Exercise Should Be the First Treatment for Tendinopathy
Tendon repair can be tricky business. When the process gets interrupted for any reason, the tendon may get stuck in a lose-lose situation. Too much inflammation (and even sometimes not enough inflammation) can result in a process that produces a problem we call tendinosis or tendinopathy.
Tendinopathy refers to any tendon that has been damaged in some way but is no longer in the acute inflammatory phase, which would be called a tendinitis. Examination of tendon tissue in patients who have had chronic pain over months and sometimes even years shows scarring and fibrosis but no active fluid, swelling, or white blood cells at the site needed for healing.
What can be done to kick the tendon out of this no-win situation and back into a healing strategy? Treatment efforts are many and varied. The latest idea being tried is called platelet-rich plasma or blood injection therapy.
The patient's own blood is drawn and processed to collect the platelets. Then those platelets (suspended in a solution of the blood's plasma) are injected into the damaged tendon. Platelets have lots of growth factors that get to work stimulating the repair process once again.
Another approach tried has been shockwave therapy (SWT). Pulsations (vibrations) from this treatment create a mini-trauma to the tissues. The hope is to restart the healing process. Low-intensity ultrasound has also been used in the same way.
The old standby: corticosteroid injections are still used but there are more and more doubts about using this treatment. Steroid injections may have a short-term benefit but nothing that lasts. The negative effects on the tendon reduces tendon strength. Tendon rupture may not be worth the initial pain relief provided.
Surgery to clean the area up and restore blood supply to the tendon has some positive benefits. Mid-term results show significant pain relief and improved function after three years. Nerves that have grown inside the scar tissue can be one cause of the persistent pain experienced with some tendinopathies. The surgeon can try using a motorized shaver or radiofrequency to destroy these nerves.
Any of the treatment approaches mentioned so far have potential complications and limited favorable results. Studies are not conclusive yet to suggest one treatment rises above all others as the best. That brings us to the next possibility: exercise. There is very little cost involved, no postoperative complications to deal with, and the potential for proper tendon repair.
The downside of exercise as a treatment for tendinopathy is the patient's own patience and cooperation. It does take time for consistent exercise to support the body's innate ability to heal itself. But studies show that eccentric exercise has the ability to enhance tendon repair and even cause the nerve to pull back from the tendon.
During an eccentric muscle contraction, the muscle and its tendon starts in a shortened position and then lengthen as the body part moves. A daily program over a period of six weeks' time results in good outcomes with pain relief, improved function, and without adverse effects.
Though time-consuming this exercise approach can be successful. When supervised by a physical therapist, motivation and compliance improve. The risk of reinjury is also less. Heavy, slow eccentric load may work better than static stretching or fast eccentric load. Combining static stretching with slow eccentric movements has been shown to be very helpful in a few studies. More studies are needed to pinpoint the most effective way to introduce and progress eccentric exercise. But for now, the research consistently shows the positive benefit of exercise as a first-line of treatment for tendinopathy.
Paul W. Ackermann, MD, PhD, and Per Renström, MD, PhD. Tendinopathy in Sport. In Sports Health. May/June 2012. Vol. 4. No. 3. Pp. 193-201.