Treating Tendinopathies Physical Therapy Treating Tendinopathies Renee McKenzie, DPT

Modalities and Treatments Stretching Ultrasound Iontophoresis Phonophoresis Low-level Laser Eccentric exercise Instrument-Assisted Manuals ASTYM Graston

Ultrasound, Iontophoresis, Phonophoresis Evidence supporting the use of ultrasound, iontophoresis or phonophoresis in combination with other treatments, or as the sole treatment, is lacking

Low-Level Laser Level of effectiveness may be dependent on dosage A review of 13 randomized placebo-control trials (730 patients) for the treatment of lateral elbow tendinopathy1 Significant improvement seen with tendon application 904nm and possibly 632nm Tendon application of 820nm and 1064nm; unable to establish effectiveness A review of 25 controlled clinical trials 12 showed positive effects and 13 were inconclusive or showed no effect2 The review failed to state what dosages were used, only that the 12 studies with improvement followed current dosage recommendations

Eccentric Strengthening Though results are promising, further research is needed to determine the level of effectiveness A review of 11 RCTs (443 tendons) assessing the effectiveness of eccentric exercise concluded that “there is a lack of high‐quality evidence to support the effectiveness of eccentric exercise in comparison with other treatments for relieving pain and improving function or satisfaction in patients with tendinopathies.”3 Eccentric exercise remains a favorable approach. They are simple to perform and provide a cost effective, safe and efficient way to treat tendinosis.4 Despite the lack of evidence, eccentric exercise has the strongest evidence of efficacy.5

Eccentric Strengthening Author, year Groups No. of participants Length of study/follow-up (weeks) Satisfactory and back to pre-injury activity Fahlström, Martin et al., 20036 Chronic Achilles tendinosis mid-portion 78 (101 tendons) 12 89% Chronic insertional Achilles tendon pain 30 (31 tendons) 32% Maffulli, Nicola et al., 20087 Tendinopathy of the Achilles tendon 45 (45 tendons) 60%

Eccentric Strengthening Studies that included Eccentric Training as an intervention for Lateral Elbow Tendinopathy Author, Year Design Groups (sample size) Training protocol, location Length of study, follow-up (weeks) Outcomes Differencea at longest follow-up Svernlov, 2001 Randomized pilot study 1. Stretching (n=15) 2. Eccentricb training, stretching (n=15) 3 sets of 5 slowly twice daily 12, 52 VAS (pain), subjective change, MG Yes (subjective) Martinez-Silvestrini, 2005 RCT (stratified for gender) 1. Stretching (n=28) 2.Concentricb training, stretching (n=26) 3.Eccentricb training, stretching (n=27) 3 sets of 10 slowly once daily 6, 0 VAS (pain, PFG, patient satisfaction, function No Croisier, 2006 NRCTc 1. Physiotherapyd (A) (n=46) 2.Eccentrice training, physiotherapyd (A) (n=46) 3 sets of 15 slowly 3 times weekly 9, 0 VAS (pain), isokinetic strength, disability Yes (all outcomes) Stasinopoulos, 2006 NRCT 1. Cyriaxf (n=25) 2. PPNL (n=25) 3. Eccentricb training (n=25) 4, 28 VAS (pain, function), PFG Note. RCT, randomized controlled trial; NRCT, non-randomized controlled trial; VAS, visual analogue scale; MG, maximal grip; PFG, pain free grip strength; PPNL, Polarized polychromatic non-coherent light. amore favorable outcome in eccentric group compared with other group(s);bwrist extensors;cmatched for age, gender, activity;dice, transcutaneous electrical stimulation, friction massage, wrist extensor stretching;ewrist extensors, elbow supinators;fdeep friction massage, Mill’s manipulation. Table 1

Instrument-Assisted Manuals ASTYM Graston

ASTYM Developed in the mid 90’s Set of three acrylic instruments Who can be certified Physical Therapist Physical Therapist Assistant Occupational Therapist Certified Athletic Trainer

