Many of us have experienced muscle and tendon strains or minor tears, but what happens when the tears are larger and more serious?
There are two classifications of tears—traumatic and atraumatic (degenerative)—and within these classifications, we have two grades of severity:
- Partial thickness: This relates to the tear being shallower in the muscle or tendon without tearing through all layers of fibres. An example would be like cutting halfway through a piece of cake while leaving the bottom intact.
- Full thickness tears: These tears are through all layers of the tissue but don’t necessarily mean the rupture of the tendon or muscle. Imagine having the same cake, but we slice all the way through while leaving half the slice connected. This is like a full thickness tear.
Anatomy: What are muscles and tendons?
Muscles are a contractile connective tissue made from numerous myofibrils (muscle fibres) containing Actin and Myosin, which slide against each other to change the length of the muscle. The muscle is connected to a tendon on each end.
A tendon is connective tissue that attaches muscle to bone. Tendons have very limited stretch due to their high collagen to elastin ratio, but combined with a muscle they can use the bone and joint as levers to create movement. The literature suggests that tendons are the most frequently torn structure compared to muscle, which is likely due to its limited ability to stretch.
Factors influencing risk of tears:
- Age: As we age, our ability to replenish collagen (the main ingredient of tendon strength) and heal the body diminishes. This results in reduced tendon strength and increased risk of degenerative tears.
- Strength: Strength refers to how much load a body tissue can cope with before failing. We increase our tendon strength by progressively loading. Current literature suggests a heavy and slow exercise program with aspects of individual functional activities is best for tendon strength as well as maintaining collagen in a healthy tendon. A torn tendon requires individualised progressive loading through exercise.
- Activity participation: Inactive tendons and muscles become weaker and have reduced ability to deal with increased stress of movement. On the other hand, a sudden substantial increase of movement or the absence of a healing period can also increase the risk of muscle and tendon tear. It’s important to keep active while gradually increasing activity.
Can larger tears heal?
The body is amazing at healing and will attempt to heal all tears. Larger tears will undergo some partial healing, reconnecting some of the tissue with the development of scar tissue. However, when fibres are distanced apart, it is unlikely that these will knit together.
What happens to my movement and function when my tear doesn’t fully heal?
The muscle or tendon that is torn will become weaker as less fibres can contract throughout the muscle. This can change the bodies biomechanics, causing abnormal movement. The good news is that with a full thickness tear, function can be restored. Research suggests that the muscle fibres around the tear can be strengthened, and other surrounding muscles can assist in creating the desired movement.
What are my options?
Conservative management:
This involves a combination of exercise therapy and manual therapy as well as various modalities to aid in the reduction of pain and increase in strength, range and function. Massage, dry needling, cupping and physiotherapy manipulations have been found to assist in pain reduction and the acute restoration of partial function. Other modalities such as hot and cold therapy, pain relieving and anti-inflammatory medication, ultrasound therapy, shock therapy, and TENS machines can assist in rehabilitation. Exercise therapy in the form of hydrotherapy, Pilates, and resistance training are key in strengthening the surrounding muscle fibres to restore function. Risks of conservative management are limited to mild risk of increasing the tear size.
Surgery:
Surgery involves stitching the muscle or tendon back together or reconnecting the tendon to the bone. This can increase function and movement once rehabilitation has been completed; however, rehabilitation will be prolonged to allow for adequate healing of the surgical site and tendon. Surgery is often offered to those under the age of 60 as an initial option, and conservative is often suggested initially for those over the age of 60 due to the decreased ability to heal over time. Risks of surgery include retear, complete rupture and possible infection.
Both options are advantageous and should be discussed with your GP or surgeon.
If you have a muscle or tendon tear, function can be restored through exercise rehabilitation +/- surgery. Let a Pivotal physiotherapist take you through your rehab journey and get you back to daily life feeling strong and mobile.
~ Jacob Spencer, Physiotherapist
References:
Radovanović, G., Bohm, S., Peper, K.K. et al. Evidence-Based High-Loading Tendon Exercise for 12 Weeks Leads to Increased Tendon Stiffness and Cross-Sectional Area in Achilles Tendinopathy: A Controlled Clinical Trial. Sports Med – Open 8, 149 (2022). https://doi.org/10.1186/s40798-022-00545-5
Guzzoni V, Selistre-de-Araújo HS, Marqueti RC. Tendon Remodeling in Response to Resistance Training, Anabolic Androgenic Steroids and Aging. Cells. 2018 Dec 7;7(12):251. doi: 10.3390/cells7120251. PMID: 30544536; PMCID: PMC6316563.
