Tendinopathy

Pain from a tendon, tendinopathy, tendinitis, tendinosis What do these words all mean?

Essentially all these terms refer to a painful tendon (Scott et al., 2020). All these terms have been used in the past however, tendinopathy is the preferred term to reach some form of consensus (Scott et al., 2020).

How does it develop?

This is actually still not completely understood (Rio et al., 2014). There are however, several risk factors that increase the risk of developing tendinopathies:

• Excessive body weight (Cardoso et al., 2019)

• Older age (Cardoso et al., 2019)

• Genetics (Cardoso et al., 2019)

• Diabetes (Cardoso et al., 2019)

• Inflammatory and autoimmune conditions (Cardoso et al., 2019)

• Hyperlipidaemia & Hypercholesterolaemia (Cardoso et al., 2019)

• Certain medications, for example: Fluoroquinolones, Glucocorticoids and Retinoids (Cardoso et al., 2019)(Albee et al., 2019)

• Excessive load (Cardoso et al., 2019)

• Smoking (Shiri et al., 2006)

• Psychological factors

How is tendinopathy diagnosed?

Tendinopathies can be diagnosed by physiotherapists or medical doctors. They will base this on your history and physical assessment. Some indicators that you may have a tendinopathy are the following (Rio et al., 2014):

• No or minimal pain at rest

• Worse pain with loading of the tendon

• Improvement in pain during exercise

Do you need imaging to confirm a tendinopathy?

The answer is no. In fact, the relation between imaging findings and clinic symptoms for tendinopathy is quite poor (Rio et al., 2014)(Malliaras & Cook 2006)(Cardoso et al., 2019). Imaging can be useful in ruling out any other possible sinister pathology (Cardoso et al., 2019).

What areas of the body can experience tendinopathy?

The most common tendons affected by tendinopathies are the Achilles, Rotator Cuff (shoulder), Patella (knee), Gluteal, Hamstring, lateral epicondylitis (tennis elbow) and others.

What do tendinopathies all have in common and how do they differ?

Tendinopathies all have a few common features, firstly they are all painful (Rio et al., 2014). Pain is also dependent on load (Rio et al., 2014), load meaning how much stress the tendon is put under (including over the course of a day in total). This is why load management is the cornerstone of tendinopathy treatment.

As outlined above, tendinopathies are always painful. However, this pain is not closely related to damage or the extent of damage (Rio et al., 2014). Pain in tendinopathy can be a result of a sensitized nervous system (Plinsinga et al., 2015).

Tendinopathies have something in common with all pain conditions, that is that it is never purely a biomedical/physiological problem. Psychosocial factors will always influence pain and its consequential disability, with different degrees between individuals (Stubbs et al., 2024)(Mallows et al., 2017). This should not be ignored by your treating healthcare provider.

From Edgar et al., 2022

Strength exercises, the core intervention for tendinopathies

Gradual progressive strengthening programmes for tendinopathies is the cornerstone in the recovery (Cardoso et al., 2019). This should always be the core treatment in tendinopathy rehabilitation (Cardoso et al., 2019).

If you google tendinopathies there is very likely to be a reference made to ‘eccentric’ exercises. This is one form of strength training that is shown to be effective in the treatment of tendinopathies (Irby et al., 2020). The good thing is that you likely don’t have to worry about this as the superiority to regular strengthening exercises is questionable (Couppe et al., 2015)(Stasinopoulos & Stasinopoulos 2017).

Do you need dry needling, shockwave therapy, massage therapy, or other ‘manual therapies’ to recover?

Shockwave therapy is considered a promising treatment in tendinopathies. Its exact mechanism of action is not very well understood (Cardoso et al., 2019). It currently also does not have high quality evidence supporting its use in tendinopathies (Cardoso et al., 2019)(Buchbinder et al.,2015). It is however, generally considered safe (Cardoso et al., 2019). The main problem with shockwave therapy is that you need multiple sessions completed by healthcare professionals (not cheap), with the possibility that it may not do anything for you.

TENS, ultrasound therapy and laser therapy have not shown to outperform sham treatments in tendinopathies or provide short term pain relief at best (Cardoso et al., 2019). Dry needling has mixed reviews with some studies suggesting it could be helpful to improve pain while others show no effect (Krey et al., 2015)(Gabbie et al., 2015)(Stoychev et al., 2020). Overall the studies for these are again considered to be low quality (Gabbie et al., 2015).

Overall these treatments can help some people sometimes in providing pain relief (often only short term). Which can be very helpful. However, overall the evidence suggests that if anything it should be an add-on not the focus of treatment. If you have the money and time for these treatment then they could be a good option as part of your treatment. If you don’t, it may be worth skipping these.

