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Tendinopathy: Evaluation and Treatment of Common Tendinopathies

Douglas W. Martin, MD, FAAFP

ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

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DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Douglas W. Martin, MD, FAAFPMedical Director, UnityPoint Health–St. Luke’s Occupational Medicine, Sioux City, Iowa

Dr. Martin is a graduate of the University of Nebraska College of Medicine, Omaha, and completed his family medicine residency in Davenport, Iowa. He also completed a mini-residency in occupational medicine at the University of Cincinnati, Ohio. The majority of Dr. Martin’s practice is focused on musculoskeletal-related diagnoses. He has given numerous lectures on occupational medicine topics, with emphasis on upper-extremity repetitive motion injuries, disability medicine, and medical review officer functions. In addition, he has authored book chapters for AMA Guides on causation analysis, return to work, and how to navigate disability systems. Dr. Martin is an international expert on the construct of complex regional pain syndrome and has lectured at the Royal Society of Medicine in London. He is a former president of the Iowa Academy of Family Physicians and the American Academy of Disability Evaluating Physicians (AADEP). A Diplomate of the American Board of Family Medicine (ABFM), he is currently on the board of directors for both the American College of Occupational and Environmental Medicine (ACOEM) and the Interstate Postgraduate Medical Association (IPMA).

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Learning Objectives1. Use evidence-based practices to diagnose patients presenting

with joint pain for tendinopathy, and assess for red flags indicating infection or other serious condition.

2. Develop an evidence-based treatment strategy for patients with tendinopathy.

3. Counsel patients diagnosed with tendinopathy on prevention and immediate self-treatment strategies.

4. Coordinate referral to physical therapy for tendinopathy.

Audience Engagement SystemStep 1 Step 2 Step 3

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Associated Session

• (PBL) Upper & Lower Extremity Musculoskeletal Exam Techniques: Evidence-Based Treatment

• Talk a little about pathophysiology

• Talk a little more about anatomy

During Our Short Time Today, We Will

• Discuss evaluation and treatment for four common tendinopathies

• Please note that “four” is a forced choice, as there are multiple tendinopathies, but I only have an hour.

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Strain v. Tendinopathy

• Strains - acute overload– Inability to take intensity (more volume of intensity)

• Tendinopathy - chronic overload– Inability to take volume

We Need Overload to Progress

• Normal Tendon

– Regular Collagen Fibers

– Minimal Vascularity

– Spindle Shaped Tenocytes

Tendinopathy• Tendinopathic

– Disorganized Collagen Fibers

– Vascularity and Nerves

– Round Tenocytes

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Tendinopathic Changes– Increased angiogenic factors (VEGF)– Increased matrix degradation (MMP family)– Increased inflammation (IL-6, COX-2)– Increased cell rounding

Changes do not occur in entire tendon!!

Not necessarily symptomatic

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AES Question #1

Which of the following does not occur in tendinopathy?A. Neoangiogenesis leads next to painB. Collagen fibers organizeC. Cox-2 is releasedD. Chronic overload

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Four Tendinopathies We Will Discuss

• Tennis elbow (lateral epicondylopathy)

• DeQuervain’s (radial styloid tendinopathy)

• Achilles tendinopathy

• Plantar “fasciitis”

Tennis Elbow

• Dx is rather straightforward

• Usually no imaging necessary

• Resisted apprehension technique

• Differential considerations– Tender point in FMS

– Radial nerve entrapment (rare)

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What is Tennis Elbow?

• Is not inflammatory

• Is angiofibrotic dysplasia– Incomplete healing of micro tears in fibers

primarily due to insufficient blood supply (Nirschl, Kraushaar)

• Same process in golfers elbow

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Medications – Tennis Elbow

• NSAIDs

• Acetaminophen

• Nothing else really seems to make a difference

What about bracing and splinting?• Wrist extension splints = Consensus says “yes” but no

definitive conclusions with lateral elbow pain (Struijs, Jansen, ACOEM)

• Tennis elbow bands = Literature generally is supportive, but not all. Might have something to do with quality of support.

(Thurston, Solveborn, Foley, AAFP)

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What about rehab?

