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Last month I had this patient that had an acute exacerbation of some anterior knee pain that he has had before. He is a hockey player and his patellar tendinopathy always seems to act up in the summer when he is training more. This made me want to discuss tendinopathies in this months newsletter. So little is understood on how to treat them and what to expect in terms of prognosis. I also get so many questions from patients about what there IMAGING means when it comes to tendinopathies.
If you treat athletes, active people, or even desk workers, tendinopathies are ubiquitous and if you know how to treat them this will change your practice forever! So many people deal with chronic tendon issues and they can occur in virtually anywhere in the body. Tendinopathy can be a source of debilitating pain and result in potential retirement from sport [1]. Statistically, one third of athletes presenting with patellar tendinopathy are unable to return to sport within 6 months, and about 53% are forced to retire [2]. Individuals with lateral elbow tendinopathy often don't experience improvement for 1 year and sometimes never get full resolution [3] [4].
The onset of tendinopathy is typically insidious and resolution can be frustratingly slow. Without proper rehabilitation to address related pathomechanics many individuals are caught in cycle of chronic and acute-on-chronic pain as they attempt to return to full activity leaving risk factors and root causes including kinetic chain factors unaddressed. |
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What is tendinopathy?Tendinopathy is an umbrella term used to describe a non-rupture injury to the tendon. It is the clinical condition that describes PAIN and DYSFUNCTION of the tendon, which is independent of pathology within the tendon. When talking about the pathology there are generally two terms used in the literature, tendinitis vs tendinosis. |
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These terms are used to describe what is happening to the tissue. Tendinitis is used interchangeably with tendinopathy and is used to describe the presence of inflammation. Degenerative changes that occur within the tendon observed histologically or on imaging independent of symptomatology is termed Tendinosis.
Tendon Pathomechanics
Tendons have a specific physiologic capacity. A tendons role is to transfer muscular force to the skeletal system. Furthermore, it plays and important role in the development of power and efficiency of muscle contraction through the storage and release of elastic energy. Repetition of movement and high load without sufficient rest can induce pathology in this tissue.
When tendons are chronically exposed to high magnitude or volumes of load they experience cumulative cycles of injury, inflammation and repair.
Histologically tendons consist of 3 main components: Type 1 collagen, well-hydrated non-collagenous extracellular matric rich in glycosaminoglycans and fibroblasts. In tendinopathy the histopathology is a follows: disorganization of collagen fibers, neovascularization, increase number of sensory nerves, proliferation and derangement of type 3 collagen fibers, increase in hydrated components of the ECM and an increase in cell number of a metabolically more active phenotype. The figure above depicts these changes. |
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Does imaging tell the full story?The current model of tendon pathology is based on progressive structural changes identified through medical imaging. These changes include: tendon thickening, focal hypoechogenicity, hypervascularity and increased signal intensity. |
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However, changes in symptoms does not reflect the changes in structure. Consider this, while there is little evidence suggesting an association between structural disorder and symptomology, nearly 50% of asymptomatic individuals present with structural abnormalities [5] [6]. In addition, partial tears especially in the rotator cuff are frequently identified.
The clinical presentation of tendon pathology is defined by the structure but more importantly also by MOTOR IMPAIREMENTS and the PAIN SYSTEM. Effective treatment of tendinopathy will result in significant improvement of symptoms in about 12 weeks [7]. On the other hand, structural changes can take from 24 weeks to even 1 year to fully resolve [8]. As seen in the above image, this model of tendon pathology shows pain system changes happen faster than structural changes. This is attributed to increased nervous system sensitivity in tendon pathology, especially in the chronic state. |
The Story of Central SensitizationIt is clear that there are peripheral and central nervous system changes involving inflammatory and non-inflammatory pathways that occur and result in hyperalgesia and allodynia [9]. You can review our previous newsletter on Central Sensitization HERE but, for now we will review how it plays a role in tendinopathy symptomatology and HOW WE CAN HELP!
Central sensitization occurs in many chronic musculoskeletal disorders, here we will discuss its role specifically in the pathophysiology of Lateral Elbow Tendinopathy and other tendinopathies.
In LET, there is evidence of heightened nociceptive withdrawal reflex and wide-spread mechanical hyperalgesia [10] [11]. Furthermore, impairment in sensory and motor function is commonly seen in patients with LET and may persist beyond resolution of local tendon symptoms [12]. Affected individuals commonly present with reduced pain-free grip force, grip with a more flexed wrist position and display weakness of short wrist extensors (extensor carpi radialis brevis) [13]. Neck pain is also more common in patients with LET [14]. In other studies, a lowered pressure pain threshold is observed across multiple tendinopathies at the site of tendinopathy BUT also at other sites [15]. |
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Management
Management of tendinopathy should focus on reducing inflammation and inflammatory signaling, developing load tolerance of the tendon and musculoskeletal unit, addressing the kinetic chain and key biomechanical risk factors, improving motor function and reducing nervous system sensitization.
In a systematic review, results indicate that cervical spine manual
In instances of acute tendinopathy or acute -on - chronic, I like to use ICE in combination with electro-acupuncture. The ice helps to calm down the inflammation in the tendon and reduce secondary injury. Lately, I have been using "freeze - sleeves" (in image below) and my patients have been loving them. Some of them have even bought some. I have linked the images below to take you to website for your convenience! |
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Electro-acupuncture also helps to address the sensitized nervous system. Failure to address this and restore proper motor control is one explanation for persistent recurrence of symptoms resulting in chronic tendinopathy and potential retirement from sport. Electroacupuncture not only helps to restore proper neurological signaling and reverse central sensitization but it also causes a local release of Nitric Oxide and vasodilation therefore improving blood flow. Read more here.
Don't let the imaging scare you or your patient, address the clinical presentation of their symptoms and the entire kinetic chain.
- Dr. Mike Prebeg |
P.S.
Registration for the FALL Contemporary Medical Acupuncture Program at McMaster University is still available. Stay ahead of your competition by seeking greatness. The paradigm taught in this course will help you understand the role of the nervous system in pain systems which will make you better at treating these issues like above than any of your friends.
Info and registration can be found at the link here: https://mcmasteracupuncture.com/ |
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