Dr. Jeffrey Tucker ‘Raw’ on Tendinopathy
Let’s talk! I have not signed any indorsements or contracts yet so let me tell you like it is. I can name ‘names’ in this article because this is our Journal. Dr. Garbutt and Schrieber have made this our safe space. No editors to say “No Jeff, you can’t mention that brand.” I’m in the day-to-day practice of helping patients feel better just like you. Here are my current thoughts on the topic of tendinopathy. If you want more references I suggest you do some more research than what I find real on a day-to-day basis, or chime in on the rehab blog and share your best practice tips as well.
The key points in making a diagnosis of tendinopathy are:
Tenderness at the involved tendon.
Pain with resistive testing of the involved muscle-tendon unit.
Sometimes pain with passive stretch.
Occasionally palpable thickening or nodularity of the involved tendon.
What is the pain generator in patients with tendon pain?
Some combination of mechanical, neural, and vascular component. Most of the time, it is not inflammatory! Most of the research I read shows pathology in the tendon to be devoid of inflammatory cells.
A summary list of the common treatment interventions are:
Relative rest: We can encourage patients to cross train. For example, if we are dealing with an upper extremity tendinopathy from swimming we can suggest cycling instead. If the patient has a lower extremity tendinopathy we can suggest the use of upper extremity CLX elastic bands made by Performance Health for a cardio and strength workout while the lower extremity is stationary and resting.
Cold: This therapy decreases blood flow and has an analgesic effect so it is probably useful in the tendinitis phase. However there is not really much evidence for the use of cold in tendinopathy.
Modalities: Iontophoresis therapy is typically used by physical therapists to treat sports injuries by delivering anti-inflammatory medications directly into the skin. This is probably useful in the tendinitis phase but, like cold therapy probably not as useful as with tendinosis.
Ultrasound: “There is strong supporting evidence from animal studies about the positive effects of ultrasound on tendon healing. In vitro studies have also demonstrated that ultrasound can stimulate cell migration, proliferation, and collagen synthesis of tendon cells that may benefit tendon healing.”(Am J Phys Med Rehabil. 2011 Dec;90(12):1068-73). For those of us who have used ultrasound over the years, I think it is safe to say that therapeutic ultrasound can positively influence the tendon healing process in the various stages of tendinopathy. If you want the most beautiful looking equipment on the market contact the Rehab Council’s friends at Meyer Distributing and Zimmer.
Laser: The availability of various laser devices has only made this modality more exciting to me as a practitioner. Most of what I’ve read concurs what I find in practice…the application of low intensity laser was better than placebo in improving tendonitis and other tendinopathies. As a rehab practitioner I find the contribution of an exercise program combined with the laser is even more effective.
Tumiltyet al.12 (2008) verified the effectiveness of low intensity laser associated with eccentric exercises in the treatment of Achilles tendinopathy. He had 21 patients divided in two groups, laser and placebo. The use of laser/placebo was three times a week during four weeks. Plantar flexion eccentric exercises were performed at six sets of 15 repetitions, twice a day, seven days per week for twelve weeks.
Stergioulaset al.14 (2008) demonstrated that low intensity laser associated with eccentric exercises can produce a faster improvement of Achilles tendinopathy. He had 52 athletes divided into two groups: laser+exercises and laser+placebo. They had twelve sessions in eight weeks. The eccentric exercises were performed four times a week for eight weeks. There was an acceleration of the recovery process when laser was associated with an eccentric exercise program.
Types of Laser: I personally have two lasers in my office. A class 4 Light Force Laser and a class 3B TheraLase laser. If you want to know why I have two lasers, you can call me! Here’s what I remember to tell you…the 660-nm laser does something to the macrophages that produces conditions that contain growth factors capable of modulating the proliferation of fibroblasts. By increasing fibroblast production, the proliferative phase of repair is accelerated, and thus, Low Level Laser Therapy (LLLT) could be of considerable benefit in the treatment of tissue injuries. Webb et al. suggests that photoenergy at 660 nm wavelength at given parameters, possibly induced fibroblasts to secrete growth factors like bFGF (basic FGF) that could promote chemotaxis, proliferation and differentiation of vascular endothelial cells. Ghali and Dyson showed that, of the endothelial cell exposed to 660-nm wavelengths from 15-mW laser diodes induced the release of mitosis-promoting cytokines and growth factors. LLLT is efficient in the increase of angiogenesis during tendon repair. Dose is everything…read to the end of the article for a blockbuster recommendation!
Laser helps increase neoangiogenesis due to the stimulatory effects in inflammatory cells (macrophages and fibroblasts) to release growth factors specially FGF and VEGF, which are related to be potent angiogenic stimulators. I can’t pretend to understand it all but those of you way smarter than me can share your knowledge.
Most sales people of laser mention that ‘photobiostimulation’ occurs through the electron transport chain enzymes in mitochondria, by producing ATP, which increase cellular metabolism and function. Patients get that!