• Limited data on PT/OT secondary to difficulty in measuring outcomes

• Exercise, ROM & strengthening by patient probably just as good as formal rehab (Field, Pienimaki)

• If PT/OT used, should be limited to 2-3 weeks (Piligian, Boyer, Sevier)

What about injections?• May be some benefit in short term relief of pain,

patients requiring multiple injections have poor prognosis.

• Very commonly performed• Corticosteroid injection does not provide any long-term

clinically significant improvement in the outcome of “epicondylitis” • (Combes, Bowen, Reveille, Newcomer, Smidt, Stahl)

• APG Guidelines recommend for chronic, but no recommendation for acute

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What about surgery?

• Limited available studies – natural history is that 95 % recover with conservative care

• Both APG and ODG support if

Failed conservative care for 12 months

Functional Limitations

• MRI is a good test for consideration of sx

– Confirms dx

– Provides roadmap for sx

Alternative Treatment Methods –The Evidence

• Acupuncture = Short term benefit – more helpful in chronic (Green, Fink)

• Chiropractic = Same as PT/OT data • Nitroglycerin patch = maybe some help• Modalities

– ASTM, biofeedback, diathermy, e-stim, ESWT, Laser, ionto, phono, TENS, ultrasound

– Little available evidence. If there is some available, poor long term outcomes. PT/OT modalities, if used, no more than 2-3 weeks.

• (Haake, Piligian, Boyer, Sevier, Demirtas, Klaiman)

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Tennis Elbow “Sexy Treatments”

In comparisonautologousblood does the best

AES Question #2

Which of the following is TRUE regarding tennis elbow:

A. It is an inflammatory condition

B. Early injection therapy is recommended

C. Acupuncture can be helpful if chronic

D. Plain film x-ray is helpful in confirming the dx

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DeQuervain’s Tenosynovitis

• This is indeed a true inflammatory disorder

Extensor Compartment Tendinoses, including de Quervain’s Disease

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There are anatomical variants

• deQuervain’s tendonitis (tenosynovitis)– Sometimes not inflammatory [i.e., Mechanical]

– Anatomy (APL, EPB) 3APL, 1 EPB

Diagnostic Considerations

• de Quervain’s tendonitis (tendinosis)– Finkelsteins test

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de Quervain’s v. Intersection

MedicationNSAIDs (oral or topical) recommended Acetaminophen as an adjunctDose Optimal dose unknown. No quality comparative trials. Regularly scheduled dosing recommended for acute, significantly symptomatic presentations.

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Splints

• Thumb spica splints– Soft variety better than rigid, but this is often

in the eye of the beholder

• Frequency/ Duration– Awake hours only

– Until symptoms subside and wean away

Iontophoresis with Steroid or NSAID

• Indications – Generally fail prior NSAIDs, splints, and activity modifications or decline injection.

• Dose Glucocorticoid generally used; however, quality studies for lateral epicondylalgia with NSAIDs via iontophoresis; thus, appear reasonable for this as well.

• Frequency/Duration – Generally 2-3 appointments; additional 4-6 if efficacious. If improvements continue at 6, 4-6 more reasonable.

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Injections• Indications – Generally 1+ week non-invasive treatment to see if resolves

without injection. – Reasonable to initially inject, but no quality evidence. – Failure or suboptimal results needing additional injection(s) uncommon,

reinjection is (are) usually successful. (Anderson 91; Sakai 02).

– Consider repeat injections with modestly higher dose.• Dose Optimal dose unknown. Studies of:

– methylprednisolone acetate 40mg (Anderson 91),

– triamcinolone acetonide 10mg. (Sakai 02)

– Adjuvant anesthetic typically used. (Anderson 91; Sakai 02)

– No maximum number of injections to treat episode or in a lifetime.

