Tendon Pain?
Treatment of tendinopathy: what works, what does not, and what is on the horizon.
Andres BM, Murrell GA. Clin Orthop Relat Res. 2008 Jul;466(7):1539-54. Epub 2008 Apr 30.
Introduction: Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options.
Methods: We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated.
Results: We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes.
Conclusion: The ideal treatment for tendinopathy remains unclear.
Some of my thoughts: The authors of this study set out to review literature on tendinopathy treatments. Tendinopathy is a broad term that pretty much means injury to the tendon, which creates pain. The word tendinopathy often replaces the term tendonitis, as tendonitis by definition is inflammation of a tendon, however research shows that there is often times no inflammation present with this type of overuse injury, causing the name tendonitis to by inaccurate. The fact that inflammation is often not present in this condition is interesting to note, as a typical therapeutic treatment for these injuries involves ice and other means to try and decrease or prevent inflammation (a quality that may not even be present).
Another term in this category is tendonosis, which is a more chronic type of tendinopathy. Tendonosis is characteristic of degenerative changes in the tendon and deals with damage to the tendon on a cellular level, creating micro tearing of the tendon and pain. Tendonosis is typically a condition that arises when someone has “tendonitis” for an extended period of time; hence it being a “chronic” condition.
Tendons can also go through several changes, including a thickening or hardening (calcification) in relation to overuse and trauma, which potentially creates greater amounts of friction between tendon and bone, leading to greater pain and irritation.
This study was basically looking at a variety of treatment options available to those suffering from some sort of tendinopathy, and concluded that the idea treatment remains unclear. One thing that I think is difficult with these types of studies is that they are only looking at treatment to the tendon itself. Part of the problem is that if we want to make someone “healthy”, we need to determine WHY the tendon is damaged. A lot of this comes back to postural evaluations and why things get overused or have to work harder than they potentially need to in order to produce movement (whether it is movement in the gym, on the playing field/court, or activities of daily living).
Personally, I believe that a lot can be changed with regard to tendon problems by addressing soft tissue abnormalities and postural distortions. One thing that this study looked at was “physical therapy modalities”, which was a junk bag term (in this study) that referred to things like strengthening and stretching, eccentric exercise protocol, cold laser treatment, ultrasound, iontophoresis and transverse fiber friction. The authors made the note that different therapists will choose different therapies, so it is difficult to determine what you will get when you attend physical therapy. The issue with this is that some therapists are more skilled than others and can bring a lot more to the table with regard to soft tissue treatments and exercise-based programs. Again, the problem is also that these modalities are only treating the tendon itself. They are not performing soft tissue work to the muscle belly of the muscle, which attaches into that tendon; moreover, they are not dealing with the overall movement and posture of the individual to try and prevent the injury from coming back. Just because you make someone asymptomatic, does not mean they are out of the woods! You need address the other issues which are creating the problem.
I have spoken to several skilled massage therapists who get great results with tendinopathy issues because they look to treat the overall person, instead of boiling them down to a diagnosis; a problem with modern medicine and the way it is taught and practiced today in this country. Oftentimes, in rehab clinics, people are simply defined by their one single injury diagnosis and the concept that they are a whole person gets thrown out the door. Medical insurance companies are partially to blame for this as therapists wont perform a treatment that doesn’t reimburse them as highly as another modality might. As well, therapists typically don’t have enough time to treat a patient as they need to increase the amount of patients have to see in a day in order to make enough money to keep their clinic running. Both of these problems create very watered down and “low-grade” treatment for the patient. The final problem is that therapists are taught different things in schools depending on where they go. Some schools do not put as much of an emphasis on soft tissue work as other schools do (and definitely not as much emphasis on soft tissue work as schools over seas), causing therapists skill levels to be all over the map with regard to their ability to treat these issues. In a massage therapy setting, with a skilled therapist who understands clinical, orthopedic or medical massage, they have more time to work with clients (often times treatments will be 60-90 minutes long) and they are not restricted by medical insurance companies (although some may take insurance, most run cash only practices), so they are free to perform their treatments as they please, allowing them to not only address the tendon, but the muscle affecting that tendon and the overall posture and structure of the person; leading to a more holistic treatment.
Physical therapists that have the appropriate amount of time to treat patients and do not allow themselves to be restricted by insurance billing have a greater opportunity to help treat patients with tendinopathy than their colleagues who may be working in a facility that sees several patients an hour and doesn’t take the time to address the whole person.
