As we now understand from the Tendinopathy introduction article, collagen is a principal constituent of a tendon. Changes in collagen properties and composition have been identified in tendinopathies, specifically a reduction in the total collagen content (Xu Y, 2008) (Riley, GP 2005) The declination of collagen synthesis has been associated with impaired tendon function and performance. (de Boer et al, 2007) (Baar, K 2018) And on a larger scale, disuse (i.e casting, bed rest) leads to a greater diminution in collagen synthesis, decreased stiffness and greater mechanical hysteresis. (de Boer et al, 2007) Conversely, mechanical loading and physical training have repeatedly shown to increase the rate of collagen deposition and induce hypertrophy in tendons. (Heinemeier, K et al 2013) (Baar, K 2017) Loading based interventions work on a fundamental basis to influence structural, biochemical and clinical outcomes. Tendinopathies can be managed through a rehabilitation program as a first line of management, with the exception of tendon ruptures. The principles of an exercise-based program are identified through education, load monitoring and management. In order to improve performance, reduce the risk of injury and/or rehabilitate an injury, we must understand the effects of training through various loading interventions. As we know, tendons are highly responsive to mechanical loading; both excessive and insufficient stress can be detrimental. (Rumian, A et al 2009) A tendons ability to tolerate load in tendinopathy is often limited by pain. While pain needs to be taken in consideration and reduced, load capacity needs to be improved. The VISA- questionnaire for tendinopathy (Achilles, Patellar) can be used to assess symptoms, though, it should not be used as a diagnostic tool. (Robinson JM, 2001) (Cardoso et al 2019) Working through tolerable discomforts reduces sensitizations and allows for greater adaptions for progression. This will be dictated by the tendon’s response and patient’s symptoms. (Cardoso et al 2019) (Docking et al 2019) (Bohm et al, 2015) Educating your patients on associated pains, expectations and length in recovery will eliminate the perplexity of the overabundance treatment options available that may not be supported by evidence. (Cardoso et al, 2019)
Before we discuss treatment, let’s review the anatomy. A tendon attaches to bone on one end (osteotendinous junction) and muscle on the other (myotendinous junction). Tendons serve to transmit tensile forces from the muscle to the bone to elicit movement. Tendons have different sizes and shapes depending on their location and the role of the muscle it attaches to. For example, extensor tendons are more flattened than flexor tendons, which are often oval/round in shape (Benjamin, M et al 2008) Flattened tendons are called aponeuroses. Some examples of these are the tendons of the latissimus dorsi and pectoralis major. Muscles that perform fine motor movements, such as the ones of the hands, are often have associating tendons to be long and thin. Muscles that generate larger forces, often have wider and shorter tendons, such as the glutes and pecs. (Benjamin, M et al 2008) Its anatomical arrangement is often underappreciated, as it functions to be a variable mechanical tissue. A healthy tendon has more compliance near the muscle and possess stiffer properties as it extends to the bone. It is understood that the compliant end of the tendon acts as a shock absorber, to protect the attached muscle from injury. The stiffer end in tendons require larger forces to stretch but allow for greater force production. (Docking, S et al 2019) So, which is superior of the two contrasting tissues, stiffer or compliant? It is unclear to determine which may be more advantageous to physical performance as tendons adapt to the different types of training. A healthy tendon has appropriate metrics of both, and different training methods favoring one over the other can be beneficial for different tendons. Specific training can alter these demands to augment sports or different types of movements. Understanding the demands of the sport is important to navigate training methods for appropriate transference of contractile forces to optimize stiffness or compliancy. (Docking, S et al 2019)
This part of tendons is extremely important in the healing phase, thus worthy to note. Tendons obtain their blood supply from the myotendinous junction and the osteotendinous junction. Additionally, they source through surrounding vessels such as the paratenon or synovial sheath. Tendons are typically much less vascularly supplied in comparison to their muscular counterparts. Tendons that are contained within a sheath have better defined, vincular supply, while unsheathed tendons vessels may pass to surrounding paratenon. Some tendons have areas of reduced vascularity include the supraspinatus, biceps tendon, achilles tendon, patellar tendon, and posterior tibial tendon. Areas of avascularity in tendons is important, as these are clinically seen to be common sites of degeneration and/or ruptures. (Benjamin, M et al 2008) A common degenerative tendon is the supraspinatus, in which it is seen more commonly as we age, however, there is often no symptoms associated, presenting as age-related findings with no clinical significance. (Fenwick, SA et al 2002) Although these areas of reduced vascularity are common sites of degeneration and/or rupture, there is no current evidence that suggests that hypo-vascularity is a cause of rupture or symptoms. In general, blood supply to tendons decreases with age and mechanical loading. (Sharma, P et al 2006) Areas of avascularity are not entirely understood in their contribution to tendinopathies, thus, it is more likely that a combination of factors is responsible for predisposing tendons to injury. (Fenwick, SA et al 2002)
With its evolving nature, we continue to trial and error various measures of treatment. Complex biological contexts may not be fully understood to iterate specific methods; however, treatments should be individualized and correspond to the tendon response. This next section will present treatment options and the current evidence of their use.