Do you need an injection or medication to recover?

More recent studies have found negative longer term effects of corticosteroid effects on tendinopathies (Dean et al., 2014)(Cardoso et al., 2019). It can provide short term pain relief (Irby et al., 2020). Steroid injections for tendinopathies have also been advised against (Cardoso et al., 2019). Platelet Rich Plasma (PRP) injections don’t seem to fare much better than no treatment (Masiello et al., 2023)(Irby et al., 2020).

Medications are often prescribed and can be useful in pain management. However, its long term use is often problematic. Patches and gels may be preferred over oral medication due to less systemic side effects.

What are other recommended interventions and treatments?

As highlighted earlier, pain is never “just in the tissue” or purely due to damage, psychosocial factors can impact pain (Stubbs et al., 2024)(Mallow et al., 2017). In tendinopathy things like excessive fear, excessive worry, depression, anxiety and stress can result in worse outcomes (Mallow et al., 2017)(Edgar et al., 2022). This can be of varying degrees for different people. Psychotherapy is often an appropriate therapy option if these do play a significant role or even to assist people in coping with their pain.

Surgery is always an option however, it is considered the last option and is not always a guaranteed success in tendinopathies (Cardoso et al., 2019). For example one study (note this is only one study!) did not find a significant difference in pain or function when comparing wait and see and surgery for rotator cuff tendinopathy (Beard et al., 2018).

What about doing nothing?

There are not many studies that have looked into this however, there is a study that tried to answer this question by reviewing all the available studies (Garzon et al., 2024). They found that after 12 months there would not be a full resolution of pain and function related outcomes.

Top tips for tendinopathies:

1. Load management is key. Decreasing load temporarily and gradually increasing it over time is important.

2. Exercise to treat tendinopathies can be painful, this does not mean that this is a sign of further damage (Edgar et al., 2022) and instead could potentially be beneficial.

3. Pain in tendinopathy is not always a good indicator of physical damage (Edgar et al., 2022)

4. Although rest may feel good and can be useful during tendinopathy recovery (Cardoso et al., 2019). We can not rest away tendinopathies. In fact, excessive period of rest can actually worsen this condition (Cardoso et al., 2019).

References

1. Alves, C., Mendes, D., & Marques, F. B. (2019). Fluoroquinolones and the risk of tendon injury: a systematic review and meta-analysis. European journal of clinical pharmacology, 75(10), 1431–1443. https://doi.org/10.1007/s00228-019-02713-1 
   

2. Buchbinder, R., Green, S. E., Youd, J. M., Assendelft, W. J., Barnsley, L., & Smidt, N. (2005). Shock wave therapy for lateral elbow pain. The Cochrane database of systematic reviews, 2005(4), CD003524. https://doi.org/10.1002/14651858.CD003524.pub2 
   

3. Cardoso, T. B., Pizzari, T., Kinsella, R., Hope, D., & Cook, J. L. (2019). Current trends in tendinopathy management. Best practice & research. Clinical rheumatology, 33(1), 122–140. https://doi.org/10.1016/j.berh.2019.02.001 
   

4. Couppé, C., Svensson, R. B., Silbernagel, K. G., Langberg, H., & Magnusson, S. P. (2015). Eccentric or Concentric Exercises for the Treatment of Tendinopathies?. The Journal of orthopaedic and sports physical therapy, 45(11), 853–863. https://doi.org/10.2519/jospt.2015.5910 
   

5. Dean, B. J., Lostis, E., Oakley, T., Rombach, I., Morrey, M. E., & Carr, A. J. (2014). The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Seminars in arthritis and rheumatism, 43(4), 570–576. https://doi.org/10.1016/j.semarthrit.2013.08.006 
   

6. Edgar, N., Clifford, C., O'Neill, S., Pedret, C., Kirwan, P., & Millar, N. L. (2022). Biopsychosocial approach to tendinopathy. BMJ open sport & exercise medicine, 8(3), e001326. https://doi.org/10.1136/bmjsem-2022-001326 
   

7. Irby, A., Gutierrez, J., Chamberlin, C., Thomas, S. J., & Rosen, A. B. (2020). Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments. Scandinavian journal of medicine & science in sports, 30(10), 1810–1826. https://doi.org/10.1111/sms.13734 
   

8. Krey, D., Borchers, J., & McCamey, K. (2015). Tendon needling for treatment of tendinopathy: A systematic review. The Physician and sportsmedicine, 43(1), 80–86. https://doi.org/10.1080/00913847.2015.1004296 
   

9. Malliaras, P., & Cook, J. (2006). Patellar tendons with normal imaging and pain: change in imaging and pain status over a volleyball season. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine, 16(5), 388–391. https://doi.org/10.1097/01.jsm.0000244603.75869.af 
   

