Treatments « Tendon Disorders: A Resource of Medical Evidence & Research

Tendon Disorders: A Resource of Medical Evidence & Research

Treatments

Astym treatment:

Delivered by qualified, specially trained physical and occupational therapists. Astym treatment is highly effective and was scientifically developed to stimulate regeneration of tendons and other soft tissues. Astym has its foundation in basic science research and is supported by clinical trials, case studies and extensive outcomes collected from multiple treatment sites3-18. This is a non-invasive treatment (no needles, no surgery). Instruments are applied topically (on top of the skin) to put light to moderate pressure on the underlying tissue and stimulate a healing/regenerative response. Most conditions resolve within 6 weeks. A prescription from your doctor may be necessary to go to therapy if your state requires it. Almost all states (all except Alabama, Hawaii, Indiana, Michigan, Missouri and Oklahoma) allow you to make an appointment with the therapist first for an evaluation. A directory of therapists who are qualified to provide Astym can be found at http://www.astym.com. Be sure check that directory to confirm your therapist is certified in the Astym rehabilitation process. Certification is extremely important, otherwise you will not receive proper treatment. Astym treatment is usually covered by insurance.

Autologous Blood Injections:

Delivered by medical doctors (MDs). There is no certification or special training required, however, there is some instruction available to doctors. Make sure to inquire as to your doctor’s training and experience. Basically, a physician draws your own blood and then injects your own blood back into you around the spot that hurts, hoping to cause a physiological response that will ease pain and increase function. No controlled studies have been published on this treatment, and further study is needed to determine whether this approach will be useful in the treatment of tendon disorders. Health insurance companies generally consider this investigational and do not pay for this treatment, so if you would like to try it, you will most likely have to pay cash.

Corticosteroid Injections:

Delivered by medical doctors (MDs). Corticosteroid medication is injected around a tendon to reduce inflammation and ease pain. The use of corticosteroid injections ("CSI") for the treatment of tendon disorders is controversial. There can be side effects. Repeated injections may weaken a tendon, increasing the chance of a rupture or tear. There have been a number of case reports of tendon rupture after CSI19,20. Additionally, corticosteroid medications should never be injected directly into the tendon because that could contribute to a tendon rupture. In order to reduce this risk, the injection may be done with the assistance of image guidance (such as ultrasound or fluoroscopy) to ensure that the injection is being done around the tendon rather than into the tendon. This approach is often successful in reducing pain, however, since its goal is to reduce inflammation, it is questionable whether there is any long-term healing benefit to the tendon, and positive results are often short-lived. CSI in tennis elbow has been studied, and although it was somewhat effective in the short term (2-6 weeks), patients received no long term benefit21,22. Long term effectiveness for this approach has not been demonstrated23. The true cause underlying most tendon disorders is degeneration, so addressing this problem with a treatment aimed at stimulating regeneration would be more productive.

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Eccentric Exercise:

Supervised by physical therapists, occupational therapists, trainers and exercise instructors. This is a supervised exercise program focusing on the "return" or "lowering" portion of exercise. Eccentric exercise can be tedious, requiring focus and time to allow for multiple repetitions of the exercise in the range of 100-150 times per day (7 days a week) for a period of at least 12 weeks. The exercises can be uncomfortable, but they have been shown to be effective in certain cases. These exercises are generally not suitable for more frail patients. There is some limited support for this approach in the medical literature, particularly for chronic, mid-portion tendinopathy of the Achilles tendon 24, however, a recent study showed that the success of this approach was markedly lower than previously thought.25

Electrical Stimulation and Iontophoresis:

Delivered by physical and occupational therapists. Therapists use equipment to deliver electrical current into the affected area. Multiple sessions are usually done. Often a corticosteroid cream or patch is added and this medication is then pushed through the tissue with the electricity (this combination is known as Iontophoresis). There is little to no medical evidence that this works for chronic tendon disorders. The Cochrane Review, an official medical review analyzing medical literature concluded that no definite statements could be made about the efficacy or clinical usefulness of electrotherapy modalities for neck pain26. Further investigation and study is needed. Health insurance companies are now becoming hesitant to pay for this, so check with your health insurance carrier if you plan on getting this treatment.

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Extracorporeal Shockwave Therapy (ESWT):

Delivered by medical doctors (MDs). A physician (for high-energy application) or a physician’s office assistant (for low-energy application) uses equipment to deliver a series of high or low-energy shock waves directly over the painful area. Although this has been studied for over ten years, how ESWT may work is unclear. More importantly, whether it works is unclear. The studies have revealed that the shock waves result in degeneration of animal epidermal sensory nerve fibers (which may just reduce the sensations of pain rather than fixing the underlying problem), and the studies also reveal evidence of tenocytes releasing growth factors in response to ESWT that may aid healing27. The studies show conflicting evidence as to whether ESWT is effective in treating tendon disorders. Two systematic reviews conclude that ESWT provides little or no benefit in the treatment of tennis elbow (lateral epicondylitis)28,29. The most promising application seems to be in the treatment of calcific tendonitis of the rotator cuff30, however, two controlled, randomized clinical trials reported no major benefit with ESWT versus placebo for the treatment of noncalcific tendinopathy of the supraspinatus31,32. The application of ESWT can vary widely in the intensity and frequency of shock waves, how long the treatment lasts, and the timing and number of treatments. This makes it hard to gauge its overall effectiveness. ESWT can be very painful, and the high energy waves are only administered under sedation or anesthesia in an operating room setting with the assistance of imaging to make sure the shock waves are being delivered to the right area. The low energy waves can be done in an office, but be aware that it is usually quite uncomfortable and each session will last approximately 15 minutes (multiple sessions are usually required). ESWT remains a controversial treatment for tendon disorders and is rarely covered by health insurance.

