Physiotherapy Treatment of Tendinopathy – Research Evidence

The following is a summary of the Research Evidence in relation to Tendinopathy. In particular the Physiotherapy Treatment of Tendinopathy. As per previous “Research Evidence” posts I plan to re-visit this post to keep it up to date.

General Research on Tendinopathy Treatment

Wasielewski and Kotsko (2007)

  • Systematic review looking at the use of eccentric exercise in management of lower limb tendinopathy.
  • Conclusions/Results:
    • Eccentric exercise is likely a useful treatment for lower extremity tendinosis, but whether it is more or less effective than other forms of therapeutic exercise is unclear.
    • Future investigators should recruit sufficient numbers of subjects and use valid, reliable, and patient-oriented outcome measures to evaluate the role of eccentric exercise in treating lower extremity tendinoses.

Woodley et al (2007)

  • Systematic review investigating the effectiveness of eccentric exericse on chronic tendinopathy.
  • Conclusions:
    • This review demonstrates the dearth of high-quality research in support of the clinical effectiveness of EE over other treatments in the management of tendinopathies.
    • Further adequately powered studies that include appropriate randomisation procedures, standardised outcome measures and long-term follow-up are required.

Drew et al (2012)

  • Systematic review to investigate the relationship between the observable structural change and clinical outcomes following therapeutic exercise.
  • Conclusions:
    • The available literature does not support observable structural change as an explanation for the response of therapeutic exercise except for some support from HSR.
    • Future research should focus on indentifying other explanations including neural, biochemical and myogenic changes.

Kaux et al (2011)

  • Literature review.
  • Conclusions:
    • Currently, eccentric training remains the treatment of choice for tendinopathy, even though some studies are contradictory. Moreover, many interesting new treatments are now being developed to treat tendinopathy, but there is little evidence to support their use in clinical practice.

Kaux et al (2011)

Cook (2011)

  • Article in British Journal of Sports Medicine.
  • Platelet-Rich Plasma:
    • A randomised trial has shown that it is no better than saline for pain, and did not improve ultrasound appearance, a surrogate measure for pathology.
  • Prolotherapy:
    • Added a small advantage over eccentric exercise alone in the short term (RCT).
  • Glyceryl Trinitrate Patches:
    • Longer-term outcome is no better than standard treatment.

Skjong et al (2012)

