Is Exercise The Best Treatment for Tendinopathy?
What treatments should be use to manage those tricky tendinopathies?
Tendonopathy most comon affects the wrist flexors, wrist extensors, rotator cuff, patellar and achilled tendons. It is characterised by a clinical syndrome of pain, swelling and loss of function and it is theorised that is is caused by an abnormal healing response within the tendon itself, although this is often debated. The term tendinopathy is a generic descriptor of the clinical conditions ( both pain and pathological characteristics) associated with overuse in and around tendons.
Conservative treatment is the mainstay in tendinopathy treatment with ultrasound, laser therapy, shockwave and exercise being the main treatments of choice. The best treatment protocol for each of these treatment choices is poorly definied and there are lots of conflicting studies which exist many of which are modality specific not disease orientated. This causes further confusion as although histological studies confirm similar process of pathology as each tendon there are differences present.
The aim of this sytematic reivew was to summarize evidence in the last decade regarding the efficacy of physical therapy interventions to treat tendinopathy, as a single disease entity, as determined in systematic reviews (SRs) and/or meta-analyses (MAs).
To be included within the review studies had to be systematic reviews or meta-analysis with the objective to determine the efficacy of physiotherapy interventions in treating tendinopathy. Only studies written in English and published in peer reviewed journals after 2010 were included. Studies which included drugs, surgery or were non-efficacy studies were excluded.
The search strategy involved searching four databases, PEDro, Scopus, PubMed and NIH, and the following search terms were used:
((“Tendinopathy/reha- bilitation”[Mesh] OR “Tendinopathy/therapy”[Mesh]) AND ((sys- tematic[sb] OR Meta-Analysis[ptyp]) AND English[lang])) AND (“2010/01/19″[PDat]: “2020/01/16″[PDat]). The search strategy of Scopus database was: TITLE-ABS (tendinopathy) OR TITLE-ABS (tendinitis) OR TITLE-ABS (tendinosis) AND PUBYEAR > 2010 AND (LIMIT-TO ( DOCTYPE, “re”))
The quality of the studies was assessed using AMSTAR 2 and the overall confidence of the findings was assessed using GRADE.
The outcome measures of interest include pain measures by VAS or NPRS and function measured through tests specific to the site of tendinopathy. For example achilles tendinopathy and the heel raise test or tennis elbow and the PRTEE.
In total 40 systematic reviews and/or meta analysis were included within the results. In terms of overall confidence of findings based on AMSTAR 2, one study was rated as high overall confidence, 16 as moderate overall confidence, 21 with low overall confidence and two critically low confidence.
Quick Summary of The Best Tendinopathy Treatments
- LLLT may be effective at improving pain for rotator cuff and achilles tendinopathy
- ESWT appears effective for improving pain and function in achilles and patellar tendinopathies
- Eccentric exercise is an effective treatment for multiple tendinopathies including rotator cuff, patellar, achilles and tennis elbow. Combining exercise with LLLT and ESWT may be of additional benefit
- It’s inconclusive that dry needling, manual therapy and deep tissue frictions are effective treatments.
- Ultrasound is not superior to placebo
6 studies supported the use of low level laser therapy to manage pain in achilles and rotator cuff tendinopathy however the overall confidence of the studies is rated as critically low to moderate. The overall improvement in pain was between 1 and 2 points on VAS & NPRS.
Extracorporeal shockwave therapy was evaluated in 3 studies with moderate-low overall confidence. The studies concluded that ESWT was effective in reducing pain and improving function in people with achilles and patellar tendinopathies and may also be useful for shoulder calcific tendinitis.
6 studies with moderate-low overall confidence suggest that exercise is effective at reducing pain and improving function in people with tennis elbow, achilles, patellar and rotator cuff tendinopathies. Eccentric exercises appear to be the most effective with some evidence suggesting combing exercise with LLLT or ESWT is beneficial.
There appears to be inconclusive evidence that deep tissue frictions, dry needling, TENS, iontophoresis or joint mobilisation are effective treatment choices. The same can be said for taping and orthotics however ultrasound has been shown to not be superior to placebo and this did not change when compared to ESWT.
The results of this systematic review are consistent with other studies and it appears that eccentric exercise is still the go to treatment for the majority of tendinopathies. Shockwave may provide an alternative option to reduce pain and allow an opportunity for pain to be reduced to a point where exercise can commence.