As it is with any other injury, chronic tendinopathy can lead to anxiety, depression and poor quality of life. This tends to affect athletes due to the lengthy nature of healing and the inability to perform their sport. In rehabilitation, individuals may develop kinesophobia, which can make them less compliant or more reluctant to load and exercise. (Silbernagel et al, 2020) Education regarding the expected timeline of process and fluctuations in symptoms throughout is highly encouraged. Practioners should take psychological matters in consideration when presenting a management plan.
Immobilization/inactivity is an absolute contraindication in the management of tendinopathy.
In tendinopathies, a tendons capacity to load is often limited by pain. Pain often leads to disuse, and thus, affecting the kinetic chain and surrounding musculature. Evidence has shown that reduction in load has negative effects on the tendons mechanical and structural properties. (Docking, S et al 2019). The changes after immobilization show an overwhelming decline in both biochemical and biomechanical properties. (Amiel, D et al 1982) (Cardoso et al 2019) (Couppe, C et la 2012) The effect of immobilization has a downregulation of collagen synthesis and degradation increases contingently upon days of immobilization. Short durations (i.e. 10 days) of immobilization has demonstrated reductions in rate of tendon synthesis by up to 50%, (Baar, K 2019) and 2-3 weeks of immobilization can increase to up to 80%. (Magnusson et al 2019) (Rumian et al 2009) The declination of collagen synthesis is strongly associated with impaired tendon functions. (Baar, K 2019) Additionally, it has shown to decrease strength and negatively affect the kinetic chain. (Cardoso, et al 2019) In both animal and human studies, we see a reduction in strength, a longer duration of rehabilitation, reduced collagen synthesis and reduced stiffness in the tendon associated with immobilization. (Amiel, D et al 1982) (Magnusson et al 2019) It is conclusive that complete rest is detrimental to tendon repair and health. Due to these findings, its best recommended to reduce loads or modify activity with intent to decrease symptoms but maintain structural composition. Gradual loading is the most appropriate approach supported by research as first line tendon management.
With the highest level of evidence for most tendinopathies, exercise rehabilitation is favored as the first line of treatment. The purpose is to provide mechanical load to promote remodeling, reduce symptoms, and improve function. Whether symptoms are acute or chronic, the intention is to stimulate cellular activity and increase blood flow to the affected tendon. (Ahmad, Z et al 2019) There are many ways practitioners attempt to achieve this, and there is no right way, but we can attempt to correspond the physiological adaptions to multi-stage training methods. Symptoms may arise during the rehabilitation process, and it’s important to understand that pain does not reflect tissue damage. Working through tolerable thresholds and making modifications as needed should be factored in. Regulating tolerance to increase thresholds contributes to the development of self-management. The key to these methods is to never completely unload the tendon. Since tendinopathies are a load-related problem, it requires a load-related solution. Loading factors have not been unanimously established, however, what is known is that tendons respond well to increasing loads. Load-based interventions have variables, this includes intensity, repetitions, sets, intervention duration, training frequency, and type of contraction applied. A rehabilitative tendon prescription will often include one or more of the following: isometrics, isotonics, eccentrics, concentrics, heavy slow resistance, plyometrics, etc. Truthfully, a combination of all is best suited for tendon health when dosed appropriately during rehabilitative stages. (Bohm, et al 2015) (Magnusson, P et al 2019). The paramount variables are less important than moderating load progressively. To date, there is no consensus on how to apply these interventions, but there is evidence of success in some. The purpose of exercise is to provide a viable strategic load to promote remodeling, decrease symptoms, and improve function and performance.
Historically, rehabilitative programs have centered around eccentric strengthening of tendons. This mainstay in treatment upsurged after findings revealing the impact on collagen synthesis and increased blood flow to the affected area. (Hody, S et al 2019) (Docking et al 2019) In time, studies evaluated isometrics, isotonic and concentric contractions and found similarly positive results. Equally, heavy slow resistance training also appeared to show similar clinical effectiveness. (Clifford, C et al 2020) (Magnusson et al 2019) (Malliaras, P et al 2013) That said, it is unclear if a tendons response is differentiated on the type of contraction or if the importance lies within the time frame that the tendon is loaded. Nonetheless, what is known is that these contractions are necessary for tissue adaptation in the early stages. (Silbernagel et al, 2020) (Ahmad, Z et al 2019)
Rehabilitation can be broken down into four phases:
- Symptom Management/Load Modification
- Speed & Sport Specificity
- Return to Sport/ADL