Fenestration (percutaneous tenotomy):

Performed by medical doctors (MDs). This procedure involves puncturing an affected area multiple times (50-100 punctures usually) per session with a needle. Local anesthesia is usually given so the patient can tolerate the procedure and it is often done under the guidance of ultrasound imaging. Usually patients receive only one session, however, if positive results are seen and the condition recurs, then the patient may receive more sessions. The local trauma and bleeding that results from the multiple punctures may cause a similar physiological response to actually injecting your own blood around the affected area (autologous blood injections), which may be how this might help tendon problems to heal. In addition to multiple punctures to the tendon, the procedure can include mechanically breaking up calcifications and abrading the adjacent bone. Preliminary research indicates that this procedure improves tendinopathy in a notable number of patients33, 34. If you elect to have this procedure done, it is important to select an experienced physician. It is questionable whether health insurance will pay for this procedure, so you may have to pay cash for it.

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Friction Massage – both tooled and traditional:

Delivered by almost anyone. Many people do this technique on themselves. Basically, it is a deep massage across muscles and tendons with the goal of mechanically breaking down tissue. There is little to no medical evidence showing that this approach consistently works, however, there have been anecdotal reports from individuals who have had some positive benefit. The Cochrane Review, an official medical review analyzing medical literature, concluded there was no benefit to this approach over controls35. There are quite a few different tools that are used to do this type of massage. Some of the tools seen more often are: Acuforce, Graston, GSO, Fuzion, Sastm, Intracell, T-Bars, Jacknobbers, handles of reflex hammers and various kitchen utensils. Some tools promote a friction massage approach called Instrument Assisted Soft Tissue Mobilization or Instrument Assisted Cross-Fiber Massage, such as Graston and Sastm. The only published article on Instrumented Cross-Friction Mobilization shows that it has minimal to no long-term (12 weeks or more) benefit on healing36.

Glyceryl Trinitrate (Nitroglycerin) Patches:

Prescribed by medical doctors (MDs). These patches are normally used to treat cardiovascular disease and their use in treatment of tendon disorders is an off-label use. In other words, the FDA has not approved this drug’s use for the treatment of tendon disorders. There is no standard dosing, so effectiveness and side effects can vary by how much you are given. Typically, patients have to cut these patches into smaller pieces and then apply the patches over the affected area daily for at least 12 weeks to experience any noticeable change in symptoms. As a whole, studies performed on this approach show that there can be benefit with pain relief and healing, although there is some question as to whether this simply has an analgesic (pain-relief) effect rather than a healing benefit in the treatment of tendon disorders37. A recent study showed that there are no significant, comparative long term clinical benefits from this approach in the treatment of chronic tennis elbow38. The most common side effects are headaches and a drop in blood pressure that can result in fainting. These side effects can become severe enough to require stopping this kind of treatment.

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Laser/Light Therapy:

Delivered by chiropractors, physical therapists, and occupational therapists. Laser or light energy is directed over the affected area, either through "cold" low level laser therapy (LLLT) or through light emitting diodes (LED) or super luminous diodes (SLD). The efficacy of this type of therapy for tendon disorders is not supported by the medical literature, however, there is some evidence that it may have a positive effect on the healing of skin ulcers/wounds. Low-level laser treatment (LLLT) has been studied with inconsistent results. Four systematic reviews in the medical literature have addressed LLLT, and all agreed the evidence does not support its use in the treatment of tendinopathy39,40,41,42. This therapy is generally not covered by health insurance for the treatment of tendon disorders.

NSAIDs/Anti-inflammatory Drugs:

These prescription strength drugs are prescribed by medical doctors (MDs). Over the counter products are also available. Oral NSAIDs (non-steroidal anti-inflammatory drugs), have been used to treat tendon disorders for decades. Recently, gels or patches with this type of medicine have also been used. The medical literature contains frequent mention of the use of NSAIDs in the treatment of tendinopathy, however, there is "surprisingly little quality evidence supporting this …option"1.

The studies and trials reveal that although these drugs may provide short-term pain relief, there is little to no evidence of a positive effect on long-term healing37. In fact, there is conflicting evidence in animal models regarding the effect of NSAIDs, with a suggestion that NSAIDs may actually inhibit healing43,44,45. Now that we know tendon disorders are primarily degenerative in nature, rather than inflammatory, we understand why a drug designed to reduce inflammation has little effect on the underlying degenerative tendon problem. Instead of trying to reduce inflammation, the better goal would be to stimulate regeneration (which is the real cause of most tendon disorders).

