Part 3 – Treatment

In part 1 of our series we established that training error is one of the more common causes of the development of tendon pain – this error can either contribute to the development of tendon pain, but is certainly often a factor in a failed rehabilitation, and is probably better termed “rehabilitation error” when progressions of exercises or training are simply too quick, too long or too heavy. In Part 2 we reviewed the evidence behind pathology/changes shown on scan and the actual relevance of this pathology to the tendon pain and problem – the outcome being that we cannot place too much emphasis on scan results, but more reliability comes from our own clinical judgements and the reports back from patients.

In Part 3, we will look at what to do when you have tendon pain, and there are plenty of potential options out there. It is not within the scope of this article to investigate each option fully, or even list every available option, but we will list the more commonly available treatment options for tendon problems and discuss briefly the pros and cons of each.

CORTISONE: Cortisone has been around a long time and has been widely used for a variety of different problems over the years. In a nutshell, Cortisone is an anti-inflammatory medication, delivered in a high and concentrated dose into the local area of damage. There are a few inherent issues with the use of anti-inflammatory injections for tendon problems – firstly, research shows that there is actually minimal (if any) inflammation in most tendon problems; secondly cortisone has been showed to potentially have a short to medium term weakening effect on the tendon, by disturbing the production of tenocytes (the cells that are responsible for tendon health and repair). And thirdly, there are reported episodes of tendon rupture or major damage following cortisone injections into tendon (followed by incorrect post injection management). So… cortisone is not a primary treatment modality for tendons.

PRP: Platelet Rich Plasma (or more simply known as blood injections) has gained enormous popularity over the last few years – the theory is great: take a sample of your own blood, spin it in a centrifuge, extract the growth cells or platelets, and inject the good stuff back into the area of damage. Problem is there is absolutely no evidence that this actually works. Plus the fact it is expensive (over $300 per injection), you would often need at least a couple of injections to have any chance of success, and Medicare have pulled their funding completely, and this sits alongside cortisone as not high on the list of interventions for tendons.

SHOCK WAVE THERAPY: SWT has gained more ground of recent times as some good studies indicate the benefit, particularly for lower limb tendon problems (achilles and patella tendon mainly, and also plantar fascia). In SWT, high pressured acoustic shock waves are administered over the area of damage, stimulating tissue repair and pain relief. Whilst it’s not a particularly pleasant technique to experience, there have been some good results reported in long term, chronic tendon problems that have failed other treatment modalities. A good exercise program is a critical component of a successful shock wave program – you can’t rely on the shock wave only!

GREEN TEA: I’ve added this in because we often get asked if green tea will help. Green tea is part of the anti-oxidant family that may help inhibit the production of one of the harmful proteins found in irritated tendons. Once again, there’s not a lot of evidence about how beneficial green tea is, but when you’re desperate, it’s probably not going to do any harm…it’s just a matter of if it does any good!

EXERCISE: I’ve left this to last because that’s what we keep coming back to with most people in the management of their tendon problem. Usually exercises are the first port of call, and when progress is slow (or non-existent) we start looking for miracle cures, only to return to exercise as the management of choice. There is no doubt: exercise is the most evidence based treatment for tendon problems. There are so many different factors to consider when selecting an exercise – it’s a complex task. Exercise can consist of:

  • isometric (static holding), isotonic (the muscle contracting and shortening as the joint moves or eccentric (the muscle lengthening as the joint moves)
  • Fast, medium or slow pace.
  • High , medium or low load/resistance
  • Functional strength, or isolated strength exercises

It was originally thought that doing eccentric exercises (doing calf raises/lowers on a step for an Achilles, for example) was a panacea for tendon problems. We now know that there is no single perfect exercise type for tendinopathy – your therapist needs to find the right type of exercise, in the right position, with the right weight and pace, and then suggest repetitions and sets! For many active people, your program will be geared towards ensuring the tendon can tolerate HIGH and FAST loads safely before you return to sporting activity.

So amongst all the information and hype out there – the absolute basis of any tendon management program should be a great exercise program, designed specifically for your unique tendon problem. This cannot be done without a close working relationship with your physio, and strict compliance to the program on your behalf – for months, not weeks!

In the next article, we will look at the buzz term in tendon management: “Load Capacity”.


Anthony Lance

SSPC Physiotherapist