In the early stages, loading modifications are initially utilized with the goal of reducing symptoms and initiate adaption. Loading modifications can be manipulated by reducing the frequency, intensity and volume of the activity. In the absence of loading, the tendons will contingently adapt to a lower capacity. Thus, modifying some of these variables will allow tendons to be stimulated at a lesser pain frequency. Pain modulation can be achieved through isometrics, which may be better tolerated in comparison to other loading mechanics in early stages. (Cardoso et al, 2019) (Malliaras, P et al 2013) This reduces the high energy storage activities that may be aggravating, and initiate loading of the muscle-tendon unit permitted under tolerance. (Ahmad, Z et al 2019) As tolerance increases, isotonics, eccentrics and concentric contractions can be introduced with the intent to change length of the tendon-muscle unit. Neurological adaptations will be improved when changing tempo and using these strategies to change length of tendon-muscle unit, as it increases neuroplasticity. (Cardoso et al 2019) Heavy loads and slower contractions are beneficial in this early stage, as it contributes to the tendon strength and size. (Silbernagel et al, 2020) (Cook, et al 2016) Before increasing the resistance, exercise selection should include both bilateral and unilateral movements. Unilaterally, to challenge both capacity and stability; and bilaterally, to increase heavier loads through functional ranges of motion. With a large focus on single-limb movements, it is essential to increase load tolerance and generate force. Following an appropriate continuance of loading and symptom regression, introductions to speed/sport specificity will subsequently follow. Load on the tendon can be increased by increasing the speed of the movement. There is typically a slow introduction to these dynamic movements for a stretch-shortening cycle. Both unilateral and bilateral movements will be incorporated making this energy storage phase very important. (Malliaras, P et al 2013) (Cardoso et al 2019) Individual sport-specific movements will reflect the demands of the sport (i.e. basketball requires a demand for dynamic loading, aka jumping). For those without a specific sport, preparation for basic athletic movements will be done in this phase (i.e. sprinting, acceleration, deceleration, plyometrics, etc). (Silbernagel et al, 2020) Frequency of loading based interventions and adequate recovery should be taken in consideration over the course of rehabilitation, as loading impacts its etiology. Typically, tendon tissues will require up 36-72 hours of recovery after heavy loading, whereas lighter activities can be performed more frequent. (Sibernagel et al 2020) Based on the current data, perpetual loading early on is most effective to elicit tendon adaptation, and that longer interventions (>12 weeks) show more significant clinical effectiveness. (Bohm et al 2015). There is no exact science that dictates the order of operation, thus, metrics from each phase can be used in an overlapping fashion. When dosed appropriately for individualistic needs, these phases can be done concurrently through means of specific training. The given rehab phases can be used as a generalized approach in tendinopathy management, essentially used to check off the boxes for appropriate athletic development.
Note: tolerance can be evaluated during activity and post-activity.
Extracorporeal Shockwave Therapy: Though the mechanism is not fully understood, its application postulates the release of growth factors that induce tenocytes, while simultaneously offering an analgesic effect. Majority of the research supported its use in calcific tendinitis in the shoulder, however, studies in all other tendinopathies did not reveal significant findings or were of lower quality research. A more recent review focused high energy v low energy ESWT on insertional Achilles tendinopathies, and results revealed overall good outcomes, primarily in reduction of symptoms. (Zhi, X et al 2021) Theories currently lie with the dose-dependent response; higher/frequent doses for better outcomes. Overall, ESWT is deemed relatively safe, but requires much larger studies with set protocols, dosages, and quality for a conclusive opinion in clinical settings. (Cardoso et al 2019) (Girgis et al, 2020) (Ahmad, Z et al 2019) (Zhi, X et al 2021)
Ultrasound (Therapeutic): The proposed mechanism of ultrasound is to use a thermal effect on the affected tissue to stimulate cellular activity and increase blood flow. Few studies show short-term pain relief. Most studies are consistent in that it is not superior to placebo or exercise. With the bulk of studies being of lower quality, it cannot be conclusive to determine if electrophysical agents have a positive role in tendinopathy management. (Cardoso et al 2019) (Girgis et al, 2020) This also includes the use of Transcutaneous Electrical Nerve Stimulation (TENS) and pulsed electromagnetic field.
Low level laser: Consists of a local application of monochromatic light, coherent and of short wavelengths. With all studies taken in consideration, it does not show consistency with symptom improvement or function, thus having inconclusive evidence. (Ahmad, Z et al 2019) (Nogueira, AC et al 2015)
Non-steroidal anti-inflammatory drugs (NSAIDs): With the lack of inflammation truly present in some tendinopathies, the use of NSAIDs may not be effective beyond providing short-term pain relief. A study revealed one week of NSAID administration has shown to cause a reduction in PGE2 and minimized adaptive increase in collagen synthesis in patellar tendons induced by exercise. (Christenson, B et al 2010) Growing research shows adverse effects on the healing tendon and downregulation in the cellular response, thus, not using this as a recommendation until further studies have validated its use. (Ahmad, Z et al 2019) (Cardoso et al 2019)
Corticosteroids: This class of drugs work to reduce inflammation. All reviews of use in tendinopathies only show effectiveness in short-term pain relief, and long-term results remain equivocal. With more information now, it is concluded that corticosteroids should not be used, due to its detriment to healing. This data revealed more collagen aggregation, necrosis, cell proliferation, and in even more serious cases, tendon ruptures. Corticosteroids seem to consistently show negative effects on tendons. A single systematic review showed that even at best, corticosteroids had no effect in clinical outcome. (Ahmad, Z et al 2019) (Cardoso et al, 2019) (Shah, A et al 2019)
Sclerotherapy: This method uses polidocanol (local anesthetic and antipruritic) to be directly inject into the blood vessel. The existing literature shows some efficacy, specifically seen in tennis elbow, patellar and Achilles tendinopathy. It is currently deemed as safe in the aforementioned tendons but must be proceeded with caution due to subjected adverse effects. Larger studies are mandated before advocating this modality. (Ahmad et al 2019) (Girgis, B et al 2020) (Cardoso et al 2019)
