Managing Tendinopathy

   Tendinopathy (pain or pathology of a tendon) is a complex topic.  Contrary to public opinion, it is relatively poorly understood by both healthcare providers and researchers alike.  When you get into the specifics of the cellular aspects of tendon pain and healing, you need to understand substances that have pro and anti-inflammatory effects, for example TNF∝, interleukin, substance P, neurotransmitters such as glutamate (frankly, I have a poor understanding of those things as well) and other factors such as neural and vascular ingrowth and fibrotic development.  There are also non-cellular factors that need to be considered such as central and peripheral sensitization.   In addition, non-synaptic intercellular signalling is poorly understood. The fact is, understanding the biology, physiology and anatomy of tendinopathy is in its infancy. throbbing achilles

  With all these cellular and neural pathways to consider, it is easy to understand why researchers and clinicians don’t fully understand tendon healing or what even causes pain to be felt in tendons.  As such, many clinicians turn to the simple solution of recommending some pain relievers or administration of an injection.  However, more recent research is showing that these solutions may do more harm than good.  For example…

The Use of Non-Steroidal Anti-Inflammatory Drugs (NSAID’s, such as Motrin, Ibuprofen etc)..

  1. Researchers found detrimental effects on tendon healing if oral Ibuprofen was administered within 7 days after surgical tendon repair as compared to no Ibuprofen given or Ibuprofen given after 7 days after surgery.  Study published in August 2014 – Clinical Orthopedics and Related Research
  2. Tendon to bone healing was reduced after administration of parecoxib or indometacin (both are non-steroidal anti-inflammatory drugs in Europe – similar to Celebrex and Ibuprofen).  Study published in 2008 – Bone and Joint Journal
  3. As I outlined above, there are many cellular factors involved in tendon healing.  These require certain “signalling” processes along with “migration” of other cells to the repair site.  It has been found in these two studies here and here, that Celebrex and Ibuprofen both inhibit these cellular processes from occurring which may, in part, account why tendon healing is impaired.
  4. Contrary to the negative studies I just listed, there is a potential benefit to taking non-steroidal anti-inflammatory (NSAID) meds such as Ibuprofen and that is reduction in adhesion formation and improved range of motion (here and here).  Some tendons in the body require the tendon to be able to glide freely relative to it’s sheath or surrounding soft tissues.  Any restrictions in motion could potentially be harmful (although manual soft tissue techniques such as Active Release Techniques may remedy this).  NSAIDs have been shown to reduce adhesion formation, thus improve the gliding ability of the tendon relative to its surroundings.  The tendon in question needs to be considered in this case.  For example, the Achilles or patellar tendons do not need to glide through a sheath or surrounding soft tissues like the flexor tendons of the wrist do.  However, the Achilles and patellar tendons are subjected to much higher loads, so full tendon healing strength is a priority.  Since NSAID’s appear to reduce healing strength, administration of NSAIDs for these tendons is questionable.

Use of Steroid Injections…

  1.  A 2013 study showed the use of corticosteroid injections in patients with “tennis elbow” resulted in better immediate improvements compared to placebo, however the patients who had the steroid injections were significantly worse off 6 months later and 1 year later.  There were also more recurrences in the steroid injection group.
  2. At the risk of being boring and listing many other studies just like the one above, let me just note a 2010 study that looked at 41 different published trials on the use of steroid injections for tendinopathy.  This review paper showed that there is “consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms.”  In other words, people feel better for a while after a steroid injection, but  later, they are typically worse off than patients who did not get a steroid injection for a tendinopathy.

   In our clinic, we heavily rely on mechanotherapy for patients with tendinopathy.  If you are unfamiliar with mechanotherapy, it is simply the use of mechanical loading on a tendon in order to stimulate cellular responses and structural changes.  For example, if you lift weights, your muscles will grow.  This is an example of a mechanical loading process, stimulating cellular responses which cause structural change.  Weight bearing exercises are another example in that they stimulate bone growth.  Conversely, if you are sedentary, there is no mechanical stimulation and muscles and bones will weaken.  The same can be said for tendons.  If you stimulate the tendon in the proper manner, tendon cells (tenocytes) will be stimulated through a process of cellular signalling that I won’t get into in this post.  If you are interested in the cellular processes, please read this article.

  What is well established, is that mechanotherapy, if done properly, has the best available evidence for treating tendinopathy for the long term.  The words “if done properly” are not there by accident.  Too little mechanical load doesn’t stimulate the tendon enough, whereas too much mechanical load may exceed the tissue tolerance and worsen the condition.  One must find the “Goldilocks” phenomenon – not too little and not too much mechanical load.  In addition, certain area of the tendons will respond better to certain types of loads.  For example, utilizing eccentric drops with end ROM dorsiflexion on an insertional Achilles tendinopathy causes compression of the tendon at the end ROM dorsiflexion and will likely make the condition worse.  Read more about the role of compressive loads and how it aggravates tendons here.

  The “art” of therapy is designing a program for each individual patient, based on the tendon that is injured, the location of the pain within the tendon (musculotendinous, mid-portion or insertional), the age of the patient, the patient’s beliefs about their tendinopathy and how to manage it, the goals of the patient, the biomechanics of the patient, the motivation of the patient, the compliance of the patient and quite a few other factors that will get boring if I list them all.

  In summary, the biologic and therapeutic understanding of tendinopathy is poor.  That being said, utilizing medications that alter the healing process is a bit of a shot in the dark, since we don’t fully understand how they affect tendons, but we know there are significant detrimental alterations.   For the better long term prognosis, however, I believe it is more prudent to progressively load the tendon and examine the patient’s biomechanics and training load/frequency.