Diagnosis and Management of Tendinopathies

The following is a review of several of Craig Purdam’s presentations on tendinopathy at the recent 2011 Pan Pacific Conference for Medicine and Science in Sport, held in Honolulu.

Craig is the head of physical therapies for the Australian Institute of Sport and had a wealth of information to share during the weekend. I was very grateful to be in attendance.

Craig proposed that the pathology and the response to treatment are different in the various tendinopathy presentations and therefore interventions should be dictated by the specific pathology. More specifically, that there exists a continuum of tendon pathology. Namely:

• Reactive tendinopathy
• Tendon Dysrepair (failed healing)
• Degenerative Tendinopathy

Craig stressed that rather than looking at the above as three distinct phases, that a continuum should be kept in mind.

http://bjsm.bmj.com/content/43/6/409/F1.large.jpg.

Classification of Stages must be identified via:

• Clinical picture, and
• Diagnostic imaging

Stage characteristics:
​
Reactive Tendinopathy

• Pathology: Non-inflammatory proliferative response secondary to acute tensile or compressive overload (i.e. too much too soon). Note that tensile forces cause also compression (think of an elastic band narrowing in width (compression) as it is being stretched (tension). Tendon thickening results, presumably as a protective mechanism. Upregulation of large proteoglycans, resulting in increased binding with water, accounts for the observed swelling
• Diagnostic Ultrasound: Cleaving of collagen (longitudinal separation) as exhibited by diffuse hypoechogenicity
• Demographic: Common in younger athletes (i.e. a lengthy basketball tournament) or in the young deconditioned athlete who is now exposed to moderate load exposure.

Tendon Dysrepair

• Pathology: Failed attempt at healing (greater tissue matrix breakdown) results in matrix disorganization and further collagen separation. Changes are more focal and increased thickening is certainly present
• Diagnostic Ultrasound & Doppler: collagen fascicle discontinuity and focal hyoechogenicity, as well as increased vascularity
• MRI: swelling and increased signal intensity
• Demographic:May be secondary, but not limited, to chronic overload in young athletes. In older athletes with less adaptive, stiffer tendons, this stage may develop with lower loading exposure

Degenerative Tendinopathy

• Pathology: Perhaps the most clearly described stage in the literature. Cell death is apparent, as well as matrix disorganization, vascularity, and little collagen. Reversibility of pathology is minimal
• Diagnostic Ultrasound & Doppler: Hypoechogenicity and vascularity
• MRI:Increased tendon size and intratendinous signal intensity
• Demographic: Primarily in older athletes but may present in chronically overloaded tendons of young elite athletes. Focal nodularity with or without general thickening. Typical history of repeat bouts of tendon pain with short-term relief. Injury often returns with changes in tendon load. Rupture may occur.

For ease of interpretation, the above continuum is divided into:

• Reactive/Early Tendon Dysrepair, and
• Late Tendon Dysrepair/Degenerative

Cornerstones of Rehabilitation:

• Confirmation of actual tendon involvement
• Stage identification
• Symptom and function quantification via outcome measures
• Load modification via training alteration and biomechanical efficiency
• Load progression
• Pharmacological and Modality interventions

Considerations:

• Mono-therapy is rarely successful
• Tendon unloading must only be reserved for significantly “hot tendons” and must be performed for only short periods of time. Otherwise may result in decreased tissue strength

Rehabilitation Principles:

• Unloading interventions – i.e. biomechanical efficiency
• Priority given to muscle wasting – need hypertrophy
• Early rehab – static and slow
• Speed progression
• Volume progression of functional activities
• Late rehab – elasticity
• Load management

Treatment Strategy:

Reactive Tendinopathy:

• Load management
• Slow tempo
• Moderately heavy loads with full recovery between sessions
• Inner range then outer range
• Isometric
• Downregulate sensitization – you do not want to push this stage and aggravate further

Tendon Dysrepair:

• Gradually increase length (outer range)
• Introduce Speed and Contractility
• Undulate loading in 3 day (High, Low, Moderate) cycles

Degenerative Tendinopathy:

• Introduce Contractility and Elasticity
• Load undulation
• Eccentric progression
• *Note that this is the only stage where eccentric exercise was suggested. Perhaps this may shed some light as to why eccentric exercise has demonstrated mixed-results in tendinopathy rehab. Are some of you utilizing rehabilitation modality at the wrong stage?

*Note modalities such as cross-friction, therapeutic ultrasound, and shockwave are only appropriate in the Late Tendon Dysrepair and Degenerative Tendinopathy Stages

*For (hopefully) obvious reasons, I have intentionally omitted recommendations pertaining to pharmacological treatment..

Purdam has authored and co-authored numerous articles on tendinopathy but perhaps three of the most significant ones you may be interested in are:

• Cook JL & Purdam CR. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43; 409-416
• Allison GT & Purdam C. (2009). Eccentric loading for achilles tendinopathy – strengthening or stretching? British Journal of Sports Medicine, 43; 276-279
• Malliaras P, Purdam C, Maffuli N & Cook J. (2010). Temporal sequence of greyscale ultrasound changes and their relationship with neovascularity and pain in the patellar tendon. British Journal of Sports Medicine, 44; 944-947