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Treatment of Tendinopathy – Research Update – February 2014

I thought it might be time to begin revisiting some of the key topics I have covered thus far. The first topic to update being Treatment of Tendinopathy. For those interested, my last post in this topic can be found here.

One of the great recent articles I reviewed was by Rio et al (2014). The title being –  The pain of tendinopathy: physiological or pathophysiological?

Some of the key points that Rio et al (2014) made were:
  • Some clinical features of tendinopathy are consistent with tissue disruption, whilst others are not.
  • Results of investigations do not always match symptoms.
  • The relation between pain and evidence of tissue disruption is variable.
  • The investigation into mechanisms for tendon pain should extend beyond local tissue changes and include peripheral and central mechanisms of nociception modulation.

don’t think too many of us would disagree with the above!

Onto the Treatment of Tendinopathy….

Eccentric Exercise

Malliaris et al (2013) published a systematic review to evaluate the evidence in studies that compare two or more loading programmes (e.g. concentric vs eccentric) in treatment of achilles and patellar tendinopathy. Thirty-two studies were included in the final review.

Key results/conclusions from Malliaris et al (2013) being:

  • Limited (achilles) and conflicting (patellar) evidence that clinical outcomes are superior with eccentric loading compared with other loading programmes.
  • The only potential mechanism that was consistently associated with improved clinical outcomes in both achilles and patellar tendon rehabilitation was improved neuromuscular performance (e.g. torque, work, endurance), and Silbernagel-combined (achilles) HSR (heavy slow resistance) loading (patellar) had an equivalent or higher level of evidence than isolated eccentric loading.
  • In the Achilles tendon, a majority of studies did not find an association between improved imaging and clinical outcomes, including all high-quality studies.
  • In contrast, HSR loading in the patellar tendon was associated with reduced doppler area and anteroposterior diameter, as well as greater evidence of collagen turnover, and this was not seen following eccentric loading.
  • HSR seems more likely to lead to tendon adaptation and warrants further investigation.
  • There is little clinical or mechanistic evidence for isolating the eccentric component, although it should be made clear that there is a paucity of good quality evidence and several potential mechanisms have not been investigated.
  • Clinicians should consider eccentric-concentric loading alongside or instead of eccentric loading in Achilles and patellar tendinopathy.
  • Good-quality studies comparing loading programmes and evaluating clinical and mechanistic outcomes are needed in both Achilles and patellar tendinopathy rehabilitation.

Glyceryl Trinitrate Patches

Steunebrink et al (2013) conducted a randomised, double-blind, placebo-controlled clinical trial to assess if continuous topical glyceryl trinitrate (GTN) treatment improves outcome in patients with chronic patellar tendinopathy when compared with eccentric training alone. The treatment was a  a 12-week programme of using a GTN or placebo patch in combination with eccentric squats on a decline board. Measurements were performed at baseline, 6, 12 and 24 weeks. Primary outcome measure was the VISA-P questionnaire. Conclusions from the study being:
  • Continuous topical GTN treatment in addition to an eccentric exercise programme does not improve clinical outcome compared to placebo patches and an eccentric exercise programme in patients with chronic patellar tendinopathy.

 Extracorporeal Shock Wave Therapy (ESWT) for Chronic Achilles Tendinopathy

Al-Abbad and Simon (2013) conducted a systematic review on this treatment for insertional and non-insertional Achilles tendinopathies.  Conclusions being:
  • There was consistent evidence from 4 reviewed studies on the effectiveness of ESWT in the management of patients with chronic Achilles tendinopathies at a minimum 3 months’ follow-up.
  • Common methodological deficiencies in the included studies were not blinding the clinician and participants.
  • The review showed satisfactory evidence for the effectiveness of low-energy ESWT in the treatment of chronic insertional and non-insertional Achilles tendinopathies at a minimum 3 months’ follow-up before considering surgery if other conservative management fails.
  • Combining ESWT with eccentric loading appears to show superior results.

Surgery for Achilles Tendinopathy

Alfredson et al (2012) conducted a study to evaluate the outcome of surgery for Achilles tendinopathy. The study was an observational one that followed the outcomes of 13 patients with chronic painful bilateral mid-portion Achilles tendinopathy. Key elements of the study being:

  • The most painful side at the time for investigation was selected to be operated on first.
  • Treatment was ultrasound-guided and Doppler-guided scraping procedure outside the ventral part of the tendon under local anaesthetic. The patients started walking on the first day after surgery.
  • Primary outcomes measured were:
    • Pain (visual analogue scale).
    • Specimens from Achilles and plantaris tendons in three patients with bilateral Achilles tendinosis were examined.