Prolotherapy: This involves an irritant, such as dextrose to be injected directly to the target site, in effort to stimulate white blood cells into a healing process. Though it has not shown to be more effective than physiotherapy exercise, it has shown some efficacy. Literature shows that this treatment modality is safe, but limitations are acknowledged with a lack of larger studies to make definitive opinions. (Cardoso et al 2019) (Ahmad, Z et al 2019)
Iontophoresis: This method involves a corticosteroid transdermally applied through an electrical current for greater absorption. Dexamethasone and lidocaine are most commonly used, and evidence has only shown a decrease in symptoms due to its analgesic effects. Most information regards epicondylitis, so there remains a gap in research to dictate its use in other tendons. (McKivigan, J et al 2017) (Cardoso et al 2019)
Dry Needling: It is intended to directly needle the affected area in attempt to stimulate a healing through an inflammatory process. Evidence revealed that it there has some positive clinical outcomes with few studies, however there is no unified conclusion due to the little information available with small studies. (Krey, et al 2015) (Girgis, S et al 2020) (Cardoso et al 2019)
Growth Factors: Using novel technology for tissue regeneration by use of autologous blood injections, blood derived concentrate of platelets (PRP) or cell differentiation (stem cells) is still deep in research due to the various biological sources and therapeutic applications.
Platelet Rich Plasma (PRP)- This method is designed to produce growth factors and cytokines to promote healing. Currently, there are no high-quality evidence to support the use of PRP in tendinopathies. The biggest confliction seen is a standardized use for dosage and location (site of injection, amount, frequency, etc) (Ahmad, Z et al, 2019)(Krey, et al 2015) (Cardoso et al, 2019)
Stem cells- Theoretically, injections of stem cells can improve cell differentiation into tenocytes for tissue regeneration. With little data on effectiveness and risks, usage is currently unknown for clinical therapies. Experiments are still underway, but it is currently not recommended for use of tendon treatment. (Van Den Boom et al, 2020) (Cardoso et al, 2020) (HIMFL, P et al 2017) (Biehl, JK et al, 2009)
Deep Friction Massage: There is no physiological evidence of manually changing the morphology or physiology of adhesions or scar tissue, making this less effective by nature. A Cochrane review revealed no benefit for tendon health or improvement of strength. (Brosseau, L et al 2002) (Ahmad et al 2019) (Cardoso et al 2019)
Manual Therapy: Though symptoms may be temporarily reduced, it is unclear if there is any improved function. Other passive modalities such as Ice, Stretching, Acupuncture all have little to no efficacy in tendinopathies, and in some cases, showing worsening symptoms. (Brosseau, L et al 2002) (Ahmad et al 2019) (Cardoso et al 2019)
Surgery- Common procedures include the debridement and decompression of the tendon but is considered a last resort or a first option for ruptures. (Cardoso et al 2019)
Further data is required to indicate optimal protocol interventions and length of proposed use. There is no single intervention that seems to be superior to rehabilitative exercise for long-term relief. To use these therapies adjunctly to exercise is entirely decided by the treating clinician and should be made on a case-by-case basis. Thus, it should be noted that some of these low-yielding interventions may create a patient dependency, movement hesitancy and increased sensitivities. The pathoetiology of tendinopathies is complex, thus clinicians should be mindful of the current evidence of body that is supported.
As it is with all injuries, nutrition is an important intrinsic factor that should be incorporated with rehab. Adequate intake of both micronutrients and macronutrients is essential for all populations, and especially athletes with a greater demand due to sport and/or injury. Specific dietary supplementation for treating tendons is still under investigation in current literature. (Hijlkema, A et al, 2022) Few studies reviewed nutrients such as amino acids, specific vitamins, trace minerals, and types of protein as being potentially advantageous for tendon treatment.
The structures of musculoskeletal tissues are dependent on their collagen-rich extracellular matrix. As previously mentioned, in states of injury or distress there is poor matrix production, thus reducing collagen content. Utilizing nutritional strategies to improve connective tissue collagen synthesis have been of great interest in research. (Lis, D & Baar, K, 2019) This also includes the protein expression of collagen as being a considerable investigation more recently. (Docking, S 2019) Gelatin and hydrolyzed collagen (HC) are collagen-derived peptides, and have a similar amino acid profile and are particularly high in glycine, proline, hydroxyproline and arginine. (Eastoe et al, 1955) (Barr, K 2017) Gelatin comes from collagen with the skin, tendons, ligaments and bones of fish, pigs or cattle. Hydrolyzed collagen will take that gelatin and boil it for isolation. This is then followed by acidic processing using enzymes to end up with HC peptides. (Eastoe et al, 1955) (Barr, K 2017)
These supplements showed positive clinical and/or structural outcomes in tendinopathy treatment in small studies. Despite having shown improvements over 2-3 months of supplemental use, the type of collagen varied amongst studies (type I-II). Tendons are composed primarily of type I collagen, while cartilage contains type II collagen. (Merolla, G et al 2015). Currently, collagen has shown to positively treat tendinopathies. (Hijlkema, A et al, 2022) (Merolla, G et al 2015). Though, we do see some success in collagen data, scientific validity lags due to the limited understanding as to how collagen products affect amino acid in the blood, and collagen synthesis. (Lis, D & Baar, K, 2019) (Hijlkema, A et al, 2022) (Merolla, G et al 2015).
