Tendinopathy Treatment: Where is the Evidence?
Section snippets
Prevalence
In epidemiologic terms, overuse injuries, including tendinopathy, account for approximately 7% of all physician office visits in the United States.4, 5 This is in large part because of the increased participation in recreational sports as well as the increased duration and intensity of training within organized athletics.6 In fact, greater than 30% of injuries related to sports activity result from or have a component of tendinopathy.7 More specifically, 30% of all running-related injuries and
Pathophysiology
Tendinopathy is a general descriptor that includes any painful condition occurring within or around a tendon. Often in response to overuse, it is characterized by activity-related pain, focal tenderness to palpation, and decreased strength in the affected area. Tendinopathy is often labeled an overuse injury theoretically resulting from tendon cells being exposed to a high volume of repetitive load. Certain anatomic locations are therefore predisposed to injury, including the Achilles,
Anti-inflammatories
Traditionally, nonsteroidal anti-inflammatory drugs (NSAIDs) have been used as a treatment for tendon overuse injuries for decades. Classically, and most commonly, oral administration has been the preferred application; although, local NSAID administration, through the use of gels or patches, has recently become an acceptable alternative. There are, however, 2 flaws with this approach. First, there is little histologic or biochemical evidence of inflammation in the pathogenesis of tendinopathy.
Eccentric Exercise
Eccentric exercise has long been utilized as a component in rehabilitation and treatment of various forms of tendinopathy. Eccentric muscle contractions are those in which a muscle elongates while under tension (Fig. 3). Compared with concentric exercises (muscle fibers contract under tension), eccentric movements result in less oxygen consumption, less energy expenditure, and greater force production.31 It is hypothesized that this creates an environment with less heat and fewer waste products
Extracorporeal Shock Wave Therapy
Extracorporeal shockwave therapy (ESWT) has been used for treatment of various soft tissue injuries, including tendinopathy. ESWT involves administering a series of shock waves directly to a painful tendon. Its proposed mechanism of action is disruption of neoneuralization found in tendinopathic tissue that may be linked to symptomatic pain.42 There has also been evidence linking ESWT administration to increased tenocyte proliferation, which would benefit the healing process of an injured
Injection Therapy
Injectable substances have been used in the treatment of tendinopathy for decades, first reaching widespread acceptance with the use of corticosteroids when it was believed, albeit incorrectly, that an inflammatory process was the underlying cause of symptoms. This avenue of therapy has since evolved to include myriad options, including autologous whole blood injections, platelet-rich plasma, and injectable sclerosing agents. Promising results have been shown; however, investigations are of
Operative Management
The use of operative management for treatment of tendinopathy focuses on the excision of fibrotic adhesions and areas of affected tendon that have failed to heal. Ultimately, the aim is to restore vascularity and stimulate viable tenocytes to initiate protein synthesis and promote repair.121, 122 A recent study has found that tenotomies made in Achilles tendon did indeed trigger angiogenesis and increased blood flow, lending credence to the idea that surgical intervention can help create a more
Authors’ Preferred Technique
Achilles tendinopathy is a common cause of pain and disability in the running athlete and ranks among the most common conditions found in athletic training rooms and sports medicine clinics. While the mainstay of treatment is conservative, each treatment regimen ought to be customized to the athlete and his/her sport.
Initial treatment is centered on pain control and reducing inflammation. Relative rest from running, ice, elevation and compression are helpful acutely. We discourage our running
Summary
Tendinopathy is a common and debilitating condition that results in significant deficits in performance and prolonged time away from activity. For this reason, much effort has been placed in defining beneficial and cost-effective treatments. This review has outlined the current literature on some of the most widely used therapies for cases of tendinopathy. As such, recommendations remain limited by the evidence available.
The variability in both quantity and quality of research into tendinopathy
References (136)
- et al.
Genetic aspects of tendinopathy
J Sci Med Sport
(2008) Oxygen free radicals and tendon healing
J Shoulder Elbow Surg
(2007)- et al.
[Transdermal nitroglycerin versus corticosteroid infiltration for rotator cuff tendinitis]
Aten Primaria
(2001) - et al.
Successful treatment of shoulder pain syndrome due to supraspinatus tendinitis with transdermal nitroglycerinA double blind study
Pain
(1996) - et al.
Evidence of the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systematic review and meta-analysis
Arch Phys Med Rehabili
(2010) - et al.
Shock wave application to rat skin induces degeneration and reinnervation of sensory nerve fibres
Neurosci Lett
(2001) - et al.
Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinitis and increase TGF-beta1 and IGF-I expression
J Orthop Res
(2004) - et al.
Extracorporeal shock wave therapy for lateral epicondylitis—a double blind randomised controlled trial
J Orthop Res
(2002) - et al.
Autologous blood injections for refractory lateral epicondylitis
J Hand Surg Am
(2003) - et al.
