1. Treating Tendinopathies
Physical Therapy
Treating Tendinopathies
Renee McKenzie, DPT

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

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

4. 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

5. 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

6. 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%

7. 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

8. Instrument-Assisted Manuals
ASTYM
Graston

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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 (2010): 3-16.
3: Chronic tendinopathy: effectiveness of eccentric exercise [Database of Abstracts of Reviews of Effects DARE ]. In: The Cochrane Library, Issue 3, 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):
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 (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: " N.p., n.d. Web. 30 Nov2011.
Table 3: " . N.p., n.d. Web. 30 Nov 2011