerve must regrow. Additionally , age plays an important factor in your healing as younger individuals have a stronger chance of healing faster. The location of your nerve injury is also pivotal in your recovery as nerves injured closer to your affected muscle will regrow faster as it’s less distance compared to a longer nerve that innervates a further muscle. Direct clean cuts to your nerve usually heals easier than a stretching or crushing type of nerve injury. Lastly , timed intervention also plays a part in your prognosis. Muscles that are innervated by your affected nerve will begin to waste away if the nerve has not been treated , therefore leaving you with functionally decreased abilities and massive muscle atrophy.

Lets go through the details of each nerve injury and how it affects your healing time.

• Neurapraxia: Graded on the Sunderland score as a Gr1 nerve injury , these are considered to be the mildest form of injury. Basically the nerves signal or conduction is blocked but the nerve itself is usually unharmed. Recovery is spontaneous and nerve conduction typically occurs within 0 – 12 weeks.
• Axonotmesis: When the axon of the nerve is damaged , it’s considered a medium / moderate injury and is graded as a Gr2 injury on the Sunderland score sheet. As the axon of the nerve is damaged , the nerve still has it’s protective outer layer in tact which is imperative to healing as this can guide the regrowth of the nerve and axon. Healing is slow , but expected although the time frame associated with it can take months up to a year depending on the injured site.
• Neurotmesis Grade 3 , 4 & 5: These are considered severe injuries as the entire nerve has been incomplete or completely ruptured. As the internal structure of the nerve itself has been damaged , the scarring tissue , nerve endings and conduction needs time to regain it’s capabilities. Spontaneous recovery is not possible , therefore even after successful surgery , rehabilitation is often anticipated to take months and often years to heal.

As we continue to strive towards giving you the best care we possible can, lets have a look at some of our strong alternative and additional forms of treatment that can aid us in your rehabilitation journey:

• If need be , a referral to your local GP will aid us in the appropriate medication for your healing and rehabilitation process. Nerve injuries require a specific type of medication as the usual anti-inflammatories would not work (Ibuprofen or Paracetamol). We are able to guid you into which of these medications are needed.
• Splints and braces can be used to manage the consequences of muscle imbalance and to improve function without the flare up of nerve symptoms. Be keeping the affected joint in a neutral position , we can prevent further damage to your nerve injury , improve your functional in your day to day activities and more importantly – protect the structure by keeping it immobilised.
• Electrical neurostimulation – In order to “kickstart” your axon and nerve regeneration we are able to treat and rehabilitate this effectively by applying a low frequency trans electrical stimulation along your nerve pathways. Research has shown that providing a charge of 20Hz current for one hour to the nerve proximal to the repair site has great effects by increasing intracellular levels and shows significant acceleration of axonal regeneration and earlier innervation of targeted muscles.

Surgical intervention for your nerve injury is mainly dependant on the type of nerve injury, severity of the injury and the prognosis of the nerve healing on it’s own. The goal of surgery for a nerve injury is to reattach the loose endings as to provide a stable pathway for conduction to take place. Lets have a look at some of the clinical signs that are indicated for a surgery:

A high grade injury such as a Grade 4 or 5 on the Sunderland nerve injury score sheet is a massive indication for surgery as the nerve has completely torn or ruptured and the indications for it healing independently are near impossible. Furthermore , even on a Grade 3 score , if a conservative approach has failed after a period of at least 6 months , surgery would be considered by the surgeon as to determine the return of function of the injured nerve.

In certain instances surgery is needed immediately to restore the injured nerve’s pathways. Lets have a brief look at what this entails:

• Direct trauma – Sharp cuts such as a knife or massive lacerations to your limb will require surgery as these types of injuries usually completely or partially sever’s the nerve itself.
• Tumor – Benign or malignant tumor’s can directly compress the nerve therefore surgery would be aimed at removing the tumor as well as repairing any nerve damage the tumor has caused.
• Wounds , crushing or scarring injuries – Traumatic injuries that compress , stretch and infect the nerve beyond repair needs to be removed so that the nerve can be realigned and begin regenerating.

The different type of surgeries will also vary dependant on what needs to be achieved. Below is a brief outline on the different types of surgeries for your nerve injury:

• Autografts – Using your own body’s tissue and a donor nerve is what makes this type of surgery the preferred choice of nerve surgery. By harvesting a donor nerve in your body , a surgeon is able to use it to fill in the gap of your injured nerve , allowing natural healing to occur.
• Allografts – When a autograft is not available , another type of surgery is where a nerve is taken from another human donor (usually a cadaver). This is then processed until it’s appropriate and then used to fill in th gap of the injured nerve.
• Nerve Conduits – These are used for smaller nerve injuries (3cm or below) whereby a artificial hollow tube is sutured at the end of the injured nerve stumps. This then provides a safe conduction “tunnel” for the nerve axon to regenerate and heal.
• Neurorrhapahy – This term refers to a direct end to end repair when the nerve has been completed cut in two. The surgeon is able to trim away the injured nerve endings and tissue , ensuring the healthy ends are reattached with precision and without any tension on the nerve as this way hinder the healing abilities of your injured nerve.

Surgery is merely the first step in a rehabilitation journey as we will then guide you through your unique post-operative rehabilitation program , whereby we strive to get the nerve to regenerate , desensitise and conduct efficiently.

• Neuritis – Inflammation of a nerve due to injury.
• Muscle strain – An common injury affecting your muscle fibres.
• Radiculopathy – Associated with back pain whereby a nerve is known to be “pinched”.
• Tenosynovitis – The inflammation of the sheath that surrounds the tendon itself.
• Arthritis – Inflammation of the joint space.

• Tendinitis
• Tendinosis
• Inflamed tendon
• Sprained tendon