Surgery

• Generally a consideration when– Failure of conservative care

– Failure of two injections

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Achilles Tendinopathy

Diagnostic Considerations

• Heel pain- superior heel pain– Haglund’s disease (pump bump)

– retrocalcaneal bursitis

– achilles tendinitis

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Achilles Imaging

• Generally no imaging is necessary– Unless there is confusion

• A plain film showing a spur at insertion point or intratendinous calcification is indicative of disease

Achilles Tendonitis – Evidence Based Treatment

• Physical Therapy – yes– 9 visits over 5 weeks max– Low Laser Light (LLLT) showing some promise

• NSAIDs – yes• Heel lifts – probably no help• Injections – despite the “traditional” concern about

rupture complication, there is support for chronic• But not for acute or subacute

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Achilles Tendinopathy

Considerable effectiveness with eccentric strengthening

Can also couple with soft tissue therapy on calf and also tendon

Alfredson’s Eccentric painful heel drop protocol‐ Gastro‐ knee fully extended‐ Soleus‐ knee flexed to 45‐ Both start in demi‐pointe with heel raised and 

lower until foot parallel with ground‐ Once no longer pain, increase intensity

Achilles Tendonitis – Surgical Considerations

• If not better after 30 days of conservative care, redirect to other pathology considerations

• Six months of nonsurgical therapy is appropriate for middle-aged patients or athletes with chronic Achilles tenosynovitis.

• Those that fail this treatment will improve with a limited debridement of diseased tissue without excessive soft tissue dissection of the tendon.

• Those patients who respond to nonoperative therapy tend to be younger than those who have degenerative tendon changes requiring surgery.

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AES Question #3

What do deQuervain’s disease and Achilles tendonitis have in common?A. They are both named after mythology

figuresB. Injection therapy is helpful in acute phasesC. Bracing is effective for bothD. NSAIDs are good choices for medication tx

Plantar “fasciitis”

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• Heel or arch pain, often with first steps

• Pain at insertion of the 

medial calcaneal tuberosity

• Differential dx:

– Nerve entrapment

– Stress Fracture

– Painful heel pad

• If needed to confirm dx

– US or MRI both will show fascia thickness increase signal

Plantar Fasciitis

The Heel Spur Farce

• Heel spur lies within origin short toe flexors at origin of plantar fascia

• Present in 50% of patients with pain

• Not the cause!!

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Plantar fasciitis

Plantar fasciitis conservative treatment

• Treatment:– NSAIDs– Stretching

• plantar fascia, gastroc and soleus• Straussburg sock

– Massage with frozen water bottle– Supportive shoes with arch at all times– PT short term

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Plantar fasciitis – Evidence Based Treatment

• Modalities – no support• Dorsiflexion night splint – excellent support• Taping – Yes (better than drugs)• Orthoses

– The percentages improved in each group were: (1) silicone insert, 95%; (2) rubber insert, 88%; (3) felt insert, 81%; (4) Achilles tendon and plantar fascia stretching only, 72%; and (5) custom orthosis, 68%. (Pfeffer, 1999)

• ESWL maybe of help for chronic cases

Plantar fasciitis injections

• Literature states provides only short term relief

• Best for chronic cases• But is sure done a lot for acute situations• Approach should be medial• DO NOT GO THROUGH THE FAT PAD

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Plantar fasciitis – Surgery

• In general, heel pain resolves with conservative treatment

• In recalcitrant cases, however, entrapment of the first branch lateral plantar nerve should be suspected.

• Surgical release of this nerve can be expected to provide excellent relief of pain and facilitate return to normal activity.

Why Absolute Rest is Bad• Causes tendon degradation

• Decreased musculotendinous strength

• Screws up kinetic chain

• Decreased neuromuscular performance

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Heavy Slow Resistance Training• Increased growth hormone (Doessing et al 2010)

– Collagen synthesis

• Increased fibril density (Kongsgaard et al 2010)

• Increased anaerobic threshold (Weyand and Bundle)

• Increased endostatin (Pufe 2005)

– Decreased angiogenesis

Practice Recommendations• Eccentric exercise for tendinopathy is by far the

best, easiest, and most effective means to treat and then prevent

• You rarely need expensive diagnostic tests to diagnose these disorders

• PRACTICE PEARL: Do not be afraid to mix the conservative treatments that are indicated by EBM…its not a “one shot deal” and your care is a LOT better than having to send the patient off for a surgery

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Questions

Contact InformationDouglas W Martin MD FAAFP FACOEM

FIAIME4230 War Eagle DriveSioux City, IA 51109

712-224-4300douglas.martin@unitypoint.org

@OccDocDMMD