As more studies emerge, data on specific benefits, type of collagen, dosage, timing, and duration are likely to be further investigated.
Other nutritional interventions, such as consuming a protein supplement, have the potential to increase tendon hypertrophy that results from strength training. (Baar, K 2017) As it is with many other musculoskeletal injuries, an increase in protein consumption for tendinopathies is favored to improve synthesis of collagen and improve tendon function for an accelerated return to play. To date, leucine-rich proteins have shown to be most effective in tendons and muscles as it augments collagen synthesis and tendon hypertrophy. (Farup, J et al 2014) (Baar, K 2017) (Hijlkema, A et al, 2022) Leucine regulates many aspects of physiology and has a large role in activating the protein kinase growth regulator, mTOR1. (Wolfson RL, et al 2016) Tendon hypertrophy was evident in a single study that augmented a high-leucine whey protein with resistance exercise. (Hijlkema, A et al, 2022) (Farup, J et al 2014) A positive nitrogen balance is necessary for the repair of muscle and tendon damage, as it promotes the delivery of amino acids to the tissue. (Wall BT, et al 2016) According to the intake recommendations in injured athletes, individuals should be consuming ~1.6 g/kg/day to 2.5 g/kg/day of total body mass to maintain mass and allow for a positive protein synthesis. However, the American College of Sports Medicine and the Dietitians of Canada have come to agreement that an increased intake of up to 2.0g/kg/day may be a better suited option to prevent the loss of fat-free mass. This is especially warranted in cases where there is a reduction in physical activity of energy restriction. (Quintero, KJ et al 2018)
Vitamin C has antioxidant properties and is known to be a cofactor for collagen synthesis. It increases intracellular levels of reduced glutathione and participates in hydroxylation of proline and lysine to hydroxyproline and hydroxylysine, in collagen molecules. (Noriega-Gonzalez et al 2022) As we know that vitamin C deficiency results in scurvy, a disease characterized by a loss of collagen. Deficiency of vitamin C is associated with decreased procollagen synthesis, reduced hydroxylation of proline and lysine residues. (Noriega-Gonzalez et al 2022) (Baar, K 2017) The addition of vitamin C to gelatin and exercises produces an increase in collagen synthesis, which has been seen in blood profiles. (Magnusson S 2019) (Shaw et al, 2016) The enrichment of amino acids is said to best be used with exercise to induce a greater collagen production. (Lis, D & Baar, K 2019) Though there have been some improvements of tendon healing when supplementing vitamin C, the use of it independently vs with other therapies is still being researched. Many of these studies have been done on animals, small human groups with different administrations and dosages, thus conclusive indications of benefits in human tendon healing requires further investigation.
In a systematic review of nutrition and tendon health, alcohol was interestingly conflicting. Studies varied on intake for effect on tendinopathy, falling mostly on frequency and consumption. Moderate weekly alcohol intake (male:7-13 drinks, female:4-6 drinks) did show an associated risk for Achilles tendinopathy, but not for patellar tendinopathy. (Hijlkema, A et al, 2022) (Owens, BD et al 2013). Excessive alcohol intake (male:>13 drinks, female: >6 drinks) was a significant risk factor for occurrence and severity of rotator cuff tears. (Hijlkema, A et al, 2022) (Passaretti D et al, 2016). These studies reveal a contingency factor of greater consumption and higher risks. Another study found a positive association between alcohol consumption and less pain and greater function after rotator cuff repair, but many conclusions have been made from that outcome. (Jain et al, 2018) Though, these are not consistent findings, alcohol is a pro-inflammatory factor that influences the body systemically. Additionally, alcohol does decrease protein synthesis and mTor-mediated signaling. This also blunts the anabolic response in skeletal muscle. (Steiner, J et al 2014) Thus, reduction in intake would likely reduce pro-inflammatory responses and decrease the inhibitory effects on muscle growth.
In a study, Curcumin and Boswellia serrata were used for tendinopathy treatment. These compounds found to have improvement of pain, but specific nutrient profiles were difficult to obtain and understand contributions individually or with other supplements. (Merolla, G et al 2015) (Hijlkema, A et al, 2022)
An important note regarding nutritional studies is the risk of bias, and the inconsistencies seen amongst all studies. It is difficult to measure accuracy of food intake solely based of subjective compliance. Some studies did not have a placebo comparison, thus, making it unclear if healing time could be accelerated with certain nutrients. Additionally, individual approaches and history with specific food groups and exposures can alter outcomes. Also, many studies did not perform blood labs before/after to identify current levels of nutrients or cellular absorption after. Up to date, only evidence for a handful of vitamins, natural plants, and supplements have been studied for the healing of tendons.
