Tendinopathy

Originally tendinopathy was thought to be a form of inflammation and was termed “tendinitis” or “tendinosis” but research has now found that inflammation is not always present with tendon pain and is therefore now term “Tendinopathy”

Common areas affected may include:

•  Rotator cuff tendinopathy (shoulder)
•  Lateral Epicondylitis (tennis elbow) Medial Epicondylitis (golfers Elbow)
•  Wrist tendinopathy (De-Quervins Tendinitis/tenosynovitis)
•  Gluteal Tendinopathy (Outer hip area)
•  Patella Tendinopathy (Knee)
•  Peroneal tendinopathy (outer foot and ankle joint)
•  Tibialis posterior (inside foot and ankle joint)
•  Plantarfacsitiis (sole of the foot)

 

FACTS ABOUT TENDINOPATHY

1. Rest does not improve tendinopathy- Pain may settle with rest, but will be back when returning to activity, because rest does not increase the tendons ability to cope with load.
2. Exercise is the top treatment for tendinopathy- Exercise is the most evidence-based treatment for tendinopathy. In a vast majority of cases (but not all) tendinopathy will not improve without the vital load stimulus given by exercising.
3. Modifying load is very important- Load modification is important in settling tendon pain. This often involves reducing (at least in the short-term) tendon load, avoiding high impact activity/compression or stress to the area. Tendons then need to be loaded progressively so that they can develop greater tolerance (strength) to the loads that an individual needs to endure in their day-to-day life.
   Applying an ice pack to help with pain and rest can help initially settle tendon pain for the first few days, following this isometric exercise should be started which help the body to produce natural pain relieving chemicals.
4. Exercise needs to be individualised- This is based on each individual’s pain and presentation. There should be progressive, steady increase in exercise to enable restoration of movement whilst respecting pain.
5. Tendinopathy responds very slowly to exercise- You need to have patience, ensure that exercise is correct and progressed appropriately, and try and resist the common temptation to accept ‘short cuts’ like injections and surgery. There are often no short cuts.
   Some tendons can take 9-12 months to gain their full strength and capacity, where-as others usually take a minimum of 12 weeks
6. Tendinopathy rarely improves long term with only passive treatments- Such as massage, therapeutic ultrasound, injections, shock-wave therapy etc. Exercise is often the vital ingredient and passive treatments are adjuncts. Multiple injections in particular should be avoided, as this is often associated with a poorer outcome.
7. Tendinopathy is not considered a classic inflammatory response- Although there are some inflammatory biochemical and cells involved in tendinopathy, it is not considered to be a classic inflammatory response. Anti-inflammatories may help if you have very high pain levels but it is unclear what effect they have on the actual cells and pathology.
8. The cause of tendinopathy can be multifactorial- The main factor is a sudden change in certain activities – these activities include 1) those that require the tendon to store energy (i.e. walking, running, jumping), and 2) loads that compress the tendon. Some people are predisposed because of biomechanics (e.g. poor muscle capacity or endurance) or systemic factors (e.g. age, menopause, elevated cholesterol, increased susceptibility to pain, etc). Predisposed people may develop tendon pain with even subtle changes in their activity.
   

   Extrinsic Risk Factor	Intrinsic Risk factors
   Sudden change in load	Age, gender & genetics
   Technique	Increased BMI (weight), increased adipose tissue, body shape
   Equipment	Other conditions: Rheumatoid Arthritis, Diabetes
   Circumstances	Metabolic and Hormonal changes
   Diet- High Cholesterol, glucose	Fitness: Muscle weakness, previous injury
   Medication- Steroids, statins, Anti-biotics	Tendon Abnormalities
   	Psychological State: anxiety and stress

9. Pathology on imaging does not equal pain- Pathology is common in people without pain. Also, if you have been told you have ‘severe pathology’ or even ‘tears’ this DOES NOT necessarily mean you will not get better or have a poorer outcome.
10. Pathology is not likely to reverse in most cases- We know that even with the best-intentioned treatment (exercise, etc) the pathology is not likely to reverse in most cases. Therefore, most treatments are targeted towards improving pain and function, rather than tissue healing, although this still is a consideration.

 

Please, note that these are general principles and there are instances when further investigations/treatment options are required and these can be discussed with your physiotherapist.

References – Abate M, Gravare-Silbernagel K, Siljeholm C, et al.: Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Research and Therapy. 2009, 11:235. – Cook J, Purdam C: Is compressive load a factor in the development of tendinopathy? British Journal of Sports Medicine. 2012, 46:163-168. – Littlewood C, Malliaras P, Bateman M, et al.: The central nervous system–An additional consideration in ‘rotator cuff tendinopathy’and a potential basis for understanding response to loaded therapeutic exercise. Manual therapy. 2013. – Malliaras P, Barton CJ, Reeves ND, Langberg H: Achilles and Patellar Tendinopathy Loading Programmes. Sports Medicine. 2013:1-20.