Posts tagged tendon pain
PRP Effects On Tendon Injury Attributed To Post Injection Physical Therapy
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Patellar tendinopathy is one of the more common sports medicine conditions seen in our Boulder Physical Therapy clinic. This condition causes increased pain along the front of the knee just beneath the knee cap and leads to pain with jumping, running, and squatting activities. Current medical evidence has described an absence of inflammatory cells and instead we find an increase in cells responsible for tendon repair. These immature cells are initially laid down in a disorganized pattern and require progressive, optimal loading through exercise to reach a mature, healthy state. In addition to exercise some physicians have advocated for PRP injections into the injured tendon in an effort to accelerate the healing process, but well constructed research trials have not been conducted and this treatment is still considered experimental. A recent research trial examined the effectiveness of PRP for patellar tendinopathy.

A well done randomized controlled trial in the American Journal of Sports Medicine examined the effectiveness of PRP vs. placebo (saline) in patients with patellar tendinopathy (> 6 months of symptoms) (Scott et al. 2019). Patients were randomized to one of three injection groups under ultrasound guidance leukocyte rich PRP, leukocyte poor PRP, and saline. Each group then received 6 weeks (3 times per week) of supervised Physical Therapy including heavy slow strength training (concentric and eccentric loading). Patients were folllowed up at 6,12,36, and 52 weeks. Authors found an improvement in all three groups but no difference in pain, function, or recovery between the three groups. If PRP added to the recovery we should have seen a superior effect of PRP and PT vs. saline and PT, but because all groups were similar we can attribute this change in function to the Physical Therapy strengthening program. This evidence supports our current view on the limited benefits of injections for tendon pain. Patients are encouraged to use a Physical Therapy exercise program consisting of progress, loading exercises to accelerate their recovery from tendon injury.

No Differences Found Between Surgery Or Physical Therapy For Tendon Injury
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Overuse tendon injuries can present as an acute inflammatory response (Tendinitis) or a chronic degeneration condition (tendinopathy).   These injuries result when an individual’s volume of activity (type, duration, frequency, and intensity) exceeds the strength and integrity of the tendon.  At MEND, we commonly see these injuries in the tendons of the rotator cuff, knee, ankle or elbow.  Recent studies summarized in our previous blog posts have highlighted the importance of a Physical Therapy exercise program.  Optimal, progressive loading of these injuries is critical to the healing process (remodeling) resulting in decreased pain and improved function.  Despite overwhelming evidence supporting exercise interventions patients may still be provided with a surgical treatment.

A recent study from the British Medical Journal reviewed the available medical evidence to determine the effectiveness of Physical Therapy compared to surgery or no treatment in patients with tendinopathy (Challoumas et al. 2019).  Authors included 12 studies of over 1000 patients to determine the impact of these treatments on a patient’s pain, function, range of motion, strength and quality of life.  Authors reported Physical Therapy was as effective as surgery in both the mid and long term for improving pain, function, and quality of life.  Authors report surgery should be reserved for patients who do not improve with 12 months of a loading program. 

Rupture Of Knee Tendon After PRP Treatment
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Platelet Rich Plasma (PRP) is becoming a popular treatment for muscle strains, arthritis/cartilage injuries, and tendinopathies, but the evidence behind its’ use is limited. Specifically there is a lack of large human trials with randomization to both placebo injections and alternative treatments. Consistent with alternative treatments PRP’s clinical utilization is outpacing the evidence leaving many more questions than answers. To date there is insufficient research to advocate for injections into injured tendons and in some cases (corticosteroid) authors have argued the risks outweigh the benefits. A recent research article highlights a risk of PRP.

A case report published in the Clinical Journal of Sports Medicine highlights a risk on the utilization of PRP for sports injuries (Redler et al. 2018). Authors describe a single patient with a degenerative patellar tendinopathy treated with a series of 4 PRP injections. Upon subsequent surgical examination authors reported a complete rupture in the patellar tendon with significant degeneration is the surrounding tendon. Although the results of this report must be taken in consideration due to its’ methodology, including a single patient, the authors state this report questions both the effectiveness and safety of using this injection in patients with severe tendinopathy.