  • An excellent review on treatment of Tendinopathy.
  • NSAIDS:
    • There is little histologic or biochemical evidence of inflammation in the pathogenesis of tendinopathy.
    • Anti-inflammatories may actually inhibit tendon healing in response to injury.
    • Evidence supports use of both oral and local forms with clear benefits as short-term analgesics (7–14 days).
    • Little evidence showing long-term benefit.
  • Glycerol Trinitrate:
    • Nitric oxide has been shown to induce fibroblast proliferation and collagen synthesis in a rat Achilles tendon model.
    • Data shows GTN provides short-term pain relief in tendinopathy sufferers.
    • Long-term benefit remains in question.
  • Eccentric Exercise:
    • An accessible and effective treatment of tendinopathy with no reported adverse effects.
    • Should strongly be considered as a first-line intervention.
  • Extracorporeal Shock Wave Therapy:
    • Proposed mechanism of action is disruption of neoneuralization found in tendinopathic tissue that may be linked to symptomatic pain.
    • Use in treatment of tendinopathy cannot be definitively recommended as a first-line treatment.
  • Autologous Whole Blood Injections:
    • Aims to promote tendon healing by stimulating an angiogenic response and subsequent collagen regeneration.
    • Limited overall evidence to assess the efficacy.
  • Platelet Rich Plasma Injections:
    • Factors in platelets have been found to play vital roles in stimulating processes in the maintenance and repair of tendon tissue.
    • Use of PRP as an injection therapy for treatment of tendinopathy shows great promise.
    • Further study with additional high-quality randomized, controlled trials is necessary.
  • Corticosteroid Injections:
    • Current knowledge suggests that inflammation plays much less of a role in tendinopathy than originally thought.
    • One hypothesis for their proposed efficacy is that the degenerative change seen within affected tendons causes an inflammatory response in the surrounding tissue that may contribute to pain and swelling seen in cases of tendinopathy. In this setting, steroids would serve to offer symptomatic relief.
    • Recent literature seems to support the above, with the literature often showing short-term improvements in symptoms with few long-term benefits.
  • Sclerosing Agent Injections:
    • Research has shown an increase in neoneurovascularization in affected tendon tissue. It is believed that this increase in neural density contributes to the pain felt during active disease.
    • Injectable caustic agents aim to destroy neovessels and their accompanying nervous structures, reducing overall pain symptoms.
    • The use of sclerosing agents seems to offer great promise but currently lacks enough high-quality supporting evidence.
  • Aprotinin Injections:
    • Aims to counteract the effects of enzymes that degrade tendon matrix components.
    • The clinical use of aprotinin clearly requires further study before any meaningful conclusions can be drawn.
  • Prolotherapy Injections:
    • Proliferants are injected at the site of injury or pain and are purported to induce an inflammatory response.
    • Further study is warranted to validate the use of alternative injection therapy before widespread clinical adoption of the techniques.
  •  Surgical Management:
    • Focuses on the excision of fibrotic adhesions and areas of affected tendon that have failed to heal. Aim is to restore vascularity and stimulate viable tenocytes to promote repair.
    • Open debridement is the most commonly reported method.
    • Although there is evidence supporting surgical intervention for cases of chronic tendinopathy, predicting which patients will have continued problems postoperatively is difficult. Treatment failure rates can be as high as 20% to 30%.
    • Surgical intervention should be held as a last resort for only those patients who have not responded to an extensive course of conservative management.
  • Overall Conclusions:
    • A reasonable first line of treatment for tendinopathy should include a course of NSAIDs and eccentric exercise-based physical therapy.
    • Corticosteroid injections seem to offer excellent short-term pain relief but lack long term efficacy.
    • Alternative injections, such as PRP, have shown short-term efficacy for tendinopathy sufferers.
    • Data is lacking to support sclerosing agents and proteinase inhibitors.
    • Operative management seems to offer some benefit in symptomatic relief but carries a higher complication rate than other treatment options and should be reserved only for patients recalcitrant to other more conservative options.
    • It is important to note that a lack of high-quality evidence supporting specific treatments does not necessarily imply that they are inherently ineffective.

Specific Tendinopathies

Achilles Tendinopathy Treatment

Kingma et al (2007)

  • Systematic review investigating the effect of eccentric trainng in patients with chronic achilles tendinopathy.
  • Conclusions:
    • The effects of eccentric exercise training in patients with chronic Achilles tendinopathy on pain are promising; however, the magnitude of the effects cannot be determined.
    • Large, methodologically sound studies from multiple sites in which functional outcome measures are included are warranted.

Wiegerinck et al (2012)

  • Systematic review looking at treatment (surgical, extracorporeal shock wave ttreatment, ecccentric exercises) of Achilles Tendinopathy.
  • Conclusions:
    • Despite differences in outcome and complication ratio, the patient satisfaction is high in all surgical studies. It is not possible to draw conclusions regarding the best surgical treatment for insertional Achilles tendinopathy.
    • ESWT seems effective in patients with non-calcified insertional Achilles tendinopathy.
    • Although both eccentric exercises resulted in a decrease in VAS score, full range of motion eccentric exercises shows a low patient satisfaction compared to floor level exercises and other conservative treatment modalities.

Kramer et al (2010)

  • Systematic review investigating eccentric training in chronic achilles tendinopathy.
  • Conclusions:
    • In spite of different compliance, effects of eccentric training in conservative treatment of chronic mid-portion-Achilles tendinopathy are promising.
    • Because of the heterogeneous outcome variables (ordinal scale, VAS, FAOS, AOFAS, VISA-A) and the methodological limitations of the trials, no definite recommendation can be published concerning dosage and duration of eccentric training in chronic Achilles tendinopathy.

