Managing Difficult Tendinopathies

Introduction

Painful conditions that emerge around or in tendons in response to overuse are called tendinopathy. The pathology of tendinopathy is multifactorial and complex and remains difficult to treat. Tendinopathies are delineated as non-rupture damage in the tendon magnified with mechanical loading. The difference between tendinitis and tendinopathy is that the latter generally does not present with inflammation. Tendinopathy presents with chronic pain, decreased physical function, and reduced participation in activities and accounts for up to 50% of all musculoskeletal disorders.

Tendons can be difficult to manage. People who struggle with tendinopathy or pain related to tendons have often tried multiple treatment strategies and seen a few healthcare practitioners. Sometimes, when someone has seen a variety of people and has a multitude of different ideas and treatment options, the best thing to do is to start from the beginning with a thorough, subjective and objective history.

Confirm The Diagnosis

A correct diagnosis is the cornerstone of managing any condition. With tendinopathy, the differential diagnosis is extremely important. When considering the diagnosis of tendinopathy, the aim is not to determine if the tendon has pathology but instead to determine whether or not the tendon is the source of pain. Just because a tendon shows pathoanatomical changes on imaging does not mean that the tendon is the source of the symptoms. If a patient comes with a diagnosis of tendinopathy, check that their clinical presentation fits the criteria that are characteristic of tendinopathy. Hallmark features, such as pain that is localised to the tendon and increases with dose-dependent loading, should be present. Classic tendinopathy would most likely present with the “warm-up” phenomenon, where their pain improves during a specific activity but is worse the day after high high-loading activity. Certain tendinopathies have hallmark features such as morning stiffness in an Achilles tendinopathy or pain with sitting in hamstring tendinopathy.

If the patients presenting clinical signs and symptoms do not match the clinical signs and symptoms of tendinopathy, it may be useful to go through a new differential diagnosis process to get a more accurate clinical picture.

When a patient presents with insertional tendinopathy or plantar heel pain, it could be a sign of spondyloarthropathy (SpA). Paul Kirwin developed a clinical tool to help identify SpA. The Pneumonic is SCREEND'EM. The therapist should ask the following questions during assessment:

S - Skin: rash or psoriasis

C - Colitis or Crohn's disease

R - Relatives: family history of inflammatory arthritis or who are HLA-B27 positive

E - Does early morning stiffness last more than 30 minutes? (not related to activity)

E - Eyes – has the patient had uveitis?

N - Nail involvement? Like pitting, thickening, onchylosis (detachment of nailbed)

D - Dactylitis? (sausage-like swelling of the fingers)

E - Enthesopathy? (inflammation of the entheses, the sites where tendons or ligaments insert into the bone)

M - Medication and Movement response? (Improvement with activity but not with rest; respond positively to NSAIDs)

Check their Previous and Current Loading History

Tendon load and capacity is an important concept to understand in tendinopathy. A tendon's capacity will only ever exceed the load placed upon it, and injuries occur when the loads placed upon a tendon exceeds its capacity. This is particularly evident when compressive loads are particularly provocative for tendons. When managing a difficult tendinopathy patient, it is important to carefully identify the initial aggravating load and any loads that continue to provoke the tendons.

This will differ according to the type of person. An elite athlete with an Achilles tendinopathy may still be doing a lot of plyometric activities that is a very high tensile load for the Achilles. Or perhaps they are performing their exercises in a dorsiflexed position, maintaining compressive loading on the tendon. An elderly sedentary patient with hamstring tendinopathy may have adopted a rehabilitation programme but continues to sit for prolonged periods on hard surfaces, compressing the hamstring tendon against the ischial tuberosities. When someone is actively following the CORRECT rehabilitation programme and is not seeing changes the rest of their day and training programmes should be carefully examined to determine if there is anything else that may be causing provocative loads on the tendon.

Check for co-morbidities

As part of an assessment, screening for any red flags and general health should be standard practice. Someone who has tendinopathy that is just not responding to standard care should be carefully screened for any systemic illnesses or conditions. Certain conditions, such as diabetes or rheumatoid arthritis, may predispose a person to the development of tendinopathies. The tendinopathy may only resolve once the systemic condition is managed appropriately.

Check their Management Programme

Check for Progressive Loading

Progressive loading refers to gradual increase the weight, frequency, or number of repetitions in individual strength training routine. Outside of strength training, it can be applied to different forms of physical activities, including cardiovascular endurance exercises.

A person suffering from tendinopathy who is just not getting better may not have received the appropriate treatment. Complete rest of a tendon is not the preferred management strategy in tendinopathy, and appropriate loading and load modification is the best evidence-based practice. Progressive loading aims to produce mechanical stimulus that provokes tendon's biochemical and mechanical responses. It supposed to generate adaptations of the tendon to load and exercise.