Patrick
Andres BM, Murrell GA. Clin Orthop Relat Res. 2008 Jul;466(7):1539-54. Epub 2008 Apr 30.
Introduction: Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options.
Methods: We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated.
Results: We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes.
Conclusion: The ideal treatment for tendinopathy remains unclear.
Some of my thoughts: The authors of this study set out to review literature on tendinopathy treatments. Tendinopathy is a broad term that pretty much means injury to the tendon, which creates pain. The word tendinopathy often replaces the term tendonitis, as tendonitis by definition is inflammation of a tendon, however research shows that there is often times no inflammation present with this type of overuse injury, causing the name tendonitis to by inaccurate. The fact that inflammation is often not present in this condition is interesting to note, as a typical therapeutic treatment for these injuries involves ice and other means to try and decrease or prevent inflammation (a quality that may not even be present).
Another term in this category is tendonosis, which is a more chronic type of tendinopathy. Tendonosis is characteristic of degenerative changes in the tendon and deals with damage to the tendon on a cellular level, creating micro tearing of the tendon and pain. Tendonosis is typically a condition that arises when someone has “tendonitis” for an extended period of time; hence it being a “chronic” condition.
Tendons can also go through several changes, including a thickening or hardening (calcification) in relation to overuse and trauma, which potentially creates greater amounts of friction between tendon and bone, leading to greater pain and irritation.
This study was basically looking at a variety of treatment options available to those suffering from some sort of tendinopathy, and concluded that the idea treatment remains unclear. One thing that I think is difficult with these types of studies is that they are only looking at treatment to the tendon itself. Part of the problem is that if we want to make someone “healthy”, we need to determine WHY the tendon is damaged. A lot of this comes back to postural evaluations and why things get overused or have to work harder than they potentially need to in order to produce movement (whether it is movement in the gym, on the playing field/court, or activities of daily living).
Personally, I believe that a lot can be changed with regard to tendon problems by addressing soft tissue abnormalities and postural distortions. One thing that this study looked at was “physical therapy modalities”, which was a junk bag term (in this study) that referred to things like strengthening and stretching, eccentric exercise protocol, cold laser treatment, ultrasound, iontophoresis and transverse fiber friction. The authors made the note that different therapists will choose different therapies, so it is difficult to determine what you will get when you attend physical therapy. The issue with this is that some therapists are more skilled than others and can bring a lot more to the table with regard to soft tissue treatments and exercise-based programs. Again, the problem is also that these modalities are only treating the tendon itself. They are not performing soft tissue work to the muscle belly of the muscle, which attaches into that tendon; moreover, they are not dealing with the overall movement and posture of the individual to try and prevent the injury from coming back. Just because you make someone asymptomatic, does not mean they are out of the woods! You need address the other issues which are creating the problem.
I have spoken to several skilled massage therapists who get great results with tendinopathy issues because they look to treat the overall person, instead of boiling them down to a diagnosis; a problem with modern medicine and the way it is taught and practiced today in this country. Oftentimes, in rehab clinics, people are simply defined by their one single injury diagnosis and the concept that they are a whole person gets thrown out the door. Medical insurance companies are partially to blame for this as therapists wont perform a treatment that doesn’t reimburse them as highly as another modality might. As well, therapists typically don’t have enough time to treat a patient as they need to increase the amount of patients have to see in a day in order to make enough money to keep their clinic running. Both of these problems create very watered down and “low-grade” treatment for the patient. The final problem is that therapists are taught different things in schools depending on where they go. Some schools do not put as much of an emphasis on soft tissue work as other schools do (and definitely not as much emphasis on soft tissue work as schools over seas), causing therapists skill levels to be all over the map with regard to their ability to treat these issues. In a massage therapy setting, with a skilled therapist who understands clinical, orthopedic or medical massage, they have more time to work with clients (often times treatments will be 60-90 minutes long) and they are not restricted by medical insurance companies (although some may take insurance, most run cash only practices), so they are free to perform their treatments as they please, allowing them to not only address the tendon, but the muscle affecting that tendon and the overall posture and structure of the person; leading to a more holistic treatment.
Physical therapists that have the appropriate amount of time to treat patients and do not allow themselves to be restricted by insurance billing have a greater opportunity to help treat patients with tendinopathy than their colleagues who may be working in a facility that sees several patients an hour and doesn’t take the time to address the whole person.
Patrick
Post a Comment