Scott et al (2011)

  • Literature review on conservative treatment of chronic achilles tendinopathy.
  • Key points/Conclusions:
    • Heavy-load (eccentric) exercise is currently the cornerstone of management of chronic Achilles tendinopathy, but it may take up to 12 weeks or longer of daily supervised exercise to see substantial improvements.
    • Nonsteroidal anti-inflammatory drugs have little long-term benefit and there is insufficient evidence to support use of shock wave therapy.
    • Corticosteroid injections should be avoided and other injection therapies are still in the experimental stage.
    • Orthotics may be helpful in patients with an identifiable biomechanical abnormality, but braces and splints have no proven benefit.

Patella Tendinopathy Treatment

Larsson et al (2011)

  • Systematic review investigating treatment of patella tendinopathy.
  • Conclusions:
    • Physical training, and particularly eccentric training, appears to be the treatment of choice for patients suffering from patellar tendinopathy. However, type of exercise, frequency, load, and dosage must also be analyzed.
    • Other treatment methods, such as surgical treatment, sclerosing injections, and shockwave therapy, must be investigated further before recommendations can be made regarding their use.
    • Ultrasound can likely be excluded as a treatment for patellar tendinopathy.
    • There is a persistent lack of well-designed studies with sufficiently long-term follow-up and number of patients to draw strong conclusions regarding therapy.

Lateral Elbow Tendinopathy Treatment

Malliaris et al (2008)

  • Systematic Review
  • Conclusion
    • Eccentric training in the management of LET has demonstrated encouraging results, although the literature is limited and eccentric programs are varied. Future studies should investigate factors that may influence the outcome of eccentric training, including whether training is painful and the duration of eccentric training.

References:

Cook J. Tendinopathy: no longer a ‘one size fits all’ diagnosis. Br J Sports Med. 2011 Apr;45(5):385.

Drew BT, Smith TO, Littlewood C, Sturrock B. Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises intendinopathy: a systematic review. Br J Sports Med. 2012 Oct 31. [Epub ahead of print]

Kaux J, Forthomme B, Le Goff C, Crielaard J and Croisier J. Current opinions on tendinopathy. Journal of Sports Science and Medicine (2011) 10, 238-253.

Kingma JJ, de Knikker R, Wittink HM, Takken T. Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. Br J Sports Med.

2007;41:e3.

Krämer R, Lorenzen J, Vogt PM, Knobloch K. [Systematic review about eccentric training in chronic achilles tendinopathy]. [Article in German]. Sportverletz Sportschaden. 2010 Dec;24(4):204-11. doi: 10.1055/s-0029-1245820. Epub 2010 Dec 14.

Larsson ME, Käll I, Nilsson-Helander K. Treatment of patellar tendinopathy–a systematic review of randomized controlled trials. Knee Surg Sports Traumatol Arthrosc. 2012 Aug;20(8):1632-46. doi: 10.1007/s00167-011-1825-1. Epub 2011 Dec 21.

Malliaras P, Maffulli N, Garau G. Eccentric training programmes in the management of lateral elbow tendinopathy. Disability and Rehabilitation 2008;30(20-22):1590-1596

Scott A, Huisman E, Khan K. Conservative treatment of chronic Achilles tendinopathy. CMAJ. 2011 Jul 12;183(10):1159-65. doi: 10.1503/cmaj.101680. Epub 2011 Jun 13.

Skjong CC, Meininger AK, Ho SSW. Tendinopathy Treatment: Where is the Evidence? Clin Sports Med 31 (2012) 329–350.

Wasielewski NJ and Kotsko KM. Does Eccentric Exercise Reduce Pain and Improve Strength in Physically Active Adults With Symptomatic Lower Extremity Tendinosis? A Systematic Review. J Athl Train. 2007 Jul-Sep; 42(3): 409–421.

Wiegerinck JI, Kerkhoffs GM, van Sterkenburg MN, Sierevelt IN, van Dijk CN. Treatment for insertional Achilles tendinopathy: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2012 Oct 6. [Epub ahead of print].

Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med 2007;41:188-198.

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Branch Councillor on the Western Australian Branch of the Australian Physiotherapy Association.

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