Results/conclusions were interesting and showed:

  • Postoperative improvement on the non-operated side as well as the operated side in 11 of 13 patients.
  • Final follow-up after 37 (mean) months showed significant pain relief and patient satisfaction on both sides for 11 patients.
  • In 2 of 13 patients operation on the other, initially non-operated side, was instituted due to persisting pain.
  • Morphologically, it was found that there were similar morphological effects, and immunohistochemical patterns of enzyme involved in signal substance production, bilaterally.
  • Unilateral treatment with a scraping operation can have benefits contra-laterally; the clinical implication is that unilateral surgery may be a logical first treatment in cases of bilateral Achilles tendinopathy.

My Thoughts?

With regards to eccentric exercise, the Malliaris et al (2013) article does not surprise me. Personally I have used eccentric exercise with patients in the past, but I have also used concentric exercise, and a combination of the two! I have to say outcomes have been similar (bearing in mind this is just my clinical evidence!). I think the critical elements in treating tendinopathy are, broadly:
  • Reduce load to a tolerable level to avoid constant symptom exacerbation. Then gradually increase it again as symptoms, and rehabilitation, allow.
  • Target rehabilitation to gradually build up the ability for the tendon to tolerate load in the functional aggravating activity(s). This may also include range of movement exercises in addition to the obvious strength/loading exercises. Where I think we sometimes go wrong with the rehabilitation is:
    • Progressing exercises too quickly and exacerbating symptoms.
    • Not progressing rehabilitation to a functional level e.g. leaving someone doing bilateral calf/heel raises to rehabilitate their achilles for running/jumping without progressing them to exercises such as single leg calf raises or hopping.
    • Not assessing for, and/or addressing, psychosocial elements! Sorry had to throw that in…..

I have to say the ESWT systematic review results were surprising. Although we have to recognise that there was only a small number of studies and the authors did report potential issues with the studies included. I have very little experience in patients receiving this form of treatment so cannot really comment further.

The Alfredson et al study was really interesting! Why would the non-operated side also improve? The most obvious explanation that jumps to my mind is that perhaps post surgery the patients overall load that their non-operated tendon was experiencing was reduced and hence recovery occurred. I.e. they took it easier after surgery than pre-surgery!

Interested to hear other views and thoughts!

Thanks for reading.

References:

Al-Abbad H, Simon JV.  The effectiveness of extracorporeal shock wave therapy on chronic achilles tendinopathy: a systematic review. Foot Ankle Int. 2013 Jan;34(1):33-41.

Alfredson H, Spang C, Forsgren S. Unilateral surgical treatment for patients with midportion Achilles tendinopathy may result in bilateral recovery. Br J Sports Med. 2012 Nov 28. [Epub ahead of print]

Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013 Apr;43(4):267-86.

Rio E, Moseley L, Purdam C, Samiric T, Kidgell D, Pearce AJ, Jaberzadeh S, Cook J. The pain of tendinopathy: physiological or pathophysiological? Sports Med. 2014 Jan;44(1):9-23.

Steunebrink M, Zwerver J, Brandsema R, Groenenboom P, van den Akker-Scheek I, Weir A. Topical glyceryl trinitrate treatment of chronic patellar tendinopathy: a randomised, double-blind, placebo-controlled clinical trial. Br J Sports Med. 2013 Jan;47(1):34-9.

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.

3 Comments on "Treatment of Tendinopathy – Research Update – February 2014"

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  1. Tom Rizzo says:

    Hi Mark,
    I, too, have found a combination of concentric and eccentric exercises to be just as helpful as pure eccentrics. And, of course, attention to the patient’s expectations and psychosocial factors!
    Thanks for another great post.

    • Mark Gibson says:

      Thanks for the comment Tom. Great point about expectations and psychosocial factors. I think that in many cases they are the most important factors!

      I also think that eccentrics are sometimes confusing for patients to understand! So it’s good to see concentrics have some evidence behind them.

      Thanks for participating on the blog.

      Cheers
      Mark

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