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1st Jan

2016

What We Know About Tendinopathy (tendinitis) Today

Tendinopathy (often referred to as tendinitis) is one of the most common disorders treated in physical therapy, and occurs almost universally in many sports.  Today we know that the mechanism of injury is often a strain overload on the tendon, but there is often also a component of compression on the tendon, in particular at its attachment onto the bone.  In combination, this results in shearing and friction of the tendon.  Tendinopathy often progresses from the acute and very painful stage, where today we have proof of the existence of cells involved in inflammation (leukocytes), and when the condition has been present for long periods, this turns into a wear and tear degenerative state of the tendon.  This is referred to as tendinosis. The affected tendon loses its energy-storing capacity, it tends to  become thicker and have higher water content, new blood vessels grow into the area with sensory nerves in the walls of the vessels, and the collagen fibers that make up a large part of the tendon become disorganized and of a poorer quality.

As the tendon heals, however, the new blood vessels and their nerve endings regress, the collagen fibers in the tendon become stronger, and the tendon becomes less thickened and more resistant to load and therefore less prone to reinjury.  Physical therapy rehabilitation is essential to stimulate this healing process.

Effective physical therapy rehabilitation often produces significant pain relief within 12 weeks, however it takes at least 24 weeks before we can see any significant structural changes in the tendon.  This is needed for long-term tendon health, and therefore we should not stop home rehabilitation once the pain has abated.  It often takes a year or sometimes more for complete recovery of normal tendon health.

Imaging such as ultrasound and MRI, have a limited role in diagnosing these conditions, as they do not directly relate to symptoms.  We know that a large percentage of people completely without symptoms present with significant changes on such imaging, including signs of tendinopathy or tendon tears.  Therefore, such imaging may play a role primarily in cases where a few to several months of physical therapy rehabilitation has not yielded sufficient progress.

Cortisone injections are often administered in medical care.  However, based on research knowledge today, such injections are typically not recommended for tendinopathy cases, as the outcome has been shown to be worse at a point one year after such injections.  These injections, however can be very helpful in cases such as frozen shoulder or bursitis (inflamed and swollen fluid filled sacs).

We know that tendons respond well to loading, and will respond more strongly to greater loads, whether they are performed with shortening (concentric) or lengthening (eccentric) contractions.  However, strong contractions are often not tolerated well early on, unless performed in a specific fashion.  Although the early use of eccentric contractions today has been questioned, based on research performed on animals and on healthy tendons, we have found in our clinic that when performed in a specific fashion and gradually progressed, this can be extremely helpful in cases such as Achilles tendinopathy, tennis elbow, plantar fasciitis, and patellar tendinopathy. Such exercises can be performed daily, which stimulates the production of new fiber in the tendon, without depleting the entire muscle of oxygen.

Research today has furthermore shown that isometric contractions held for 45-60 seconds and repeated a few times, up to several times per day, can produce pain relief for patients with tendinopathy, lasting for at least 45 minutes.  Therefore, such exercise has today been recommended to be incorporated into the training program early on.  However, it shoulder also be mentioned that there is often muscle guarding-tightness present when tendinopathy is present, and excessive static (isometric) contractions can further increase such muscle guarding, as there can be no blood circulation to the muscle when a contraction is held without release.

For Achilles tendinopathy involving the mid-portion of the tendon, gradually progressed exercise has been found to be very effective.  The key is that the exercise can be progressed to a high intensity level.  For insertional Achilles tendinopathy (pain at the back of the heel), such exercise is less effective and it is very important not to let the heel drop down too far to produce stretch on the tendon, which increases compression on the tendon at its attachment.  Therefore, with such problems, it is essential to also have a substantial  heel lift in the shoes, to prevent stretching.  These people should not add stretching exercises to their regimen.

Patellar tendinopathy, or “jumper’s knee” involves the tendon attachment onto the lower part of the knee cap.  These conditions can become chronic and take up to six months to resolve with progressed rehabilitation, if the condition has become severe enough.  Therefore, early treatment is essential.  Eccentric exercise can be helpful here as well, but apparently not in every case.  It is essential that exercises performed are not painful or at least does not produce any significant increase in pain that lasts any longer than 24 hours.  Gradually, the exercise program needs to be progressed to a high intensity resistance program, as for most other tendinopathies.  Eventually, more demanding exercise such as plyometric exercise involving quick acceleration-deceleration or jumping may be required in athletes who will need to return to such activities.  Ample rest following such training is extremely important, for at least three days since it takes that long for the tendon to recover fully after such training.

Pain on the outside of the hip is often diagnosed as trochanteric bursitis.  Today we know that the majority of these cases represent gluteal tendinopathy, involving the gluteus medius and/or gluteus minimis tendons at their attachment onto the greater trochanter on the outside of the hip.  As with the insertional Achlles tendinopathy, it is important not to put stretch on these tendons by bringing the leg across the body, which causes increased compression of the tendon at its attachment.  Rather, exercise training should start with the legs slightly apart, and be gradually progressed as tolerated.  The gluteus medius typically has become weakened, and will need to be strengthened over time.  Early on, it is essential to avoid crossing the legs, lying directly onto the painful hip, and even if lying on the opposite side, one or two pillows between the legs is necessary.

Tennis elbow, or lateral epicondylalgia, involves some of the wrist extensor muscles at the attachment on the outside of the elbow.  We have found that these people also respond very well to eccentric exercise but other movements need to be incorporated since this form of tendinopathy also often causes irritation of ligaments in joints in the elbow region.  Therefore, we usually exercise the wrist in both directions, and include forearm rotations both ways and elbow bending and straightening.  Gradually progressed resistance within pain-free limits is again a key.  Usually at least 2-3 months of rehabilitation is required to get good results.

Feel free to forward this letter to anyone who may be interested, and don’t forget to view our past newsletters, and our offer of a free consultation.

I want to wish you a Happy and Healthy New Year!

All the best,

Gunnar

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