How Heavy Should I Load My Achilles Tendon After An Overuse Injury?
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In the achilles tendinopathy (artist formally known as tendonitis) research two main themes have emerged. First, there is little to no evidence to support the use of injections of any kind into an injured tendon. Authors have advocated against steroid injections due to the risk of tendon rupture outweighing any potential benefits. Studies have also been limited in the use of PRP (platelet rich plasma) injections for tendon pain. Significant methodological concerns have impacted this area of research including the lack of large human trials, lack of placebo or alternative treatment (exercise) comparison, and small sample sizes. Without improvements in this line of research, PRP remains an expensive, experimental treatment compared to other proven treatment strategies.

Strengthening exercises remain the gold standard of care, both in the research and our Boulder Physical Therapy practice, for these tendon injuries. Although eccentric exercise was first published in the late 1990s as an effective treatment for tendinopathy, many other forms of strength training including isometric and isotonic exercise have also been shown to be effective. The key take home message from these trials remains the same, injured tendons must be progressively loaded based on their clinical presentation to recover. Initially improvements in a patient’s symptoms and function are secondary to improved strength of the surrounding muscles while long term improvements are attributed to structural healing of the tendon (remodeling).

A recent review of the evidence highlights the importance of intensity or resistance during achilles strength training exercises for patients with mid portion achilles tendinopathy (Murphy et al. Br J Sp Med. 2019). Authors reviewed the available literature on the use of heavy eccentric training for this patient population compared to a wait and see or traditional Physical Therapy approach (modalities, massage). They reviewed the data from 7 studies and reported heavy eccentric training may be superior to a wait and see approach and traditional Physical Therapy. Authors also found a trend showing these heavy eccentric exercises may be less effective than other forms of exercise (isometric, isotonic).

This review is consistent with our current understanding on tendon management. Tendons should be progressively loaded based on the tendon’s tissue tolerance and irritability. Although eccentric exercise has become popular, other forms of exercise and loading strategies should also be considered as part of the tendon loading plan of care. When it comes to tendons, one size does not fit all.

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When will my knee tendinitis get better?
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Knee tendinopathy, either in the quadriceps or patellar tendon, is a common source of knee pain among jumping athletes, but can occur in non jumping athletes or the general population as well. This overuse injury is caused by repetitive sub maximal loading of the knee through a bending range of motion. If the loading is faster and/or greater than the tendon’s capacity to tolerate this tensile loading pattern, tendinopathy can occur leading to pain and decreased knee function. Our current understanding of these tendon injuries has moved from passive care (rest, anti inflammatories) to an active Physical Therapy approach focused on optimal loading of the tendon to promote remodeling and healing of the injured tissues. A new article sheds light on when patients can expect to recover from their knee tendinopathy.

van Ark and colleagues randomized 29 volleyball and basketball players with patellar tendinopathy to a 4 week full range of motion or isometric exercise program (Am J Phys Med Rehab. 2018). Patients were assessed for symptoms and function, as well as, each player underwent a baseline and 4 week ultrasound scan of the injured tendon. Interestingly, although players reported decreased pain and improved function after the exercise program, no structural changes were detected in the injured tendon. This study is consistent with the research on achilles tendinopathy which demonstrated improved clinical symptoms after 8-12 weeks of Physical Therapy treatment, but continued healing of the injured tendon up to 12 months after the onset of symptoms.

Physical Therapy exercises are the gold standard treatment for tendinopathy but should be continued after resolution of symptoms for optimal recovery of the tendon.

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Shoulder Stabilization Improves Pain and Function in Patients with Elbow Pain
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Lateral elbow pain, tennis elbow, is a limiting condition causing pain with repetitive movements including gripping.  This condition was previously though to occur secondary to inflammation within the wrist and fingers tendons insertion into the arm, but current researchers have not found inflammatory cells in patients with this condition.  Instead, cells of the injured tendons display degeneration and disorganization consistent with the healing process.  Gradual loading of these injured tendons with exercise has been shown to accelerate the recovery process and tendon remodeling.

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Loading of the injured tendon through exercise is critical to its' healing.  Both over loading and under loading are equally detrimental to the recovery of the tendon.  New research demonstrates utilizing shoulder strengthening reduces pain and improves arm function in patients with lateral elbow pain.  Lee and colleagues randomized patients to either elbow or shoulder strengthening groups (J PT Sci. 2018).  Authors reported both groups improved grip strength, pain, and tenderness after the completion of the strengthening program.  No differences were noted between groups indicating loading of the injured tendons can be done specifically at the elbow or globally through the shoulder.  The key is loading based on the tissue tolerance of the injured tendon.  

To learn more on how to successfully manage your tendon pain contact the experts at MEND