Tendon Injury Tendinopathies
A Tendinopathy is a failure of the normal healing response of a tendon and develops after the tendon and surrounding structures has been overused. This is commonly seen in patients who have recently altered their daily activities or suddenly increased their training load, for example when preparing for a long-distance race. The tendon fibres become disrupted and some cells die. There is then a disorganised proliferation of tenocytes and a phenomena known as neovascularisation (New blood vessels develop in the tendon) resulting in pain and stiffness. This can become so severe that it stops exercise or even activities of normal daily life. If left untreated overtime these tendons become weaker and more susceptible to tearing/rupture.
Tendinopathies can occur in any tendon. However, there are some common sites clinicians see frequently:
Achilles tendon - (Ankle)
Patella tendon - (Knee)
Supraspinatus tendon – (Shoulder)
Lateral epicondylitis – (Elbow)
Medial epicondylitis – (Elbow)
Patients classically report pain at the site of the tendinopathy. This is severe at first but usually fades to an ache after a few weeks. It is worse after exercise and eases a bit with rest. Interestingly patients may well be able to complete their exercise in the early stages of tendinopathy as the pain reduces during, only to return after cessation. Another classic symptom is a feeling of pain and stiffness at the site in the mornings. When examined by a clinician, patients will often have tenderness around the area and a reduced range of movement of the affected joint. The tendon may be thickened, and the surrounding muscles may have lost bulk.
It is crucial the correct diagnosis is made as there are many conditions that present like a tendinopathy but have different pathologies. This will obviously alter the clinician’s treatment plan. Correct diagnosis is made through careful history taking (try to elicit a cause) and focussed examination. A functional screen should be performed to look for factors that pre-dispose the patient to develop a tendinopathy at that site. The tendon should be appropriately loaded during the examination and all possible alternative diagnoses should be excluded.
A diagnosis of tendinopathy may be made solely from the clinical history and examination findings. Other modalities may be used to picture the tendon and confirm diagnosis. These include Ultrasound and MRI scanning. Commonly these radiological investigations are used to rule out other causes of the patient’s pain. X-Rays can sometimes be useful to rule out a bony cause for the tendon problem, such as spurs.
The overarching principle of tendon recovery is appropriately loading the tendon to allow healing and while this is occurring, managing the patient’s exercise volume. With that in mind physiotherapy is vital. The tendon is loaded through a combination of eccentric and concentric exercises (Isometric if pain is severe in the first instance). These exercises are built up weekly until strength is increased and the patient is able to return to their activities in a graded way without resumption of symptoms. A specialised return to activity program is designed and special equipment such as alter-G treadmills can be used to help the build-up back to normal activity. The length of the physiotherapy program will vary but tendinopathies are often quite refractory, and it is often in excess of 12 weeks.
In addition to the above it is sometimes necessary to consider medical therapies, largely to help with pain and facilitate the physiotherapy program. These include:
Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
A short course may be prescribed in the first instance when pain is very severe. Long term use of anti-inflammatory drugs is generally to be avoided.
Extracorporeal Shockwave Therapy (ECST)
This is a mechanical therapy that helps to reduce pain at the site of the tendinopathy by affecting the pain receptors and promoting tissue healing. It is delivered by a clinician in courses of 3-6 sessions (1 per week) each lasting a couple of minutes each.
These are used to reduce inflammation and pain. While they show good short-term benefit, they have negative consequences for the tendon in the mid to long term and so are not widely advised or used now.
Platelet Rich Plasma Injections
This is a procedure in which 20ml of blood is drawn from the patient and spun down in a centrifuge. The platelet rich plasma floating at the top of the sample is then harvested and injected into and around the tendon. The aim is to promote tendon healing. Usually, two treatments are required.
In this procedure a needle is inserted into the tendon multiple times in order to encourage bleeding and promote tendon healing. It is done under local anaesthetic.
High Volume Stripping
This procedure disrupts the new blood vessels and nerves that have grown into the tendon during the tendinopathic process. The clinician injects normal saline into the sheath that surrounds the tendon stripping these structures. This results in reduced pain.
A surgical opinion may be considered in cases of very refractory tendinopathy. It is viewed as a last resort when other treatment modalities have failed. It does not guarantee resolution and symptoms may recur with conservative or surgical approaches.
Tendinopathies result from overuse of the tendon and surrounding structures. They cause pain and loss of function resulting in reduced exercise performance or difficulties with activities of daily life. They are diagnosed with careful history and examination and there are a range of medical treatment options available to supplement the loading and return to activity program designed by a physiotherapist.