Juli-Ann Riley of Riley Physiotherapists takes a closer look at treatment of common tendon problems.
Tendon problems are common and there is much research available – with new knowledge constantly emerging.
The old term tendonitis, implying inflammation, was later referred to as tendinosis – implying degeneration. We now realise that it’s a bit more complex, with varying stages of what we refer to as the Tendinopathy Continuum. The first stage is a reactive tendinopathy, which can become a tendon disrepair and worsen into a degenerative tendon – which could even tear (major tear or micro-tears).
Tendinopathies can be difficult to treat, with multiple management strategies and theories suggested. Tendons do not follow the usual healing process of other soft tissue injuries, so they need to be treated differently.
At present the strongest evidence supports the use of exercise as a management strategy, with loading the tendon the only intervention that can change its strength and mechanical properties. Initially, the day-to-day load on the tendon needs to be reduced by decreasing and adapting exercise or daily activities – and occasionally by also strapping, bracing or using orthotics. The initial exercises are usually isometric (static) and held for long periods, which also assist in decreasing tendon pain. Progressive loading is then suggested, with a large body of research advising eccentric training to increase tendon strength. The use of heavy slow resistance is also gaining support, and a combined approach is often used.
Importantly, rehabilitation should be progressed gradually, with sufficient time between loading periods. Tendon pain should be monitored and the program adapted appropriately –with individual factors taken into account.
Exercise programs need to be followed for at least 12 weeks, and sufficient time must be spent on active treatment before starting with provocative (sports) loading. Plyometrics and sports-specific rehabilitation is only commenced later in the rehabilitation. As a rule, a return to full symptom-free (sports) loading is only possible after a few months of active treatment, at a minimum. A return to sports is associated with a greater likelihood of recurrence.
The following additional treatment options could be considered in case of insufficient improvement in three months of the above treatment: collagen supplements, ultrasound, manual therapy, laser/light therapy, extracorporeal shockwave therapy, injection therapies and dry needling. Non-steroidal anti-inflammatory drugs are not usually recommended and Corticosteroid injections are not advised, as they may increase the risk of tendon tears. Surgery should only be considered in those patients who do not recover after at least six months of active treatment.
Making the correct diagnosis is essential to correctly manage the condition. There are different types of tendon pathologies that require slightly different exercise adaptations. There are also many structures very close to tendons that, if they are the cause of pain, will not improve and will likely worsen if treated like a tendon problem. Individual factors need to be addressed, and an individualised program designed, monitored and adapted as needed. Your physiotherapist is best suited to assist you through this rehabilitation journey.
- Gillitts Branch: 031 764 2750, Gillitts Medical Centre
- Hillcrest Branch: 031 355 0030, Le Domaine Health
- Juli-Ann Riley Physiotherapists, Kloof: 031 767 3989, Femina Health