ASTYM Outcome Reports All Diagnostic Categories Total Cases Avg # of ASTYM Tx Improved Same Worse Shoulder Girdle Biceps tendinopathy 41 8 82.9% 14.6% 2.4% Impingement/tendinopathy of rotator cuff 123 91.9% 5.7% Elbow/Forearm Lateral epicondylosis 1125 10 90.7% 9.0% 0.4% Lateral epicondylosis + carpal tunnel syndrome 48 9 89.6% 10.4% 0.0% Lateral epicondylosis + medial epicondylosis 86.2% 13.0% 0.8% Medial epicondylosis 168 93.5% 4.8% 1.8% Other tendinopathy of forearm (sprain/strain forearm) 99 92.9% 7.1% Knee Patellar tendinopathy 110 7 87.3% 12.7% Shin, Ankle & Foot Achilles tendinopathy 316 94.6% 5.1% 0.3% Plantar fasciopathy-heel pain 958 7.6% 0.5% Shin splints-tendinopathy of tibialis anterior, tibialis posterior, peroneal tendinopathy 93 95.7% 4.3% Table 2

Graston Technique Developed in the mid 90’s Set of six stainless steel instruments Who can be certified Physical Therapist/Physiotherapist Occupational Therapist Chiropractor Certified Athletic Trainer Medical Physician Dentist Osteopath Podiatrist Selected Canadian Registered Massage Therapists

Graston Technique Outcome Data Injury Average # of Treatments Complete 100% Excellent 90%+ Good 80%+ Fair 70%+ Unchanged less than 70% Success Rate  Achilles Tendinitis 8 4 73 15 92  Ankle Sprain 6 52 24 12 82  Plantar Fasciitis 7 2 44 11 19 70  Patella Femoral Syndrome 5 42 71  Cervical Pain 49 29 13  Low Back Pain 35 87  Fibromyalgia 10 31 81  Hip Pain 9 30 50 88  Hamstring Strain 58  ITB Tendinitis 64 18  Lat Epicondylitis 90  Med Epicondylitis 27 20 33 60  Rotator Cuff Tendinitis 14 40 38 3  Adhesive Capsulitis 55  Carpal Tunnel Syndrome 21 86  Wrist Tendinitis 46  Scar Pain 54  * = Median # of treatments   Success Rate: Percentage of Resolution equates to attaining the patient/clinician goals of            1) increase in function            2) decrease in pain. Table 3

Things To Consider Due to the lack of high-quality evidence, the ideal physical therapy treatment/modalities for tendinopathies remains unclear Eccentric exercise currently has the strongest evidence of efficacy Newer approaches such as ASTYM and Graston are producing results worth noting

References 1: Bjordal, JM, RA Lopes-Martins, J Joensen, C Couppe, AE Ljunggren, A Stergioulas, and MI Johnson. "A systematic review with procedural assessments and meta‐analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow)." BMC Musculoskeletal Disorders. (2008) 9:75 2: Tumilty, s, J Munn, S McDonough, DA Hurley, JR Basford, and GD Baxter. "Low level laser treatment of tendinopathy: a systematic review with meta-analysis.." Photomedicine And Laser Surgery . 28.1 (2010): 3-16. 3: Chronic tendinopathy: effectiveness of eccentric exercise [Database of Abstracts of Reviews of Effects DARE-12007005641]. In: The Cochrane Library, Issue 3, 2011. Chichester, John Wiley & Sons Ltd. Abstract of: Chronic tendinopathy: effectiveness of eccentric exercise. Woodley, B L; Newsham‐West, R J; Baxter, G D. British Journal of Sports Medicine 2007:41(4): 188-199 4:Van Usen, C, and B Pumberger. "Effectiveness of eccentric exercises in the management of chronic Achilles tendinosis." J ALLIED HEALTH SCI PRACT. 5.2 (2007): 1-14 5: Kaeding, Christopher, and Thomas M Best. "Tendinosis: Pathophysiology and Nonoperative Treatment." Sports Health: A Multidisciplinary Approach . 1.4 (2009): 284-9 6: Fahlström, Martin, Per Jonsson, Ronny Lorentzon, and Håkan Alfredson. "Chronic Achilles tendon pain treated with eccentric calf-muscle training.." Knee Surgery, Sports Traumatology, Arthroscopy. 11. (2003): 327–333. 7: Maffulli, Nicola, Gayle Walley, Murali K. Sayana, Umile Giuseppe Longo, and Vincenzo Denaro. "Eccentric calf muscle training in athletic patients with Achilles." Disability and Rehabilitation. (2008 Table 1: Malliaras, Peter, Nicola Maffulli, and Giorgio Garau. "Eccentric training programmes in the management of lateral elbow." Disability and Rehabilitation. (2008) Table 2: "http://www.astym.com/asp/marketing.aspx." http://www.astym.com. N.p., n.d. Web. 30 Nov2011. Table 3: "http://www.astym.com/professionals/process.asp." . N.p., n.d. Web. 30 Nov 2011