Treatments will vary across individuals, considering site of pathology, stage, assessment and demands needed from each person as well as pre-existing comorbidities.
Tendinopathy management is constantly evolving with our growing understanding of biophysiological changes. However, much of current research has primarily focused on tissue changes, not its implications on performance or recovery. As we know, tendons respond to load, but how to appropriately use these interventions remains ambiguous. The research on tendinopathy rehabilitation reflects empirical data, rather than a quantified scientific basis. Tendon pathology person to person vastly differs, making it difficult to standardize a form of rehabilitation. As we know, movement is a viable strategy and provided is a generalized approach to consider when treating tendinopathies. Clinicians should be educated on the magnitude of effectiveness for any prescribed intervention and parameters of each exercise to appropriately load. An understanding of the affected tissues, physiology and tissue demand required for sport would provide a basis for rehabilitative training to increase output and reduce the risk of injury. Preventing injuries entirely is impossible, but perpetual loading, adequate recovery, and nutrition can serve to reduce the risk.
Tendinopathies often arise from a load-based problem, requiring a load-based solution.
Educating patients on risk factors, duration and management plan is crucial for compliance and progression.
Symptoms are part of the process, it’s important to identify what needs to be progressed vs regressed.
Immobilization/total rest is contraindicated for recovery
Exercise-based rehabilitation is favored for long-term relief
The type of contraction used in rehab is less important than the time frame in which its loaded.
Adequate loaded training supplemented with high-leucine whey protein can augment tendon (& muscle) collagen synthesis and hypertrophy.
Coupling Gelatin/Hydrolyzed collagen and vitamin C may increase collagen synthesis.
- David Amiel, Savio L-Y. Woo, Frederick L. Harwood & Wayne H.
Akeson (1982) The Effect of Immobilization on Collagen Turnover in Connective Tissue: A Biochemical-Biomechanical Correlation, Acta Orthopaedica Scandinavica, 53:3, 325-332, DOI: 10.3109/17453678208992224
- Screen, H. R. C. (2008). Investigating load relaxation mechanics in tendon. Journal of the Mechanical Behavior of Biomedical Materials, 1(1), 51–58.doi:10.1016/j.jmbbm.2007.03.002
- Rumian A. P., Draper E. R. C., Wallace A. L., and Goodship A. E. The Journal of Bone and Joint Surgery. British volume2009 91-B:4, 557-564
- Baar, K. (2019). Stress Relaxation and Targeted Nutrition to Treat Patellar Tendinopathy, International Journal of Sport Nutrition and Exercise Metabolism, 29(4), 453-457.
- Riley GP. Gene expression and matrix turnover in overused and damaged tendons. Scand J Med Sci Sports. 2005;15:241–251.
- LaCroix AS, Duenwald-Kuehl SE, Lakes RS, Vanderby R Jr. Relationship between tendon stiffness and failure: a metaanalysis. J Appl Physiol (1985). 2013 Jul 1;115(1):43-51. doi: 10.1152/japplphysiol.01449.2012. Epub 2013 Apr 18. PMID: 23599401; PMCID: PMC3727010.
- De Boer, M.D., Maganaris, C.N., Seynnes, O.R., Rennie, M.J. and Narici, M.V. (2007), Time course of muscular, neural and tendinous adaptations to 23 day unilateral lower‐limb suspension in young men. The Journal of Physiology, 583: 1079-1091.
- Robinson JM, Cook JL, Purdam C, Visentini PJ, Ross J, Maffulli N, Taunton JE, Khan KM; Victorian Institute Of Sport Tendon Study Group. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med. 2001 Oct;35(5):335-41. doi: 10.1136/bjsm.35.5.335. PMID: 11579069; PMCID: PMC1724384.
- Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations
- Peter Malliaras,Jill Cook, Craig Purdam, and Ebonie Rio. Journal of Orthopaedic & Sports Physical Therapy 2015 45:11, 887-898
- Holden S, Lyng K, Graven-Nielsen T, Riel H, Olesen JL, Larsen LH, Rathleff MS. Isometric exercise and pain in patellar tendinopathy: A randomized crossover trial. J Sci Med Sport. 2020 Mar;23(3):208-214. doi: 10.1016/j.jsams.2019.09.015. Epub 2019 Oct 10. PMID: 31735531.
- Hody, S., Croisier, J. L., Bury, T., Rogister, B., & Leprince, P. (2019). Eccentric Muscle Contractions: Risks and Benefits. Frontiers in physiology, 10, 536. https://doi.org/10.3389/fphys.2019.00536
- Silbernagel, K. G., Hanlon, S., & Sprague, A. (2020).Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. Journal of Athletic Training.doi:10.4085/1062-6050-356-19
- Cook JL, Rio E, Purdam CR, et al. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? Br J Sports Med 2016;50:1187–91.
- Nogueira AC Jr, Júnior Mde J. The effects of laser treatment in tendinopathy: a systematic review. Acta Ortop Bras 2015;23:47–9.
- Broseau L, Casimiro L, Milne S, et al. Deep transverse friction massage for treating tendinitis. Cochrane Database Syst Rev 2002:CD003528.
