Managing Difficult Tendinopathies
- 1 Introduction
- 2 Confirm The Diagnosis
- 3 Check their Previous and Current Loading History
- 4 Check for co-morbidities
- 5 Check their Management Programme
- 6 Manage expectations
- 7 Using Outcome Measures to Monitor Progress
- 8 Conclusion
- 9 References
Tendons can be difficult to manage. People who struggle with tendinopathy or pain related to tendons have often tried multiple treatment strategies and seen a few health care practitioners. Sometimes, when someone has seen a variety of people and has a multitude of different ideas and treatment options, the best thing to do is to start from the beginning with a thorough subjective and objective history.
Confirm The Diagnosis
The correct diagnosis is the cornerstone in managing any condition. With tendinopathy, the differential diagnosis is extremely important. When considering the diagnosis of tendinopathy, the aim is not to determine if the tendon has pathology, but instead to determine whether or not the tendon is the source of pain. Just because a tendon shows pathoanatomical changes on imaging does not mean that the tendon is the source of the symptoms. If a patient comes with a diagnosis of tendinopathy check that their clinical presentation fits the criteria that are characteristic of tendinopathy. Hallmark features such as pain that is localised to the tendon and increases with dose-dependent loading should be present. Classic tendinopathy would most likely present with the “warm-up” phenomenon, where their pain improves during a specific activity but is worse the day after high loading activity. Certain tendinopathies have hallmark features such as morning stiff in an Achilles tendinopathy or pain with sitting in hamstring tendinopathy.
If the patients presenting clinical signs and symptoms do not match the clinical signs and symptoms of tendinopathy, it may be useful to go through a new process of differential diagnosis to get a more accurate clinical picture.
When a patient presents with insertional tendinopathy or plantar heel pain could be a sign of spondyloarthropathy (SpA). Paul Kirwin developed a clinical tool to help identify SpA. The Pneumonic is SCREEND'EM. The therapist should ask the following questions during assessment: 
S - Skin: rash or psoriasis
C - Colitis or Crohns disease
R - Relatives: family history of inflammatory arthritis or who are HLA-B27 positive
E - Early Morning Stiffness lasting more than 30 minutes? (not related to activity)
E - Eyes – has the patient had uveitis?
N - Nail involvement? Like pitting, thickening, onchylosis (detachment of nailbed)
D - Dactylitis? (sausage-like swelling of the fingers)
E - Enthesopathy? (inflammation of the entheses, the sites where tendons or ligaments insert into the bone)
Check their Previous and Current Loading History
Tendon load and capacity is an important concept to understand in tendinopathy. A tendons capacity will only ever exceed the load placed upon it and injuries occur when the loads placed upon a tendon exceeds its capacity. This is particularly evident with compressive loads being particularly provocative for tendons. When managing a difficult tendinopathy patient it is important to carefully identify the initial aggravating load and any loads that continue to provoke the tendons.
This will differ according to the type of person. An elite athlete with an Achilles tendinopathy may still be doing a lot of plyometric activities that is a very high tensile load for the Achilles. Or perhaps they are performing their exercises in a dorsiflexed position, maintaining compressive loading on the tendon. An elderly sedentary patient with hamstring tendinopathy may have adopted a rehabilitation programme but continues to sit for prolonged periods on hard surfaces, compressing the hamstring tendon against the ischial tuberosities. When someone is actively following the CORRECT rehabilitation programme and is not seeing changes the rest of their day and training programmes should be carefully examined to determine if there is anything else that may be causing provocative loads on the tendon.
Check for co-morbidities
As part of an assessment screening for any red flags as well as general health should be standard practice. Someone who has tendinopathy that is just not responding to standard care should be carefully screened for any systemic illnesses or conditions. Certain conditions may predispose a person to the development of tendinopathies such as diabetes or rheumatoid arthritis. The tendinopathy may only resolve once the systemic condition is managed appropriately.
Check their Management Programme
Check for Progressive Loading
A person suffering from tendinopathy that is just not getting better may not have received the appropriate treatment. Complete rest of a tendon is not the prefered management strategy in tendinopathy, and appropriate loading and load modification is the best evidence-based practice. Tendinopathy rehabilitation, when done correctly, has been shown to be very effective in managing tendons. Review a patient who is struggling with tendinopathy to see if their management to date has possibly consisted of a more passive modality approach than an active rehabilitation approach.