10. Mallows, A., Debenham, J., Walker, T., & Littlewood, C. (2017). Association of psychological variables and outcome in tendinopathy: a systematic review. British journal of sports medicine, 51(9), 743–748. https://doi.org/10.1136/bjsports-2016-096154 
    

11. Masiello, F., Pati, I., Veropalumbo, E., Pupella, S., Cruciani, M., & De Angelis, V. (2023). Ultrasound-guided injection of platelet-rich plasma for tendinopathies: a systematic review and meta-analysis. Blood transfusion = Trasfusione del sangue, 21(2), 119–136. https://doi.org/10.2450/2022.0087-22 
    

12. Plinsinga, M. L., Brink, M. S., Vicenzino, B., & van Wilgen, C. P. (2015). Evidence of Nervous System Sensitization in Commonly Presenting and Persistent Painful Tendinopathies: A Systematic Review. The Journal of orthopaedic and sports physical therapy, 45(11), 864–875. https://doi.org/10.2519/jospt.2015.5895
    

13. Rees, J. D., Stride, M., & Scott, A. (2014). Tendons--time to revisit inflammation. British journal of sports medicine, 48(21), 1553–1557. https://doi.org/10.1136/bjsports-2012-091957 
    

14. Rio, E., Moseley, L., Purdam, C., Samiric, T., Kidgell, D., Pearce, A. J., Jaberzadeh, S., & Cook, J. (2014). The pain of tendinopathy: physiological or pathophysiological?. Sports medicine (Auckland, N.Z.), 44(1), 9–23. https://doi.org/10.1007/s40279-013-0096-z 
    

15. Scott, A., Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., de Vos, R. J., Fu, S. N., Grimaldi, A., Lewis, J. S., Maffulli, N., Magnusson, S. P., Malliaras, P., Mc Auliffe, S., Oei, E. H. G., Purdam, C. R., Rees, J. D., Rio, E. K., Gravare Silbernagel, K., Speed, C., … Zwerver, J. (2020). ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. British journal of sports medicine, 54(5), 260–262. https://doi.org/10.1136/bjsports-2019-100885 
    

16. Shiri, R., Viikari-Juntura, E., Varonen, H., & Heliövaara, M. (2006). Prevalence and determinants of lateral and medial epicondylitis: a population study. American journal of epidemiology, 164(11), 1065–1074. https://doi.org/10.1093/aje/kwj325 
    

17. Stasinopoulos, D., & Stasinopoulos, I. (2017). Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. Journal of hand therapy : official journal of the American Society of Hand Therapists, 30(1), 13–19. https://doi.org/10.1016/j.jht.2016.09.001
    

18. Stoychev, V., Finestone, A. S., & Kalichman, L. (2020). Dry Needling as a Treatment Modality for Tendinopathy: a Narrative Review. Current reviews in musculoskeletal medicine, 13(1), 133–140. https://doi.org/10.1007/s12178-020-09608-0 
    

19. Stubbs, C., McAuliffe, S., Chimenti, R. L., Coombes, B. K., Haines, T., Heales, L., de Vos, R. J., Lehman, G., Mallows, A., Michner, L. A., Millar, N. L., O'Neill, S., O'Sullivan, K., Plinsinga, M., Rathleff, M., Rio, E., Ross, M., Roy, J. S., Silbernagel, K. G., Thomson, A., … Malliaras, P. (2024). Which Psychological and Psychosocial Constructs Are Important to Measure in Future Tendinopathy Clinical Trials? A Modified International Delphi Study With Expert Clinician/Researchers and People With Tendinopathy. The Journal of orthopaedic and sports physical therapy, 54(1), 1–12. https://doi.org/10.2519/jospt.2023.11903

    
    

20. Garzón, M., Balasch-Bernat, M., Cook, C., Ezzatvar, Y., Álvarez-Lliso, Ó., Dueñas, L., & Lluch, E. (2024). How long does tendinopathy last if left untreated? Natural history of the main tendinopathies affecting the upper and lower limb: A systematic review and meta-analysis of randomized controlled trials. Musculoskeletal science & practice, 72, 103103. https://doi.org/10.1016/j.msksp.2024.103103

    
    

21. Beard, D. J., Rees, J. L., Cook, J. A., Rombach, I., Cooper, C., Merritt, N., Shirkey, B. A., Donovan, J. L., Gwilym, S., Savulescu, J., Moser, J., Gray, A., Jepson, M., Tracey, I., Judge, A., Wartolowska, K., Carr, A. J., & CSAW Study Group (2018). Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet (London, England), 391(10118), 329–338. https://doi.org/10.1016/S0140-6736(17)32457-1

This blog was written by Samuel Bulten