Getting tendinopathy treatment (and terminology) right
Tendinopathy, tendinitis, tendinosis, paratenonitis—they are not synonymous. Here you’ll find a review of their pathophysiology and best approaches to treatment.
PRACTICE RECOMMENDATIONS
› Recommend eccentric exercises to treat patients with tendinosis; research has consistently shown them to be an effective and safe treatment for many types of this disorder. A
› Use corticosteroid injections with caution for tendinosis; pain relief is typically short lived, and good evidence exists for long-term relapse and worse outcomes including post-injection tendon rupture, especially in the lower extremity. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Rehabilitation: Eccentric exercises and deep-friction massage
Studies show that eccentric exercises (EEs) help to decrease vascularity and nerve presence in affected tendons, modulate expression of neuronal substances, and may stimulate formation of load-tolerant fibroblasts.2,3
For Achilles tendinosis, EE is a well-established treatment supported by multiple randomized controlled trials (RCTs). Improvements in patient satisfaction and pain range from 60% to 90%; evidence suggests greater success in midsubstance vs insertional Achilles tendinosis.15 The addition of deep-friction massage (DFM), which we’ll discuss in a moment, to EE appears to improve outcomes even more than EE alone.16
EE is also a beneficial treatment for patellar tendinosis,3,14 and it appears to benefit rotator cuff tendinosis,3 but research has shown EE for lateral epicondylosis to be no more effective than stretching alone.17
DFM is for treating tendinosis—not inflammatory conditions. Mechanical stimulation of the tissue being massaged releases cell mediators and growth factors that activate fibroblasts. It is typically performed with plastic or metal tools.16 DFM appears to be a reliable treatment option for the lateral elbow.18
Extracorporeal shockwave therapy appears promising; evidence is limited
Research has shown that extracorporeal shockwave therapy (ESWT) promotes the production of TGF-β1 and IGF-1 in rat models,2 and it is believed to be able to disintegrate calcium deposits and stimulate tissue repair.14 Research is generally supportive of its effectiveness in treating tendinosis; however, evidence is limited by great variability in studies in terms of treatment intensity, frequency, duration, timing, number of treatments, and use of a local anesthetic.14 ESWT appears to be useful in augmenting treatment with EE, particularly with regard to the rotator cuff.19
Continue to: A review of 10 RCTs...
