Tendinopathy Treatment

• Identification & elimination of the cause of tendinopathy
• Behavior modification to minimize or eliminate sources of continuing irritation
• Specialist referral for appropriate follow up care
• To reduce pain & to return function

• Effectively relieve pain & inflammation
• It is unclear whether NSAIDs are more effective than other analgesics since majority of chronic tendinopathies are not inflammatory
• Topical administration of NSAIDs, through gels or patches, has also been used to reduce tendon pain
  • Eliminates the risk of gastrointestinal (GI) bleeding associated w/ systemic use
• Analgesics & NSAIDs are good options for short-term (5-7 days) treatment of pain
  
  • Studies showed efficacy of NSAIDs in the treatment of acute shoulder tendonitis but not w/ lateral epicondylitis & Achilles tendinopathy
• No clear evidence on the efficacy of NSAIDs in the long-term treatment of chronic tendinopathy

• There are no evidence-based guidelines to recommend the use of local corticosteroids injection in tendinopathy
• Effectiveness & risk of corticosteroid treatment vary w/ the duration of symptoms & route of drug delivery
• Locally injected corticosteroids are more effective than oral NSAIDs for relief in the acute phase of tendinopathy pain; however, they do not alter long-term outcomes
  
  • Strong evidence support its use in relieving pain for up to 6 weeks but there is no evidence to support its benefit in long-term treatment beyond 6 months
• May inhibit healing & decrease the tensile strength of the tissue which may predispose to spontaneous rupture
  
  • Corticosteroids should not be injected into major tendons like Achilles tendon & patellar tendon, which may be at risk of spontaneous rupture if already weakened
• Risks associated w/ corticosteroid injections can be decreased by injecting under fluoroscopic guidance to ensure that the injection is around the tendon & not intratendinosus

• Studies showed that the administration of glyceryl trinitrate patches over affected tendons deliver nitric oxide which acts as cellular messenger & helps in tendon healing
  
  • It also provides pain relief & improves function in patients w/ lateral epicondylitis, Achilles tendinopathy & rotator cuff tendinopathy
• Larger multicenter trials are needed to validate this treatment option

Relative Rest

• Refers to avoidance of abuse & not absence of activity
• Appropriate treatment during the acute phase of tendinopathy pain
• Prevents ongoing damage, decreases pain & promotes tendon healing
• Avoid activities that are heavy & may aggravate pain
• Most physicians encourage continuation of daily activities as long as it does not worsen the pain
  • Tensile loading of the tendon enhances collagen production & promotes normal alignment of newly formed collagen fibers
• Avoid complete immobilization to prevent muscle atrophy & deconditioning
• Brief sling immobilization is a suggested treatment for calcific tendinopathy
  • Prolonged immobilization may result in adhesive capsulitis
• No specific recommendation for the length of rest needed
• Effective for short-term pain relief
• Reduces pain & swelling in acute inflammatory tendinopathies by blocking the inflammatory response
• Slows the release of blood & proteins from the surrounding blood vessels by decreasing tissue metabolism
• Based on a recent systematic review of cryotherapy, application of ice through wet towel for 10-minutes is very effective

• Appropriate during the acute phase of tendinopathy pain
• Performed after the pain has subsided
• Helps promote the formation of new collagen
• Eccentric strengthening is an effective therapy for tendinopathies
  • A 12-week course of eccentric strengthening program was more effective than the traditional concentric strengthening exercises for treating patellar & Achilles tendinopathy
    
    • There is improvement in pain levels, & thinning & normalization of the tendons on ultrasound & magnetic resonance imaging (MRI) of patients w/ Achilles tendinopathy
  • Showed success in treating lateral epicondylitis by improvement in pain, strength & function
  • More effective when combined w/ static stretching exercises, therapeutic ultrasonography, extracorporeal shock wave therapy (ESWT), ionophoresis, or low level laser therapy
• Perform stretching exercises following activity, when muscles are warm
  • Stretching before an activity does not prevent injury & may lead to decrease in muscle strength
• Regular stretching should be done 3-5 days/week
• Stretching w/ deep friction massage of the gastrocnemius-soleus complex are considered helpful in Achilles tendinopathy
• Modify the exercise program based on patient’s response after 6-12 weeks
• If patient improves, continue the exercise program for 6-12 months

Activity Modification

• Important that employers & coaches be aware of the treatment plan (eg limit the volume & intensity of loads on the injured tendon for a designated period)
  
  • Necessary to eliminate pain & promote tendon healing

• Several studies have found associations between abnormal biomechanics or specific performance characteristics & development of tendinopathy
• Specific performance or biomechanics of the task should be evaluated & analyzed by a knowledgeable sports medicine clinician, ergonomics specialist, or a trained physiotherapist or kinesiologist

• Used as adjuncts to reinforce, unload & protect tendons during activity
• Safe, widely used & helpful in correcting biomechanical problems (eg excessive foot pronation, pes planus deformity)

• Uses whole blood or platelet-rich plasma
• Studies have shown improvement in pain & functional disability in patients treated w/ platelet-rich plasma injection
• The injected blood may contain growth factors that stimulates healing of the affected tendon
• May be done only when patient is unresponsive to both conservative & pharmacological therapies

• Utilizes acoustic, low-energy shock waves directly over the painful area of the tendon to alter the structural & neurochemical properties of tissues
• Decreases pain & enhances tendon healing
• Appears to be safe & effective
• May be used to treat lateral epicondylitis, calcific & noncalcific tendonitis of the supraspinatus & Achilles tendinopathy

• Electrical & ultrasonographic impulses are used to deliver topical nonsteroidal anti-inflammatory drugs (NSAIDs) & corticosteroids to symptomatic subcutaneous (SC) tissues
• Widely used & may be effective
• Corticosteroid iontophoresis is effective in improving patellar tendinopathy pain & function

• Chronic tendinopathy is associated w/ neovascularization of affected tendons
• Injection of a sclerosing agent (eg Polidocanol) may help reduce neovascularity based on small clinical trials for chronic midportion Achilles & patellar tendinopathy
  • Injections appear to provide pain relief
  • Injections are done under Doppler ultrasound guidance
• Larger clinical trials are needed to determine the effectiveness of this treatment

Therapeutic Ultrasonography

• Produces high frequency vibrations that generate heat which penetrates superficial tissues & improve blood flow
• Reduces pain & promotes collagen synthesis
• Effective for treatment of calcific tendinopathy
• Evidence for its consistent benefit in tendinopathies is weak