Tendinopathy rehabilitation, when done correctly, is very effective in managing tendons. Review a patient who is struggling with tendinopathy to see if their management to date has possibly consisted of a more passive modality approach than an active rehabilitation approach.

Check the Amount and Type of Load Prescribed

Fast and compressive loads provoke tendons. Slow, heavy loads are not provocative to them. A tendon that is not getting better may not have enough load applied to it to meet the capacity at which it is expected to perform. Alternatively, there may be additional loads it is subjected to, such as in the warm-up or stretching programme, that continue to exacerbate it even with the correct loading programme.

Check for Single versus Double Leg Exercising

When prescribing a progressive loading programme to manage tendinopathy, it is important to prescribe single-leg loading for both the symptomatic and asymptomatic side. This loading should be proportional to the capacity of its specific side e.g. the asymptomatic side would have greater loads. Double leg exercises should not be the basis of the program as the stronger leg can carry the weaker leg.

Check The Kinetic Chain for Contributing Factors

A kinetic chain is a mechanical system by which an individual accomplishes the complex tasks required for daily activities or sports. When kinetic chain breakage occurs, it can :

• Increase distal physiological or biomechanical requirements, including high demand for muscle activation or increased distal segment velocity.
• Develop the same kinetic energy or force requirements at the distal segment.
• Increase the forces that must be absorbed in the distal joint.
• Decrease the velocity or force at the distal segment.

There may be intrinsic factors that have contributed to the development of excessive loading on that tendon. Assessing the entire kinetic chain for any weak links will identify any contributing factors. Addressing these may help to reduce the load on the tendon and thereby manage the tendon symptoms.

Check the Management Plan against the Diagnosis

If their programme was completely appropriate for the particular tendinopathy they have been diagnosed with it may be important to check that their diagnosis was, in fact, correct or that there are not any co-morbidities involved. The management for tendinopathy entails progressive loading, and if incorrectly diagnosed, this treatment could potentially worsen the condition. For example, a person with paratenonitis of the Achilles Tendon due to excessive shearing forces on the sheat of their Achilles would potentially be aggravated by cycling. In comparison, cycling would be a very suitable low-load exercise for an Achilles tendinopathy.

Manage expectations

Patients with a tendinopathy may have expectations that exceed the pathophysiology of their condition. Tendinopathies often take a long time to get better, and communicating this to a patient may help manage their expectations. If it is an athlete or someone with multiple people involved in their management, then everyone needs to know what is provocative for that tendon and what loads should be removed and replaced. A perfectly executed progressive rehabilitation programme can be undermined by excessive loading elsewhere.

Using Outcome Measures to Monitor Progress

It is important to use standardised outcome measures so you can monitor someone’s progress objectively. Often, people do not feel they are any better, but functionally, they have improved significantly. The outcome measure must be specific to the person’s injury and level of function. For example, rating their pain with a hop may be useful for a runner with an Achilles tendinopathy but not as appropriate for a sedentary person. Morning pain and stiffness may be a more appropriate outcome measure for them.

Commonly used performance outcomes include the following:

• Concentric and eccentric torque measured with an isokinetic dynamometer
• Jumping performance (countermovement jump test)
• Ankle range of motion
• Hip abductor torque

Pain on palpation should not be used as an outcome measure for tendinopathy. Tendons can remain painful for a long period even with significant clinical and functional improvement. Systematic review by Escriche-Escuder et al. concluded that pain-based criteria to determine load progression in lower limb tendinopathy is not supported by strong evidence and they should be used "cautiously and critically".

Examples of Outcome Measures Tendinopathy include the following:

• Victorian Institute of Sport Assessment (VISA): VISA-A (Achilles), VISA-P (Patella), VISA-G (Greater Trochanteric Pain Syndrome), VISA-H (Proximal Hamstring Tendinopathy)
• Patient Specific Functional Scale: self-report outcome measure of function
• Foot and Ankle Outcome Score questionnaire (FAOS Questionnaire): 42 item subjective questionnaire consisting of 5 domains: pain, symptoms, function in daily activities, function in sports, and quality of life.
• Hip Dysfunction and Osteoarthritis Outcome Score (HOOS): 40 items with five possible responses, graded from 0 to 4
• Self-designed pain scales and questionnaires

Conclusion

1. Tendinopathy can be difficult to treat.
2. Ensuring you have the correct diagnosis is the first step in managing difficult tendinopathy.
3. If the diagnosis is correct, carefully looking at the management plan so far and the contributing factors and co-morbidities involved may help provide the missing link to managing them successfully.
4. Use pain-based criteria for exercise progression with caution.