Shock wave therapy: This is another cutting edge therapy that is getting more and more attention. I was an early adopter of the EnPuls Radial Shock Wave Therapy system by Zimmer and the Acoustic Pulse Wave therapy by PiezoWave. For tendinopathy these are the devices you will want to try. Radial Pulse Therapy also known as Radial Shockwave Therapy has and is gaining popularity for the adjunct treatment of superficial orthopedic conditions especially myofascial conditions and tendinopathy. Some patients need overly dense fascia, scar tissue, soft tissue and joint adhesions broken up – do what you want but my patients like technology; and some clients need a device with specific magnitude of forces (Joules) and a controlled speed (Hertz) applied to the muscle/tendon/bone unit in order to achieve the goals of restimulating the healing process.
As practitioners, it is important to correctly identify the patient’s biggest dysfunction. I often ask myself, “What’s the biggest issue?” Is it pain related to repetitive trauma, microtrauma, macrotrauma, obesity, poor nutrition, lack of motor control, poor strength, poor mobility, etc. These devices are my “go to” for working with rotator cuff tendinopathy, achilles tendinopathy, plantar fasciitis, patellar tendinopathy, tennis elbow, iliolumbar and thoracolumbar fascial dysfunctions. I like being able to offer these treatment options especially after patients have tried manipulation, acupuncture, medications and glucocorticoid injection therapy for tendinopathy, trigger points and fascial adhesions.
Pharmaceuticals: NSAID’s – not appropriate and too many side effects; cortisone – ineffective. Need I say more?
Supplements: This list could be even longer but here are some of my top tier suggestions:
- Boswellia (Boswelliaserrata) is my most frequently used supplement for tendinopathy.
- Turmeric(Curcuma longa) is good for pain and inflammation. Turmeric is sometimescombined withbromelain, because it makes the effects of bromelain stronger.
- Vitamin C aids in healing, increase immune function, and reduces inflammation.
Magnesiumis used to aid healing of connective tissues and muscles.
- Vitamin A is used for healing.
- Vitamin E and essential fatty acids, such as fish oil or evening primrose oil to reduce inflammation.
The Rehab Council has had amazing support from Standard Process over the years. Schedule a date with your rep to learn more about supplements.
Creams: BioFreeze remains one of my main products that I sell in the office. Cannabis is an important player and you better have an opinion about it. I have the first US patent on a process to make a cannabis cream. Let me know if you want to be an investor in going after infringers on the patient? Other topical creams include combinations of capsaicin, arnica, camphor, arnica, curcumin, ginger, menthol, comfrey, and Willow bark (Salix alba) can be used to relieve pain. The ‘new kid’ on the block is Khalili Cream. Long time and loyal supporters of the Rehab Council are China Gel and BioFreeze.
Braces: Cho Pat, and other names I can’t recall, but there is not much evidence.
Orthotics: No evidence to support or refute. Aline is a Rehab Council supporter. I use them on a daily basis in my office for lots of conditions. Lately my sentiment is once I put an orthotic in a shoe ‘What exercsies can I teach my patient to try to create an arch so they can eventually get out of the orthotic”. Not a popular thought with some of the BIG orthotic companies!
Manual therapy: Purported to reduce adhesions within the tendon and promote normal collagen alignment; Animal studies have shown increased fibroblastic activity with IASTM technique (Davidson 1997, Gehlsen 1999). I’m sure there are way more recent studies on this. I’m just running out of time and space!
Exercise: Eccentric strength gets you eccentric strength (need concentric & eccentric), motor retraining (proprioception) is important. Here are some Jeff Tucker preferences:
- Patella – drop squats, tail gaters
- Supraspinatus Tendon – Scaption with CLX bands
I am pleasantly surprised at how well my patients are doing with body weight isometrics.
Stretching: It’s still recommended and these days I’m using longer and longer hold times – like 2 – 3 minutes. It is known that poor quadriceps and hamstring flexibility will show up in athletes and cause patellar tendinitis (tendinosis).
Taping: Not a lot of evidence for it overall, but if you aren’t doing it, you are old school!
Ergonomics: This could be as simple as having a talk about a patients chair, computer keyboard, mouse, and the monitor height/distance from the eyes. Human Scale is a Rehab Council supporter and I suggest looking at their ‘stand up desks’ and other stylish furniture.
Surgery: My suggestion is after a 3 week trial of therapy if you don’t see progress or you see only slight progress get an MRI. I’ve seen many full thickness tears that the patient compensated for and it’s better to know sooner than later what’s happening.
My Summary: Tendon pain is a common condition. The preponderance of evidence suggests tendon pathology is not inflammatory. We should get out of the ‘tendinitis’ mode! Tendon pain is a challenge to treat so address mechanical issues, address muscle length issues, address tendon load, use eccentric tendon loading exercises and concentric loading. The new frontier is probably in treating neovascularity. On that note and my blockbuster thought is try to dose laser every day for a week. If you don’t see at least a 50% reduction it’s a poor prognosis.