by Alan Jordan
Tendinopathy is a condition very frequently seen in any physiotherapy clinic. It is not exclusive to the active individuals but it is also common in people leading a sedentary lifestyle. The cause of tendon injuries tends to be multifactorial with both internal and external factors playing a part. Many tendons can be affected around shoulder, elbow, wrist, hip, knee & ankle joints.
In the recent couple of decades, the demand on sporting activities has increased, with competitive sports requiring more intense performances from athletes. More frequent intense training with external factors such as equipment not being adequately fitted to the individual puts the individual at a higher risk of tendinopathy.
What is a Tendinopathy?
A few years ago “tendinitis” was the term used most commonly to describe pathology of a painful tendon. Studies analyzing the cellular composition at the site of ailment revealed that although there is degeneration of tendons, there seems to be no inflammatory components. Therefore the term “tendinoathy” has been proposed for the clinical diagnosis of pain accompanied by impaired performance, and sometimes swelling in the tendon. Studies have suggested that inflammation may play a role in the initial stage of the injury but a degenerative process supersedes this, which leads to chronicity.
Progression of injury
Four stages form the classification of tendinopaties
- pain after sports activity
- pain at the beginning of sports activity which disappears with warm-up and sometimes reappearing with fatigue
- pain at rest and during activity
- rupture of tendon
When there is a repetitive mechanical strain that exceeds the capacity of the tendon, there is progressive damage to the structure of the tendon. The protein collagen is what tendons are mainly composed of. In tendinpathy, the alignment of this protein is disrupted. The type of collagen is also different, with abnormal amounts of a type of collagen associated with wound healing. There is cell death and a formation of a microvascular network.
Treatment and Management
There is passive versus active treatment and also conservative versus operative treatment. One does not necessarily exclude the other, but it is more of a question of understanding the stages of the injury and assessing the best possible treatment at that particular stage.
The acute phase is between 0 and 6 weeks; subacute phase between 6 and 12 weeks and if symptoms persist of progressively worsen then we consider the condition to be chronic. Clinical examination is the best way of examining the injury as there is poor correlation between diagnostic radiological examinations and symptoms. Ultrasound imaging is cheap, interactive and offers detail of the composition of the tendon examined. Imaging is useful for confirming the diagnosis in case of doubt, but it is not recommended for monitoring the success of treatment.
Conventional treatment such as rest or modified activity, cold, stretching, pain relieving physiotherapy modalities are initially employed in the acute phase, mainly to keep pain under control. Use of non-steroidal anti-inflammatory drugs may be also used to control acute pain, but as inflammation is not the major component to this type of injury, their use is not affective in the long term. Their use during the acute phase may lead to a sense of false improvement with the possibility of further damage if the offending activity is pursued.
Passive physiotherapy modalities such as therapeutic ultrasound, deep frictions, massage and acupuncture are frequently used but there is little evidence that this type of treatment on its own is sufficient to treat tendinopathies. Their use yields a better outcome if used with eccentric loading of the muscle-tendon complex. This means actively controlling lengthening of this complex against resistance. This type of mechanical force is converted into a cellular response with helps with improving the structure and tensile strength of the tendon and alignment of the collagen fibers. This form of treatment had the best scientifically researched outcome. Rehabilitation should also incorporate sports/activity specific exercise.
Corticosteroid injections were frequently used in the past but not so much these days. Steroids are considered to inhibit repair and protein synthesis. They may be helpful to control the pain in order to start active rehabilitation such as eccentric training as soon as possible.
External supports and orthotics can be used to reduce the tension on the injured structure and allow the treatment of choice to have the ideal environment to yield the best possible outcome. Analysis of movement is very important when a certain activity has been identified as the cause of the repetitive strain. Video analysis of running, cycling and other sports-specific movement is very important to prevent continuous insult to the effected tendon and recurrence once the problem is resolved.
Other modalities such as Extra-corporeal shock wave therapy, sclerotic injection, autologous blood injection, peritnedinous injection of aprotinin and ultimately surgery, are also used if conservative treatment has failed. These relatively new therapies still require the backing of good research.
The team approach with experienced practitioners is ideal to manage tendinopathies. The right intervention at the right time is the key point in resolving this otherwise tedious condition. At Broadgate Spine & Joint clinic out doctors, physiotherapists and consultants can advise and treat depending on the stage of your injury.
For more information please contact us on 020 7638 4330