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[ editorial ]

Tendinopathy:
Evidence-Informed Physical
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Therapy Clinical Reasoning


BILL VICENZINO, PhD
The University of Queensland, School of Health and Rehabilitation
Sciences: Physiotherapy, St Lucia, Australia.
J Orthop Sports Phys Ther 2015;45(11):816-818. doi:10.2519/jospt.2015.0110

P
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

atients presenting with pain at the tendon, which is associated are canvassed in this special issue: (a)
with physical tasks and activities that specifically load that symptom-guided management,19 (b)
tendon, are at the center of this special issue. In a classical symptom-modification management,3,9
(c) compressive versus tensile loads,7 (d)
medical model, an understanding of the underlying pathology stages of loading throughout the reha-
is deemed desirable in guiding medical management. There is some bilitation process (isometric and isotonic
difficulty in applying this model to symptomatic tendons, mainly strengthening, energy storage and re-
because the pathology of symptomatic tendons has not been clearly lease, return to play),11 and (e) what I will
refer to as movement competency.3,11,20
Journal of Orthopaedic & Sports Physical Therapy®

elucidated (see Scott et al17 herein). Com- complete removal of offending activities Essentially, these concepts emphasize the
plicating matters further is the mismatch and the introduction of appropriate and need to optimally load the tendon—in a
between reported pain (and disability) graduated loading exercises. To be effec- way that does not provoke pain—by us-
and imaging (and pathology), as well as tive, this requires patient buy-in, which ing symptom-modification procedures3,9
evidence of widespread sensory nervous is critical for the physical therapist to ob- or by limiting the joint position to one
system sensitization in some tendinopa- tain. Patient buy-in involves the clinician that does not compress the insertion of
thies.14 As Scott et al17 explain, the current educating the patient about the nature of insertional tendinopathies.3,7 In the lower
terminology for a symptomatic tendon the tendinopathy, its relationship to load- limb (Achilles tendon, patellar tendon), it
presentation is tendinopathy, as this does ing, and the likely recovery trajectory. As appears that pain up to 5/10 on a numer-
not denote an underlying pathology, but the patient learns the fundamental as- ic rating scale during and after training
rather signals that all is not well in the pects of tendinopathy, it is imperative that is not harmful and may be desirable.11,19
tendon. In contrast to the uncertainty the physical therapist implement an indi- Most authors indicate that pain and stiff-
surrounding the underlying pathology vidualized exercise program. This exercise ness within the 24 hours following train-
and pain mechanisms of tendinopathy, a program should be adequately supervised, ing, notably the next morning, are to be
diagnosis of tendinopathy is reasonably reviewed, and progressed to ensure ad- noted, and, if worse, may be indicative
easy to make clinically, on the basis of herence and resolution of the tendinopa- of overload and require commensurate
localized pain over the tendon that is as- thy. The importance of this approach is modulation of the rehabilitation loads.11,19
sociated with loading of the tendon. emphasized by all authors of the articles A fundamental tenet that has held fast
The consensus is that management on tendinopathies covered herein.3,6,7,9,19 in orthopaedic physical therapy for many
of tendinopathy should optimally in- Contemporary practice in managing decades has been that isometric contrac-
volve addressing loading of the ten- tendinopathy necessitates the physical tions in early acute painful phases of
don.3-5,7-9,11,18,19 Management of load in therapist exploring the nexus between an injury reduce stress on injured joint
tendinopathy, especially if acutely pain- symptoms (predominantly pain) and structures. As the condition resolves,
ful, usually commences with reduction or loading. In this regard, several concepts the practice has been to switch to iso-

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tonic resisted exercises to build muscle terns of the physical tasks associated tion program, there is a view that imag-
strength (hypertrophy) and endurance. with the tendinopathy. The concept of ing, such as ultrasound, can be used in
It appears that this approach is also valid movement competency is also empha- the physician’s offices to guide invasive
for the management of tendinopathy,11 sized in the papers on the management medical treatments.1 It is apparent from
especially in the acute painful stage, with of gluteal, patellar, and lateral elbow ten- research of imaging in tendinopathies
recent evidence showing that high-load dinopathy herein.3,7,11 Careful evaluation that (a) imaging-identified tendon pa-
isometrics may relieve pain and, as such, of movement and implementation of an thology exists in asymptomatic persons,6
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may be good to implement early in the re- individualized patient-specific exercise (b) a patient’s recovery can occur without
habilitation program.15 In the early acute program require regular physical thera- reversal of imaging-identified tendon pa-
painful stages of insertional tendinopa- pist oversight throughout the rehabilita- thology,16 and (c) there is no identifiable
thies in particular, isometric and isotonic tion period, as well as the monitoring of pathology of significance in some cases
exercises are performed in positions that progress with valid outcome measures.10 of tendinopathy.1,6 This underpins a case
do not compress the insertion (eg, move- Recently, a range of techniques have for the interpretation of imaging to be
ment past neutral toward hip adduction been introduced that could be termed made in context of the patient’s history,
is avoided for gluteal tendinopathy),7 be- symptom-modification techniques or symptoms, and clinical signs. The role of
cause compression is usually provocative. procedures. Such procedures seek to imaging has been increasingly interrogat-
Managing tendinopathy with isometric reduce symptoms substantially, if not ed, compelling the inclusion of a specific
contractions in non–pain-provocative totally, in concurrence with their appli- paper on this topic in this special issue.1
positions might also ameliorate sensory cation. For example, these procedures As outlined by authors in this spe-
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

