Evidence-Based Practice in Tendinopathy

Original Editor - Mandy Roscher Top Contributors - Mandy Roscher, Tarina van der Stockt, Kim Jackson and Tony Lowe

Introduction

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Evidence-based practice is about integrating best evidence research with clinical expertise as well as a patient preference[1]. Applying an evidence-based practice approach to the management of tendinopathy is not as simple as applying one set of research findings, from a single article, in a recipe format for a patient.  Every patient presents with a unique clinical picture. The therapist managing the patient should apply a broad base of evidence to clinically reason a comprehensive management plan. It is important that management is not recipe-driven but should be based on the best evidence available at that time. Evidence-based practice is fluid and constantly changes as more evidence is produced.

The Challenge of Evidence-Based Practice in Tendons

There is a plethora of research available on tendons and tendinopathy, and it can be difficult to translate that evidence directly into clinical practice. In research settings, it is important to control as many variables as possible, so the results can be as accurate as possible. Researchers often only look at one parameter and measure that parameter over a specific period of time. It is impossible in a research setting to apply an entire rehabilitation programme as an intervention and long term follow up is often difficult. Strong clinical reasoning skills are required to synthesise all the evidence available into clinically appropriate management strategies.

Tailor protocols to the individual patient

Every patient presents with a unique set of symptoms. It is a physiotherapists responsibility to perform a thorough assessment and then clinically reason the assessment findings to get a complete clinical picture. Because research needs to be specific, it is uncommon that a paper can be directly applied to a patient. Concepts and aspects of protocols within papers need to be modified and tailored for where the patient is at this the point of their journey to recovery.[2]

It is important to always consider the person who is in front and to compare that to the demographics of the groups contained within a research paper. Is it applicable that an intervention that worked for older men would be appropriate for younger females?

A study by Rio et al, in 2015, it all showed that isometric exercises reduced pain in patellar tendinopathy which has promising applications for clinical practice[3]. However, the study was conducted on young athletic men with stringent exclusion criteria and as such, should be applied to a more general population with caution. A situation such as this is where the clinical experience component of evidence-based practice is so important.  A clinician needs to synthesise the best evidence available in research and adapt it into a management plan appropriate for the patient in front of them factoring the patient’s demographics and clinical findings.

Read outside of tendon literature.

There are many aspects to treating a patient outside of the specific diagnosis. In a tendinopathy patient, you are dealing with a person as a whole. Looking more broadly at the literature around subjects such as communication, pain neuroscience, cross-education and general strengthening is useful. Synthesising all this information will help you to provide a holistically informed evidence-based practice approach

Consider Comorbidities

Tendinopathies do not occur in isolation. A person may present with a variety of comorbidities that can affect the outcomes. When applying specific research protocols to a patient, it is important to factor in their comorbidities. For example, a diabetic patient may not follow the standard trajectory of healing times or a person with a systemic inflammatory condition such as rheumatoid arthritis may not respond as positively to a loading protocol.

Even though it may not be very common, symptomatic patellar tendinopathy has been found to sometimes be associated with connective tissue diseases like psoriatic arthritis or diabetes, or metabolic or autoimmune diseases. [4] Patients should be screened during the assessment to rule out systemic comorbidities especially when an increase in load does not form part of the clinical picture. Referral for medical management alongside physiotherapy is important with these patients. [4]

Consider Patient Preferences

It is important that patients expectations, as well as personal preferences, are taken into account when developing a management plan. Every person has different goals, and these should be incorporated into the treatment plan. A patient-centred approach is important to ensure patient compliance as well as enhancing the therapeutic relationship.[5]

Application of Tendon Research

Applying tendon research to patients doesn't need to be complicated. Our primary goal should always be to assess for function and functional deficits as well as the patient's ideas, concerns and expectations. A patient-centred approach is always the best management strategy.[5] The research consistently shows that rehabilitation of tendinopathies should focus on slow progressive loading. The ideal exercise programme and prescription are still to be determined and it is possible that people with varying ages, activity levels, access to equipment and site of tendinopathy will respond to varying protocols. [6]

Always consider the patient's individual goals and manage them according to where they are at that exact point of time. A 60-year-old sedentary woman with patellar tendinopathy will have very different goals and expectations compared to a 25-year-old professional volleyball player.

Isolated training towards the rehabilitation of a specific tendon or muscle group may be effective but if a return to sport is the end goal a much more comprehensive rehabilitation programme of the entire kinetic chain is required. [7][6]

General Summary of EBP in tendons

  • Always consider a patient’s functional state
  • Assess their current capacity as well as current goals and for a treatment plan based around them
  • Slow progressive loading (tendons do not like fast changes)
  • Consider their current situation eg are they in-season or out of season
  • Patient-centred approach - make sure what you are giving them aligns with their values, beliefs, expectations and capacity

Additional Resources

References

  1. Scurlock-Evans L, Upton P, Upton D. Evidence-based practice in physiotherapy: a systematic review of barriers, enablers and interventions. Physiotherapy. 2014 Sep 1;100(3):208-19.
  2. Rio E. Evidence-Based Practice in Tendinopathy. Physioplus. 2020
  3. Ebonie Rio, Dawson Kidgell, Craig Purdam, Jamie Gaida, G Lorimer Moseley, Alan J Pearce, Jill Cook. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med 2015;49:1277–1283.
  4. 4.0 4.1 Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):887-98.
  5. 5.0 5.1 Fix GM, VanDeusen Lukas C, Bolton RE, Hill JN, Mueller N, LaVela SL, Bokhour BG. Patient‐centred care is a way of doing things: How healthcare employees conceptualize patient‐centred care. Health Expectations. 2018 Feb;21(1):300-7.
  6. 6.0 6.1 Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Practice & Research Clinical Rheumatology. 2019 Feb 1;33(1):122-40
  7. Abat F, Alfredson H, Cucchiarini M, Madry H, Marmotti A, Mouton C, Oliveira JM, Pereira H, Peretti GM, Romero-Rodriguez D, Spang C. Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part I: biology, biomechanics, anatomy and an exercise-based approach. Journal of experimental orthopaedics. 2017 Dec;4(1):1-1.