Platelet-rich plasma: new clinical application: a pilot study for treatment of jumper's knee
Injury
(2009)
Treatment of tendon and muscle using platelet-rich plasma
Clin Sports Med
Basic biology of tendon injury and healing
Surgeon
Corticosteroid injections for lateral epicondylitis: a systematic review
Pain
Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial
Lancet 23
Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: a systematic review
Physiotherapy
Neurokinin 1-receptors and sensory neuropeptides in tendon insertions at the medial and lateral epicondyles of the humerusStudies on tennis elbow and medial epicondylalgia
J Orthop Res
Evaluation of lower extremity overuse injury potential in runners
Med Sci Sports Exerc
Impact and overuse injuries in runners
Med Sci Sports Exerc
A retrospective case-control analysis of 2002 running injuries
Br J Sports Med
Pathogenesis of tendinopathies: inflammation or degeneration?
Arthritis Res Ther
Deciphering the pathogenesis of tendinopathy: a three-stages process
Sports Med Arthrosc Rehabil Ther Technol
No influence of age, gender, weight, height, and impact profile in achilles tendinopathy in masters track and field athletes
Am J Sports Med
Mechanotherapy: how physical therapists' prescription of exercise promotes tissue repair
Br J Sports Med
Prevalence of jumper's knee among elite athletes from different sports: a cross-sectional study
Am J Sports Med
The long-term clinical and MRI results following eccentric calf muscle training in chronic Achilles tendinosis
Skeletal Radiol
Nonoperative treatment of midportion Achilles tendinopathy: a systematic review
Clin J Sport Med
Long-term prognosis of patients with achilles tendinopathyAn observational 8-year follow-up study
Am J Sports Med
Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe
Clin J Sport Med
No effect of piroxicam on achilles tendinopathyA randomized study of 70 patients
Acta orthopaedica Scandinavica
Analgesic efficacy of a lecithin-vehiculated diclofenac epolamine gel in shoulder periarthritis and lateral epicondylitis: a placebo-controlled, multicenter, randomized, double-blind clinical trial
Drugs Exp Clin Res
Celecoxib effectively treats patients with acute shoulder tendinitis/bursitis
J Rheumatol
Topical ketoprofen patch in the treatment of tendinitis: a randomized, double blind, placebo controlled study
J Rheumatol
Treatment of acute tendinitis and bursitis with fentiazac—a double-blind comparison with placebo
Clin Ther
Efficacy of diclofenac in lateral epicondylitis of the elbow also treated with immobilizationThe University of Montreal Orthopaedic Research Group
Arch Fam Med
Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care
BMJ
Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial
Am J Sports Med
Modulation of tendon healing by nitric oxide
Inflamm Res
Topical glyceryl trinitrate application in the treatment of chronic supraspinatus tendinopathy: a randomized, double-blinded, placebo-controlled clinical trial
Am J Sports Med
Randomised, double-blind, placebo-controlled clinical trial of a new topical glyceryl trinitrate patch for chronic lateral epicondylosis
Br J Sports Med
Topical glyceryl trinitrate and noninsertional Achilles tendinopathy: a clinical and cellular investigation
Am J Sports Med
Five-year prospective comparison study of topical glyceryl trinitrate treatment of chronic lateral epicondylosis at the elbow
Br J Sports Med
The role and implementation of eccentric training in athletic rehabilitation: tendinopathy, hamstring strains, and acl reconstruction
Int J Sports Phys Ther
Eccentric training of the gastrocnemius-soleus complex in chronic Achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by MRI
Am J Sports Med
Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis
Scand J Med Sci Sports
Eccentric exercise in treatment of Achilles tendinopathy
Scand J Med Sci Sports
Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial
Am J Sports Med
Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study
Br J Sports Med
Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players
Br J Sports Med
Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy—a randomized trial with 1-year follow-up
Scand J Med Sci Sports
Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis
Knee Surg Sports Traumatol Arthrosc
Cited by (57)
Transcatheter Arterial Embolization for Benign Chronic Inflammatory Joint Pain: A Systematic Review and Meta-Analysis
2022, Journal of Vascular and Interventional RadiologyTendon tissue engineering: Cells, growth factors, scaffolds and production techniques
2021, Journal of Controlled ReleaseCurrent trends in tendinopathy management
2019, Best Practice and Research: Clinical RheumatologyCitation Excerpt :The authors recommend that it may be used as an adjunct due to its analgesic effect and low side effect profile, in combination with an exercise program but not as stand-alone therapy. Treatments like ice, stretching, acupuncture, deep frictional massage, have been shown to have little efficacy [17,28,77]. Stretching is now believed to worsen compression and deep frictional massage can provoke pain with no gains in tendon function and should thus be avoided [28].
Early Results of Transcatheter Arterial Embolization for Relief of Chronic Shoulder or Elbow Pain Associated with Tendinopathy Refractory to Conservative Treatment
2018, Journal of Vascular and Interventional RadiologyTendinopathy
2017, Clinical Orthopaedic Rehabilitation: A Team Approach, Fourth Edition
Dr Skjong and Dr Meininger have no disclosures.
Disclosures: Biomet (Consultant, speaker), Smith and Nephew (Fellowship Grant, speaker), OREF (Fellowship Grant), Omega Medical Grants Association (Fellowship Grant), AANA (multiple committees), AOSSM (Council of Delegates), IAOS (Past President, Board of Directors), Medscape Reference/WebMD (Editor In Chief, Sports Medicine).