- McKivigan, J. M., Yamashita, B., & Smith, D. (2017). A Systematic Review on the Efficacy of Iontophoresis as a Treatment for Lateral Epicondylitis.Research & Investigations in Sports Medicine, 1 (3), [Article RISM.000512].
- Shah A, Mak D, Davies AM, James SL, Botchu R. Musculoskeletal Corticosteroid Administration: Current Concepts.Canadian Association of Radiologists Journal. 2019;70(1):29-36.
- PasHIMFL, Moen MH, Haisma HJ, et al. No evidence for the use of stem cell therapy for tendon disorders: a systematic review. British Journal of Sports Medicine 2017;51:996-1002.
- van den Boom NAC, Winters M, Haisma HJ, Moen MH. Efficacy of Stem Cell Therapy for Tendon Disorders: A Systematic Review.Orthopaedic Journal of Sports Medicine. April 2020.
- Biehl, J. K., & Russell, B. (2009). Introduction to stem cell therapy.The Journal of cardiovascular nursing, 24(2), 98–105.
- Malliaras P, Barton CJ, Reeves ND & Langberg H (2013).Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med 43, 267–286.
- Xu, Y., & Murrell, G. A. (2008). The basic science of tendinopathy.Clinical orthopaedics and related research, 466(7), 1528–1538. https://doi.org/10.1007/s11999-008-0286-4
- Docking, S. I., & Cook, J. (2019). How do tendons adapt? Going beyond tissue responses to understand positive adaptation and pathology development: A narrative review.Journal of musculoskeletal & neuronal interactions, 19(3), 300–310.
- Screen, H. R., Berk, D. E., Kadler, K. E., Ramirez, F., & Young, M. F. (2015). Tendon functional extracellular matrix.Journal of orthopaedic research : official publication of the Orthopaedic Research Society, 33(6), 793–799. https://doi.org/10.1002/jor.22818
- Arampatzis A, Peper A, Bierbaum S, Albracht K. Plasticity of human Achilles tendon mechanical and morphological properties in response to cyclic strain.J Biomech. 2010;43:3073–9. doi: 10.1016/j.jbiomech.2010.08.014.
- Andarawis-Puri, N., Sereysky, J. B., Jepsen, K. J., & Flatow, E. L. (2012). The relationships between cyclic fatigue loading, changes in initial mechanical properties, and the in vivo temporal mechanical response of the rat patellar tendon.Journal of biomechanics, 45(1), 59–65. https://doi.org/10.1016/j.jbiomech.2011.10.008
- Magnusson, S. P., & Kjaer, M. (2019). The impact of loading, unloading, ageing and injury on the human tendon.The Journal of physiology, 597(5), 1283–1298. https://doi.org/10.1113/JP275450
- Chiquet M, Gelman L, Lutz R & Maier S (2009).From mechanotransduction to extracellular matrix gene expression in fibroblasts. Biochim Biophys Acta 1793, 911–920.
- Ahmad, Z., Parkar, A., Shepherd, J., & Rushton, N. (2019).Revolving doors of tendinopathy: definition, pathogenesis and treatment. Postgraduate Medical Journal, postgradmedj–2019–136786.doi:10.1136/postgradmedj-2019-136786
- Maffulli, N. (1998).Overuse tendon conditions: Time to change a confusing terminology. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 14(8), 840–843. doi:10.1016/s0749-8063(98)70021-0
- Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management Best Practice & Research Clinical Rheumatology. 2019; 33(1):122-140.
- Longo UG, Franceschi F, Ruzzini L, et al. Histopathology of the supraspinatus tendon in rotator cuff tears. Am J Sports Med. 2008;36:533–538.
- Longo UG, Franceschi F, Ruzzini L, et al. Light microscopic histology of supraspinatus tendon ruptures. Knee Surg Sports Traumatol Arthrosc. 2007;15:1390–1394.
- Longo, U. G., Ronga, M., & Maffulli, N. (2018).Achilles Tendinopathy. Sports Medicine and Arthroscopy Review, 26(1), 16–30.doi:10.1097/jsa.0000000000000185
- Arya S & Kulig K (2010).Tendinopathy alters mechanical and material properties of the Achilles tendon. J Appl Physiol (1985) 108, 670–675.
