In the previous two posts in this series, we learned how research over the past 20 years into tendon pain and injury had led to fundamental changes to how we understand what’s going on when someone experiences tendon pain. We discussed the change in terminology used in light of the discovery that inflammation was not a factor in tendon damage, and more recently how tendon injury can be divided into stages along a continuum. This system, increasingly embraced in the contemporary sports medicine community, has also served to simplify treatment choices, as selection is now guided by tendinopathy stage. Importantly, the realization that treatment choice is driven by stage of tendinopathy also tells us why and when a particular treatment may be inappropriate. These are discussed below.
Best practice management of tendinopathy, according to stage:
From the previous post, we learned that acute, or reactive tendon pain can occur before actual damage is caused to the tendon, and as such, is reversible. It is a time of high metabolic activity, and so it is not considered a good idea to be using treatment techniques that would stimulate this further, such as friction massage or injections. Optimal treatments during either the reactive or acute-on-chronic stage include:
- Tendon unloading or rest – this is the only stage when you might consider resting a tendon
- Isometric or static hold exercises – known to have a pain-relieving effect on acutely painful tendons, can be progressed to very slow, heavy repetitions within specific ranges
- Ibuprofen – not because of its anti-inflammatory actions (since tendinopathy isn’t an inflammatory condition), but rather because of its effect on a compound called Aggrecan. Aggrecan isn’t welcome in tendons, but starts to accumulate in the reactive stage. Ibuprofen, and to a lesser extent other anti-inflammatories like Indomethacin and Naproxen, have a helpful side effect of being aggrecan inhibitors.
- Green tea, fish oil – these compounds are known as anti-oxidants, but additionally they inhibit the formation of another undesirable protein found in reactive tendons called TNFα (tumor necrosis factor alpha if you must know!)
- Doxycycline – primarily used as an antibiotic and anti-malarial, Doxy is also an effective TNFα inhibitor. Requires a prescription. Taking this and Ibuprofen together increases the potency of Doxycyline’s TNFα inhibition effect.
Dysrepair, being an intermediate stage, takes some of its management priniciples from both acute and chronic classifications. Structural changes have started to occur in the tendon, such as a change in the collagen/ground substance mix and the ingrowth of small blood vessels. This is a progression of the ‘failed healing response’
- Exercise therapy during the dysrepair phase, like that in chronic tendinopathy, requires a more formal structure and progression, allowing time for the injured tendon to adjust to the demands that are being placed upon it. Progression from very slow, heavy resistance exercise to eccentric exercise protocols (see below) and alternating high/medium/low loading days
- Medications (see below for more information)
- Green tea, fish oil and Ibuprofen (the triple cocktail) may still provide symptomatic relief
- Polidocanol injections, designed to sclerose the new blood vessels growing into the tendon, are often employed during this stage
- Platelet-rich plasma (PRP) injections are sometimes used during this stage
- GTN (glyceryl trinitrate) patches, used in the treatment of angina, are sometimes cut into quarters and applied over the area of tendon damage with the aim of increasing local blood flow to the area.
- Massage and manual therapy – applied to the muscle belly, rather than the tendon itself, may play a supplementary role in managing local tightness and tenderness.
Fig. 1 – An example of the graduated progression of loading (strengthening) exercises for the Achilles tendon
Tendon metabolism during the chronic or degenerative stage has slowed down quite a lot – there’s not much going on in the tendon by this stage, unless an acute-on-chronic reaction is provoked. Structural damage is nevertheless present, and therefore therapies at this stage are directed more at stimulating repair and remodeling of the tendon.
- Injections – depending on the school of thought, injection therapy may comprise an effort to get the tendon to heal, initiate a scarring response, or to selectively ablate small blood vessels growing into the tendon.
- Platelet-Rich Plasma (PRP) – increasingly popular in the US, this involves taking a patient’s own blood and spinning it in a centrifuge to extract all the good bits like growth factors and healing promotors, then injected back into the tendon, with the aim of stimulating healing
- Prolotherapy – involves the injection of something like dextrose into the tendon, essentially to irritate it and generate a scarring response. Also used in the treatment of damaged or lax ligaments.
- Polidocanol – has the effect of killing off the additional blood vessels that are known to grow into the tendon during this stage. These vessels are considered by some to be a source of pain within the tendon.
- Cortisone – the use of steroid anti-inflammatories is no longer recommended, as they have been shown to weaken the tendon structure (predisposing to rupture) and also since tendinopathy is no longer considered an inflammatory condition.
- Extracorporeal Shock Wave Therapy (ESWT) is currently more popular in Europe and Australia than it is here, but there is a growing body of research that suggests it is helpful in treating chronic, recalcitrant cases of tendon pain that have proven resistant to other conservative therapies. The device used emits an acoustic pulse that stimulates tenocyte (the cell that drives tendon metabolism) activity in the damaged tendon. The treatment is mildly unpleasant but takes only several minutes.
- Massage and manual therapy – not considered to play a significant role in the management of tendinopathy, but may provide some symptomatic relief of local tightness and tenderness.
- Exercise is the most potent stimulus for tendon remodeling. Since the rate of change in tendons is much slower than that of muscles, it is critical that any therapeutic exercise program be progressed carefully and structured so that the tendon has enough time between loading efforts to adapt (sets, repetitions, frequency)
- A popular program is the eccentric exercise protocol developed by the Swedish researcher Hakan Alfredsson. It seems to be more effective with damage to the middle of the tendon as opposed to where it joins with the bone.
- Often sufferers of chronic tendinopathy have developed strength deficits or muscle wasting, which needs to be addressed through appropriate strengthening exercise programs
- Once a patient has progressed to impact loading activities – jumping, hopping, running – the exercise program can be progressed to include alternating high/low or high/medium/low load days
- A final, important component of exercise therapy with degenerative tendinopathy is the appreciation and correction of any biomechanical or movement pattern anomalies that may be contributing to the onset or maintenance of the problem. An experienced physical therapist, with their understanding of biomechanics, tissue pathology and exercise is ideally placed to deal with these kinds of issues.
Indeed, alongside the medical doctor, the sports physical therapist plays a major role in the effective management of all the different stages of tendinopathy. Occasionally some tendons may require surgical intervention, but the majority of cases can be effectively treated with a combination of the correct type and progression of exercise and prudent use of medication.