Tendinopathy Treatment Adjuncts
Original Editor - Michelle Lee
- 1 Introduction
- 2 Extracoropreal Shockwave Therapy (ESWT)
- 3 Glyceryl Trintrate (GTN)
- 4 Ultrasound Electrotherapy
- 5 Splints, Orthotics and Taping
- 6 Injections
- 7 Acupuncture
- 8 Manual Therapy and Massage
- 9 Dry Needling
- 10 Nonsteroidal anti-inflammatory drug NSAIDs
- 11 Platelet-enriched Plasma (PRP) injection therapy
- 12 Blood Flow Restriction Training (BFRT) therapy
- 13 References
On this page we are going to look at the different types of treatment in adjunct to exercises / rehabilitation . We will explain each method with a summary of each treatment and link to some more evidence for you to read.
Extracoropreal Shockwave Therapy (ESWT)
ESWT is a method which has conflicting evidence for and against the use. ESWT is when high energy acoustic pressure waves are delivered to the affected area. This is done through a probe that touches the skin similar to an ultrasound head. The evidence for use is only recommended in certain chronic/degenerative tendons with the idea that this treatment can reverse the degenerative process and take the tendon back into the acute stage to stimulate the healing process again.
There are a couple of drawback with this treatment, that the treatment itself can be painful but also the machine is very costly.
Have a futher look into the research here:
- A systematic review for shockwave therapies in soft tissue conditions: focusing on the evidence
- Extracorporeal shockwave therapy for patella tendinopathy: A review of the litrature
- ESWT in the management of patella tendinopathy
- The effectiveness of extracorporeal shockwave therapy in lower limb tendinopathy: A systematic review
Glyceryl Trintrate (GTN)
Tropical glyceryl trinitrate (GTN) has been used in the past to treat tendinopathy. The theory behind the use of GTN is that it stimulates healing within the tendon by increasing the amount of nitric oxide. It is said to induce the reaction of fibroblast proliferation, collegen synthesis and cotraction of collagen lattices. There is some conflict in the research with the use of GTN and as with all research; further research needs to be done to withdraw conclusion. But you can read some of the articles here:
- Tropical glyceryl trinitrate treatment of chronic patella tendinopathy; A randomised, double blinded placebo-controlled clinical trial
- 50 Recalcitrant Achilles Tendinopathy Treated With Exercise And Glyceryl Trinitrate: A Case Report
- Randomised, double-blind, placebo-controlled clinical trial of a new topical glyceryl trinitrate patch for chronic lateral epicondylosis
Ultrasound in a very common treatment modality. It is a non invasive procedure which involves sending soundwaves at different depths and rates into the tissue to atempt to have a physiological affect and aid in the healing process. There are many articles on the use of electrotherapy and ultrasound any of which not if favour. The BC Physical Therapy Tendinopathy Taskforce recently did an extensive litrature serach on the effectivness of treatments on tendinopathy, ultrasound was one of these modalities. They came to the conclusion that there was no evidence to support the use of ultrasound in the acute phase but this could be physiologically reasoned, but for the more chronic phase neither could be supported. Some of the research is here:
Splints, Orthotics and Taping
Splints and orthotics can be used alongside other treatments for tendinopathy. There is research looking at foot orthosis, tennis elbow clasps and taping in tendinopathy. Research does not suggest that orthotics or taping alone will treat the poblem, they may assist in the management as an adjunct. For example a heel lift may off load an achilles tendinopathy for pain management, but the appropriate rehabilitation is still required which you can read about here. Some articles of interest are listed below:
- Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial
- Cost effectiveness of brace, physiotherapy, or both for treatment of tennis elbow
- Effects of taping on pain, grip strength and wrist extension force in patients with tennis elbow
- The efficacy of taping for the rotator cuss tendinopathy: A systematic review and meta-analysis
Corticosteroid injections are a common treatment modality for tendinopathy, but do they work? Looking at the research different methodology is used therefore this makes studies hard to compare, leaving gaps in the research. More current research suggests that initially injections may be beneficial but in the intermediate and long term other treatments may be more beneficial. There has been a high incidence in reoccurance of symptoms after injection. So does it have it's place? Potentially when working with high level athletes if they have a competition or a game, but this still is not a full gone conclusion and is just based on clinical reasoning with all the risks of an invasive procedure and no long term benefits known, although is reccommended in British Medical Journal for many tendinopathies. Take a look at the research below to inform your clinical reasoning.
- Corticosteroid Injections for Common Musculoskeletal Conditions
- The challenge of managing tendinopathy in competing athletes
- Corticosteroid and other injections in the management of tendinopathies: a review
Acupuncture is an area of controversy as randomised controlled blinded studies can be nearly impossible to elicit as patient who undergo a placebo acupuncture with placebo needles or other method which include applying pressure to the acupuncture spot can elict a similar response as an acupuncture needle through acupresure, an important point to consider when resding the methodology. Acupuncture has been show effective in treating the pain in patients with tendinopathy both acute and chronic. So possibly a worth while adjunct to our rehabilitation. Here is some of the research which may help you in your clinical reasoning.
