Managing tendinopathies (part 2)
In the first part of our two-part series on tendinopathies, we explored the structure and function of tendons, the disease process of tendinopathies and characteristic signs.
Now, we will investigate how to manage tendinopathies, focusing on early interventions, modifying training approaches and specific treatments for key tendinopathies like patellar, Achilles and lateral elbow tendinopathy.
Early interventions for tendinopathies
Early intervention plays a crucial role in managing tendinopathies and preventing further progression of the condition.
Load management
There are several key strategies we consider when treating a tendinopathy, the first being load management.
Load management involves gradually modifying activity levels to reach an optimal load level.
This may involve temporarily reducing training intensity, volume or frequency to allow the tendon to heal and adapt.
This helps to reduce excessive stress on the tendon while generating enough stimulus on the tendon to drive changes in the tendon structure, increasing its capacity to tolerate higher and more frequent mechanical strain.
Complete cessation of training is not an effective way to recover from a tendon injury as training stimulus is needed to aid in the healing process.
Eccentric exercise programs
Eccentric exercises, which involves isolated, slow lengthening muscle contractions is a frequently used treatment for tendinopathy .
Eccentric exercises are effective in the treatment of pain in tendinopathies and help to restore function.
They are particularly helpful for Achilles and patellar tendon injuries.
Implementing eccentric-focused exercises tailored to the specific tendon affected can be an important part of a recovery program for tendinopathy.
Manual therapy
A multifaceted approach to the treatment of tendinopathies is often required.
Manual therapy techniques such as soft tissue mobilisation, myofascial release and joint mobilisations can help alleviate pain, improve tissue mobility and promote healing.
Eccentric exercises alone are not effective for all patients experiencing tendinopathy. As such, combining this treatment type with various manual therapies is helpful in managing this condition.
Biomechanical assessment
A thorough biomechanical assessment is essential for the treatment of tendinopathies to help understand the patient’s condition and to prescribe a relevant rehabilitation plan.
Conducting a thorough biomechanical assessment can identify underlying factors contributing to tendon overload and dysfunction.
Addressing biomechanical issues through corrective exercises or equipment modifications can also relieve stress on the tendon.
Modifying training approaches for tendon pain
When tendon pain develops, it's essential to modify the training approach to prevent exacerbation of symptoms and promote recovery.
The key goal in recovering from a tendinopathy is to improve the capacity of the tendon and muscle to manage load.
According to Goom, T (2013) a six-phase approach to rehabilitation should be considered.
This approach includes:
Reduce pain: reduce compressive load.
Improve strength: heavy slow resistance training.
Build function strength: progress strength work into more functional tasks.
Increase power: reduce reps but increase speed of muscle contraction to build power.
Develop stretch shortening cycle: include plyometrics and/or graded return to running.
Sport specific: add drills specific to requirements of activity/sport.
Some other considerations to help modify training can include:
Pain monitoring: Utilise pain monitoring scales, such as the verbal numerical rating score (VNRS), to assess pain levels during and after activities. Avoid activities that exacerbate pain beyond a tolerable level and gradually reintroduce them as symptoms improve.
Cross training: incorporate cross-training activities that reduce impact on the affected tendon while maintaining overall fitness. For example, swimming, cycling or using low-impact cardio equipment can be alternatives to high-impact activities.
Progressive loading: implement a progressive loading program that gradually increases the intensity and volume of exercises as tolerated by the tendon. This helps stimulate tissue adaptation and strength without overwhelming the healing process.
Specific treatments for key tendinopathies
Depending on the type of tendinopathy, there are specific treatments we may apply to treat the affected tendon.
Patellar tendinopathy
For a patellar tendinopathy, eccentric strengthening exercises focusing on the quadriceps and the patellar tendon are often prescribed.
Additionally, patellar tendon straps or braces may provide symptomatic relief by offloading the tendon during activities.
Achilles tendinopathy
Eccentric calf exercises, such as heel drops, are helpful in managing an Achilles tendinopathy.
Modalities like eccentric loading programs, shockwave therapy, and PRP (Platelet-Rich Plasma) injections have shown promising results in reducing pain and improving function.
Lateral elbow tendinopathy (tennis elbow)
Eccentric wrist extensor exercises, grip strength training and addressing biomechanical factors contributing to wrist and forearm strain are key in managing lateral elbow tendinopathy.
Modalities such as shockwave therapy and PRP injections may also be considered.
Early intervention, appropriate load management and targeted treatments can significantly improve outcomes and facilitate return to activity for individuals with tendinopathies but a personalised assessment should be performed by a registered osteopath before engaging in a rehabilitation program.
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