Be aware that long-term use of NSAIDs carries the risk of significant side-effects, such as increased risk of gastrointestinal bleeding, renal failure, liver damage, and cardiovascular complications associated with this type of medicine37. Common names of some NSAIDs include generic Ibuprofen (and brands such as Advil® and Motrin®) and generic Naproxen Sodium (brand name Aleve®) and prescription strength brand Celebrex®.

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Platelet Rich Plasma (PRP) Injections:

Delivered by medical doctors (MDs). The physician injects you with a derivative of your own blood. Blood is withdrawn from you, put into a machine that spins it out and leaves a layer of platelet rich plasma (PRP). That plasma is injected back into you, hoping to cause a physiological response that will ease pain and increase function.

There are several brands of machines which produce different platelet layer concentrations. This approach is similar to Autologous Blood Injections, however, the platelet rich portion of the blood is separated and only the PRP is injected, which may cause less local inflammation but will require more blood to initially be drawn out.

If good PRP is guided by ultrasound, it may work on a small area of tendinopathy (about ½ inch square) if it is followed by appropriate rehabilitation. The growth factors from a PRP injection only spread out so far and once in the tissue they degrade rapidly – that is why its effectiveness, like most injection techniques, is limited to a small area. If PRP is not guided by ultrasound to hit the area of degeneration in the tendon, it can easily miss the optimal injection site and therefore not be effective. PRP can require multiple injections (if a patient doesn’t respond immediately) and often a limitation on activity and training for a period of time (2-4 weeks) after each injection is recommended. The treatment course may easily take up to 6 months. Most of the time, PRP procedures will use a large bore needle (>22).

Previously, very limited study had been done on this method for tendinopathy46. However, a well-designed study was just published in the Journal of the American Medical Association (JAMA) and it shows that PRP is no more effective than placebo (ineffective or sham treatment) in the treatment of tendinopathy47. It is generally considered investigational or experimental by health insurance carriers and not covered under health insurance policies. If you would like to try it, you most likely will have to pay cash for this service.

Prolotherapy (Sclerotherapy):

Delivered by medical doctors (MDs). The physician injects an irritating substance into the affected area, and it is theorized that the area scars down and may destroy the nerve fibers that are transmitting the pain. Originally, prolotherapy was used to scar down an area of instability in a joint. If a joint was loose, the creation of scar tissue could help "tighten up" the area by adding dense scar tissue to the joint capsule. Some more adventurous doctors have now applied this to the treatment of tendinopathy and tendon disorders. Some initial study has been done on this technique, but so far the research has been underpowered and most research was not controlled1, so there is no solid support in the medical literature for this procedure in the treatment of tendinopathies. However, there are some positive anecdotal reports (individual stories) that have been published in the popular media. Proper scientific study would necessarily include making sure all study subjects are injected with the same substance. A concern with this procedure may be that scarring down one area could lead to increased stress on structures in other areas with the potential for additional problems in the future. This procedure is generally considered experimental or investigational by health insurance companies and not covered under their policies, so you will probably have to pay cash for this service.

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Relative Rest/Splinting/Immobilization:

Delivered or recommended by medical doctors (MDs), and physical and occupational therapists. Patients will often complain of tightness or weakness as a result and can become dependant upon their splints. A study has shown that wearing a splint can cause increased stress on other structures48. This has the potential for additional problems in related areas. Pain may decrease, but function will be sacrificed in the short term. Unfortunately, resting the involved area rarely leads to healing and resolution of the underlying problem. Return to activity may help strengthen the tissues again, but pain often returns.

Stretching/Ice:

Stretching helps guide the healing of the body, and helps tissue align properly. Stretching by itself rarely provides enough stimulation to cause significant healing of a tendon disorder. It is often prescribed as part of rehabilitation and pain management, yet relatively little is known about its effectiveness; a recent study showed that although stretching increases tolerance to the discomfort associated with the stretch, stretching did not change muscle extensibility in patients with chronic musculoskeletal pain49. Ice can have an analgesic effect and can reduce inflammation, but most times inflammation is not present in cases where symptoms are of longer duration (greater than 4-6 weeks).

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Surgery:

Performed by medical doctors (MDs). Most people consider surgery only as a last resort. The outcome can be unpredictable1. According to the American Academy of Orthopaedic Surgeons, surgery should be considered only in patients who have incapacitating pain that does not get better after at least six months of non-surgical treatment. Most of the surgical procedures involve removing diseased tendon tissue.

Ultrasound and Phonophoresis:

Delivered by physical and occupational therapists. Therapists use ultrasound equipment to deliver high frequency sound waves into the affected area. Multiple sessions are usually done. The wave energy results in local heating/warming of the tissues. Often a corticosteroid cream is applied to the skin over the affected area and this medication is pushed through the tissue with the ultrasound waves (this combination is known as Phonophoresis) There is little to no medical evidence that ultrasound is effective in the treatment of chronic tendon disorders50. Certain health insurance carriers are beginning to deny payment for this form of treatment.

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