- Acupuncture for chronic Achilles tendnopathy: a randomized controlled study
- Is there a role for acupuncture in the treatment of tendinopathy?
- Randomised clinical trial comparing the effects of acupuncture and a newly designed placebo needle in rotator cuff tendinitis
- Effects of acupuncture and placebo TENS in addition to exercise in treatment of rotator cuff tendinitis
Manual Therapy and Massage
A skill in which is used throughout physiotherapy, whether it is mobilising a joint, mobilising soft tissue, deep transver friction massage or general soft tissue massage. Clinically reasoned throughout our treatments but does it apply to tendinopathy? Evidence has suggested that manual therapy may help to decrease pain from souces of which are potentially biased and other research suggests massage has no greater effect of symptoms than other treatment modalities. Many reviews have been conducted to look at the effectiveness of hands on treatments:
- The Efficacy Of The Use Of Manual Therapy In The Management Of Tendinopathy: A Systematic Review
- Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon
- Deep friction massage to treat tendinopathy: a systematic review of a classic treatment in the face of a new paradigm of understanding
- Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial
Dry needling is another potential treatment for Tendinopathy. A combined therapy of dry needling with percutaneous hydrostatic decompression yielded promising outcomes in terms of pain and function. However,in a recent cohort study, a high-volume image-guided injection (HVIGI) without dry needling compared with a lower volume of HVIGI with dry needling resulted in greater improvement in managing Tendinopathy
Nonsteroidal anti-inflammatory drug NSAIDs
Current reasearch suggests that inital short term does of NSAIDs may help with pain relief and assist with the compliance of physiotherapy but have no longer term affects on tendinopathy. NSAIDs are a topic for discussion when it comes to tendinopathies, as in the title of nonsteroidal ANTI-INFLAMMATORY drug, when the whole discussion of inflammation within tendinopathy is debatable. If it helps in the short term with pain, is this debate and discussion necessary or just something to be aware of? Have a further read in some of the journals below and see what you think.
- Current Opinions on Tendinopathy
- The efficacy of oral non-steroidal anti-inflammatory drugs for rotator cuff tendinopathy: a systematic review and meta-analysis
- Tendons – time to revisit inflammation
Platelet-enriched Plasma (PRP) injection therapy
High concentrations of platelets and growth factors in platelet-enriched plasma (PRP) injections is believed to promote tendon repair and inhibit pain. PRP is made by extracting blood from the patient, centrifuging the sample and separating it into components to return platelets to the donor's effected tendon. Evidence is patchy however some success has been reported in the treatment of patella tendiopathy, lateral epicondylitis and plantar fasciopathy. PRP therapy is also being used to treat acute muscle injuries with ongoing research underway 
Blood Flow Restriction Training (BFRT) therapy
Although currently there is limited evidence to support BFRT in the upper limb, there are a number of case studies being published that have seen positive results in treating upper limb tendinopathy. BFRT is also known as tissue flossing. BFRT, or tissue flossing, involves applying an external pressure above or below a muscle or joint of the extremities, typically by using a circumferential, elastic band. The pressure provided by the coiled band safely maintains arterial inflow of blood but reduces or occludes venous outflow distal to the site. Read more about BFRT here.
- Paoloni JAI, Appleyard RC, Murrell GA. Topical glyceryl trinitrate treatment of chronic noninsertional achilles tendinopathy. A randomized, double-blinded placebo-controlled trial. Jounral of Bone and Joint Surgery 2004;916-22-86-A(5)
- British Medical Journal, Best Practice: Tendinopathy 2014. [Accessed 31/01/16] http://bestpractice.bmj.com/best-practice/monograph/582.html
- Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018: Using the Evidence to Guide Physical Therapist Practice. Journal of Orthopaedic & Sports Physical Therapy 48:5, 425-426.
- Zheng Z, Le H, Chen W, Shen W, Ouyang H. [Progress on treatment of tendinopathy with platelet-enriched plasma]. Zhejiang Da Xue Xue Bao Yi Xue Ban. 2016 Mar;45(2) 179-186. PMID: 27273992.
- Gaweda K, Tarczynska M, Krzyzanowski W. Treatment of Achilles tendinopathy with platelet-rich plasma. International journal of sports medicine. 2010 Aug;31(08):577-83.
- Hamilton B, Knez W, Eirale C, Chalabi H. Platelet enriched plasma for acute muscle injury. Acta orthopaedica Belgica. 2010 Aug 1;76(4):443.
- Canfield CM. Blood Flow Restriction Training as a Treatment for Lateral Epicondylitis to Improve Pain-Free Grip Strength(Doctoral dissertation, Azusa Pacific University).