- Heinemeier, K. M., Schjerling, P., Heinemeier, J., Magnusson, S. P., & Kjaer, M. (2013). Lack of tissue renewal in human adult Achilles tendon is revealed by nuclear bomb (14)C.FASEB journal : official publication of the Federation of American Societies for Experimental Biology, 27(5), 2074–2079. https://doi.org/10.1096/fj.12-225599
- Jomaa, G., Kwan, CK., Fu, SC.et al. A systematic review of inflammatory cells and markers in human tendinopathy. BMC Musculoskelet Disord 21, 78 (2020). https://doi.org/10.1186/s12891-020-3094-y
- Couppé, C., Suetta, C., Kongsgaard, M., Justesen, L., Hvid, L. G., Aagaard, P., … Magnusson, S. P. (2012).The effects of immobilization on the mechanical properties of the patellar tendon in younger and older men. Clinical Biomechanics, 27(9), 949–954.doi:10.1016/j.clinbiomech.2012.06.003
- Rumian A. P.,Draper E. R. C., Wallace A. L., and Goodship A. E.The Journal of Bone and Joint Surgery. British volume 2009 91-B:4, 557-564
- Lis, D. M., & Baar, K. (2019).Effects of Different Vitamin-C Enriched Collagen Derivatives on Collagen Synthesis. International Journal of Sport Nutrition and Exercise Metabolism, 1–20.doi:10.1123/ijsnem.2018-0385
- Optimising the Tendon for Athletic Performance. Anthony Blazevich PhD. Presentation given at the UK Athletics Strength and Conditioning Conference, Loughborough, April 2003
- Desmeules, F., Boudreault, J., Dionne, C. E., Frémont, P., Lowry, V., MacDermid, J. C., & Roy, J. S. (2016). Efficacy of exercise therapy in workers with rotator cuff tendinopathy: a systematic review.Journal of occupational health, 58(5), 389–403. https://doi.org/10.1539/joh.15-0103-R
- Farup J, Rahbek SK, Vendelbo MH, Matzon A, Hindhede J, Bejder A, Ringgard S, Vissing K. Whey protein hydrolysate augments tendon and muscle hypertrophy independent of resistance exercise contraction mode. Scand J Med Sci Sports. 2014 Oct;24(5):788-98. doi: 10.1111/sms.12083. Epub 2013 May 7. PMID: 23647357.
- Wolfson RL, Chantranupong L, Saxton RA, Shen K, Scaria SM, Cantor JR, Sabatini DM. Sestrin2 is a leucine sensor for the mTORC1 pathway. Science. 2016 Jan 1;351(6268):43-8. doi: 10.1126/science.aab2674. Epub 2015 Oct 8. PMID: 26449471; PMCID: PMC4698017
- Wall BT, Morton JP, van Loon LJ. Strategies to maintain skeletal muscle mass in the injured athlete: nutritional considerations and exercise mimetics. Eur J Sport Sci [Internet] Taylor & Francis. 2016;15(1):53–62.
- Quintero, K.J., Resende, A., Leite, G.S.F. et al.An overview of nutritional strategies for recovery process in sports-related muscle injuries. Nutrire 43, 27 (2018). https://doi.org/10.1186/s41110-018-0084-z
- Hijlkema A, Roozenboom C, Mensink M, Zwerver J. The impact of nutrition on tendon health and tendinopathy: a systematic review. J Int Soc Sports Nutr. 2022 Aug 3;19(1):474-504. doi: 10.1080/15502783.2022.2104130. PMID: 35937777; PMCID: PMC9354648.
- Owens BD, Wolf JM, Seelig AD, et al.Risk factors for lower extremity tendinopathies in military personnel. Orthop J Sports Med. 2013;1(1):1–8.
- Passaretti D, Candela V, Venditto T, et al.Association between alcohol consumption and rotator cuff tear. Acta Orthop. 2016;87(2):165–168
- Alcohol impairs skeletal muscle protein synthesis and mTOR signaling in a time-dependent manner following electrically stimulated muscle contraction. Jennifer L. Steiner and Charles H. Lang. APSselect2014 1:12, 1170-1179
- Jain NB, Ayers GD, Fan R, et al.Predictors of pain and functional outcomes after operative treatment for rotator cuff tears. J Shoulder Elbow Surg. 2018;27(8):1393–1400.
- Christensen B., Dandanell S., Kjaer M., Langberg H. Effect of anti-inflammatory medication on the running-induced rise in patella tendon collagen synthesis in humans. Appl. Physiol. 2010;110:137–141. doi: 10.1152/japplphysiol.00942.2010.
- Noriega-González DC, Drobnic F, Caballero-García A, Roche E, Perez-Valdecantos D, Córdova A. Effect of Vitamin C on Tendinopathy Recovery: A Scoping Review. Nutrients. 2022 Jun 27;14(13):2663. doi: 10.3390/nu14132663. PMID: 35807843; PMCID: PMC9267994.
- Shaw G., Lee-Barthel A., Ross M.L., Wang B., Baar K. Vitamin C–enriched gelatin supplementation before intermittent activity augments collagen synthesis. J. Clin. Nutr. 2016;105:136–143. doi: 10.3945/ajcn.116.138594.
- Zhi X, Liu X, Han J, Xiang Y, Wu H, Wei S, Xu F. Nonoperative treatment of insertional Achilles tendinopathy: a systematic review. J Orthop Surg Res. 2021 Mar 30;16(1):233. doi: 10.1186/s13018-021-02370-0. PMID: 33785026; PMCID: PMC8008511.
- Benjamin M, kaiser E, Milz. Structure-function relationships in tendons: a review. Journal of Anatomy 2008; 212: 211-228
- Fenwick SA, Hazleman BL, Riley GP. The vasculature and its role in the damaged and healing tendon. Arthritis Res. 2002;4(4):252-60. doi: 10.1186/ar416. Epub 2002 Feb 13. PMID: 12106496; PMCID: PMC128932.