Check the Amount and Type of Load Prescribed
Tendons are provoked by fast and compressive loads. Slow, heavy loads are not provocative to them. A tendon that is not getting better may not be having enough load applied to it to meet the capacity at which it is expected to perform. Alternatively, there may be additional loads it is subjected to such as in the warm-up or stretching programme that continues to exacerbate it even with the correct loading programme.
Check for Single versus Double Leg Exercising
When prescribing a progressive loading programme to manage tendinopathy. It is important to prescribe single leg loading for both the symptomatic and asymptomatic side. This loading should be proportional to the capacity of its specific side eg the asymptomatic side would have greater loads. Double leg exercises should not be the basis of the program as the stronger leg can carry the weaker leg.
Check The Kinetic Chain for Contributing Factors
Tendinopathies do not occur in isolation. There may be intrinsic factors that have contributed to the development of excessive loading on that tendon. Assessing the entire kinetic chain for any weak links will identify any contributing factors. Addressing these may help to reduce the load on the tendon and thereby manage the tendon symptoms.
Check the Management Plan against the Diagnosis
If their programme was completely appropriate for the particular tendinopathy they have been diagnosed with it may be important to check that their diagnosis was, in fact, correct or that there are not any co-morbidities involved. The management for tendinopathy entails progressive loading and if incorrectly diagnosed this treatment could potentially worsen the condition. For example, a person with a paratenonitis of the Achilles Tendon due to excessive shearing forces on the sheat of their Achilles would potentially be aggravated by cycling. Whereas cycling would be a very suitable low load exercise for an Achilles tendinopathy.
Patients with a tendinopathy may have expectations that exceed the pathophysiology of their condition. Tendinopathies often take a long time to get better and communicating this to a patient may be helpful in managing their expectations. If it is an athlete or someone with multiple people involved in their management then everyone needs to know what is provocative for that tendon and what loads should be removed and replaced. A perfectly executed progressive rehabilitation programme can be undermined by excessive loading elsewhere.
Using Outcome Measures to Monitor Progress
It is important to use standardised outcome measures so you can objectively monitor someone’s progress. Often people do not feel they are any better but functionally they have improved significantly. The outcome measure used needs to be specific to the person’s injury and level of function. For example, rating their pain with a hop may be useful for a runner with an Achilles tendinopathy but not as appropriate for a sedentary person. Morning pain and stiffness may be a more appropriate outcome measure for them.
Pain on palpation should not be used as an outcome measure for tendinopathy. Tendons can remain painful for a long period of time even with significant clinical and functional improvement. 
Examples of Outcome Measures Tendinopathy
Tendinopathy can be difficult to treat. Making sure you have the correct diagnosis is the first step in managing difficult tendinopathy. If the diagnosis is correct carefully looking at the management plan so far and contributing factors and co-morbidities involved may help provide the missing link into managing them successfully.
- Cook J. Jill Cooks latest tendon nuggets clinical pearls Slides. Accessed 8 August 2019 https://sportsphysiotherapy.org.nz/sportsphysiotherapy.org.nz/documents/jill.pdf)
- Docking SI, Ooi CC, Connell D. Tendinopathy: is imaging telling us the entire story?. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):842-52.
- 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.
- Kirwan P, March J, & Duffy T. SCREEND'EM BEFORE YOU TREAT'EM A CLINICAL TOOL TO HELP IDENTIFY SPONDYLOARTHROPATHY IN PATIENTS WITH TENDINOPATHY. Conference paper. April 2019
- Kirwan P. SCREEND'EM BEFORE YOU TREAT'EM. Infographic
- Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy?. Br J Sports Med. 2012 Mar 1;46(3):163-8.
- Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Practice & Research Clinical Rheumatology. 2019 Mar 8.
- Rio E. Tendinopathy Assessment Course. Physioplus 2019
- Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. Br J Sports Med. 2014 Apr 1;48(7):506-9.
- Rio E. Managing Difficult Tendinopathy Course. Physioplus. 2020
- Rio, E. Clinical Reasoning in Tendinopathy. Physioplus online course, 2019.