nervous system involvement that is pres- may involve (a) instructing the patient cial issue, tendinopathy is a prevalent
ent in some tendinopathies.14 The fad to move differently (using visual, verbal, and substantial problem, as it interferes
of giving all patients with tendinopathy and/or manual cues, as in “lean forward with a person’s capacity to lead a physi-
an eccentric exercise program from the with the trunk during landing”20); (b) cally active and healthy life, which has
outset has largely abated; however, after manual handling, as with Mulligan’s mo- a considerable flow-on effect on society
adequate strength of the muscle has been bilization-with-movement techniques3; in general. This issue deals with the con-
achieved, it is necessary to use eccentric or (c) use of tape or belts (external physi- temporary physical therapy management
exercises to reinstitute the energy-stor- cal devices), such as taping the scapula to of tendinopathy by providing a mix of evi-
age/return capacity of the musculotendi- improve arm elevation, as in the article dence review and clinical expert opinion
Journal of Orthopaedic & Sports Physical Therapy®

nous complex before moving to complex by Lewis et al9 published in this special on commonly presenting tendinopathies
sport-specific tasks.2,11 issue. If, on application during the prob- of the lower limb (ie, Achilles tendon,19
Movement competency refers to the lematic movement/task, the movement is patellar tendon,11 gluteus medius and
optimal usage of body segments and as- pain free, then it can be used to enable minimus tendons7) and upper limb (ie,
sociated muscles to perform movement exercise that specifically loads the ten- shoulder9 and lateral elbow tendons3).
efficiently, and is mainly about the form don. It is my contention that symptom- These papers are supported by updates
and shape (posture and alignment) with modification procedures are most helpful on clinically relevant matters pertaining
which a physical activity is performed. In when the patient can self-apply them. to exercise in tendinopathy,4 pathology,17
this special issue, we have included a case The symptom-modification approach is diagnostic imaging,6 sensory sensitiza-
report of an athlete with patellar tendi- a valuable tool to enhance patient buy- tion,14 and outcome-measure consid-
nopathy who was successfully treated by in and improve adherence to the exercise erations.10 In addition to these clinical
correction of landing technique from a program. It may also be a strategy to ad- commentaries and research reports, with
jump, as well as by addressing the weak- dress nervous system sensitization.14 the aim of enriching and enlivening their
ness in the gluteal muscles, which was Given that tendinopathy is reason- contributions, we have sought editorial
considered to be associated with the ably easy to recognize clinically, diag- commentaries on the implementation
initial poor landing mechanics.20 The nostic imaging (eg, ultrasound, magnetic of evidence in clinical practice,13 the
authors of the case propose that there resonance imaging) is advisably best un- disconnect between structural changes
was weakness of the hip extensors and dertaken when (a) the case is compli- and symptoms,16 the physician’s perspec-
poor control at the hip proximally during cated/complex and long-standing, (b) tive on imaging,1 and a salient reminder
landing, which contributed to the patel- an appropriate rehabilitation program to not treat all tendons the same way.12
lar tendinopathy through abnormal load- has failed, or (c) a thorough clinical ex- Contemporary clinical physical therapy
ing. This case serves as a good example amination has identified differential di- practice requires that the clinician be
of the need for the physical therapist to agnoses in need of exclusion. In clinical apprised of the current evidence, while
evaluate and address the movement pat- cases that fail an appropriate rehabilita- negotiating with the patient to provide

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[ editorial ]
the most appropriate rehabilitation for pathomechanics and implications for as- commonly presenting and persistent painful
the specific tendinopathy. I commend sessment and management. J Orthop Sports tendinopathies: a systematic review. J Orthop
this special issue of JOSPT for the treat- Phys Ther. 2015;45:910-922. http://dx.doi. Sports Phys Ther. 2015;45:864-875. http://
ment of tendinopathy and trust that it org/10.2519/jospt.2015.5829 dx.doi.org/10.2519/jospt.2015.5895

will prove useful in this regard. t


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http://dx.doi.org/10.1136/bjsm.2008.054239 http://dx.doi.org/10.1136/bjsports-2014-094386
Downloaded from www.jospt.org at Mugar Memorial Library on September 28, 2016. For personal use only. No other uses without permission.

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Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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Journal of Orthopaedic & Sports Physical Therapy®

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