Posts tagged tendon pain
Rupture Of Knee Tendon After PRP Treatment
PRP-injection-risk-injury

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?
achilles-tendon-exercise-treatment

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.

Click Here To Schedule Your Next Appointment With The Experts at MEND

When will my knee tendinitis get better?
knee-tendonitis-tendinopathy-treatments-healing

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 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.

Click Here to schedule your next appointment with the experts at MEND

Shoulder Stabilization Improves Pain and Function in Patients with Elbow Pain
Shoulder-stabilization-lateral-elbow-pain-treatment

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.

shoulder-stabilization-training-exercise-pain

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

Updates on the Successful Management of Tendon Pain
Photo Credit: Scott, A. CMAJ. 2011. Mead, M. Transl Sports Med. 2018.

Photo Credit: Scott, A. CMAJ. 2011. Mead, M. Transl Sports Med. 2018.

Tendon injuries have previously been diagnosed as tendonitis and were believed to be marked by an inflammatory process in the tissue.  Our current knowledge on these injuries has been improved by a better understanding of the disease process behind tendon pain.  Current research indicates tendon pain (tendinopathies) is caused by an ingrowth of nerve and blood vessels to the injured area of the tendon leading to increased sensitivity with loading.  Further, as our body begins to heal the injured area of the tissue, tendon cells become more disorganized in nature.  Conversely, healthy tendons display high degrees of organization with tendon fibers aligned in parallel along the lines of healthy stress.  Gradual loading of the tendon through exercise promotes remodeling of the injured tissue.  In short, both under and over loading tendons lengthens the recovery process.  

A summary article on the available evidence behind tendon treatments was published in a sports medicine journal recently (Mead, M et al. Transl Sports Med. 2018).  The authors reported on a general trend against the use of injections for tendon pain.  This includes corticosteroid injections which may provide short term relief, but at the risk of further tendon injury or rupture.  Further, the research does not support the use of injections including prolotherapy or PRP at this time.  Conversely, the authors reported Physical Therapy including the use of loaded exercises, including eccentric exercise, should be considered a first line treatment for tendon pain and injury.  

Click Here to learn more tendon pain solutions with the experts at MEND

Utilization of Platelet Rich Plasma (PRP) for Tendon Pain
boulder-PRP-treatment-tendon-pain-tendonitis

Overuse injuries to the upper and lower extremity tendons remains a common source of pain and lost activity for patients at our Boulder Physical Therapy practice.   Tendon injuries can be challenging to treat, but these injuries have been shown to respond to exercise interventions designed to appropriately load and promote healing (remodeling) of the injured tissue.  Often patients ask about additional interventions to accelerate the healing of injured tendons including platelet rich plasma (PRP).

PRP remains the most common biological injection provided by physicians to treat the injured tendon.  In short, blood is taken and spun (centrifuged) to concentrate the blood's platelets which are subsequently injected into the injured tendon in an effort to heal the injured tissue.  The effectiveness of this treatment is still being researched.  Authors have reported improvements in tissue structure, mainly in animal models, after PRP injections but improvements in clinical outcomes are less clear.  Improvements in tissue healing and remodeling may or may not correlate to improvements in patient's pain and function.  Further, multiple trials have not shown an additional clinical benefit of pain or improved function over a placebo injection.      

In short, more research is needed to compare PRP to placebo as well as comparing PRP to proven treatments for tendon injury including strengthening exercise.  The injections remain an expensive treatment option for patients and require more scientific inquiry before being used on a widespread basis.