Treating Tendinopathy

[21st century Physio]

Hi all,

At university we have been learning that tendinopathy treatment should be based around off loading the tendon (strenghtening weak synergists, correcting posture etc) and increasing the load capacity of the tendon through eccentric strenghtening.

We learnt that tendionopathy is degeneration within the tendon and that this degeneration results in increased vascularisation and consequently nerve supply to the tendon.

However we were taught that using ice was irrelevant as the tendinopathy itself is not an inflammatory condition. But wouldn't using ice decrease the blood flow and possibly decrease the amount of nerve endings in the tendon. This could decrease the pain?

Do you guys use ice as a means of decreasing pain in patients with tendinopathys? Is the ice used jsut after activity when there may be associated inflammation or throughout the whole day?

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[neurospast]

I was a little bit stunned by your description of tendinopathy. So I just had a look at the internet to be sure I am not going to write complete nonsense. (Just go on google or to med-line to look it up).
OK, according to my latin knowledge, which is sparse, Tendino-pathy means disease of the tendon and is none specific terminology alike lumbago. It is caused in general by overuse (short term/long term) and it has implications for the build up of the tendon, crosslinks name it. A reaction to the condition will be an increase of bloodvessels and likely an increase of nerve endings. This is a common response to injury. Tendinopathy has not necessarily as a symptom inflamation and more often not than it will have.
The use of ice has no influence on the inflamation since most likely it is not a problem. But a complete other effect of ice is pain control. an effect directly on nerve endings, look up which, which will decrease and normalise their firing speed.
You ask if ice would not decrease the bloodflow and decrease the nerve endings. Well Ice does increase bloodflow, but this is arguable, but will for sure within an application of 10-15 minutes have no effect on the amount of nerve endings.
To my opinion yes you can use ice and it could well be very beneficial. aside of stretching (rupturing crosslinks), strengthening synergist (off loading). But what about restoring balance between e.g. extensors and flexors?
Keep in mind that tendinopathy is just a general terminology which doesn't tell you anything about it's cause. which might have been poor bloodsupply in the first place!

[kripag]

well said neurospast,
indeed tendinopathy is a resultant /outcome condition we see, ... irrespective of the cause.
i think before you leap to pathological conditions you need to know your basic physiology... both structural as well as functional composition of the tendon/ligament/even muscle!
all i really understood was that the logic behing telling you to strengthen the synergists was to not only load-off/share the effort on the agonist, but also to correct any biomechanical anomalie which in the first place itself could haev been the cause of a repetitive type of tendinopathy! 2ndly via eccentric technique .. you never have any effect on the tendon... its the muscle which gains on long term eccentric training. also remember if your eccentric techniques are correct it in turn could lead to a very controlled/sustained pattern of muscle work/lengthenenig which in case of repetitive tendinopathic injuries is more crucial.
in tendinopathy... tehre is degeneration at the structural level.. there are many cross links formed that hamper the normal functioning of the tissue, like in all inflammatory processes there is an incerased vascularity, also in tendinopathy never have i learnt or come across an increase in the neural tissue.. it is the sensitivity to the chemical substances released in inflammation that causes pain.remember your number of free nerve endings that perceive pain/noxious stimuli never incerase on account of inflammation like stimuli.
normally by the time the patient comes to you with a picture of tendinopathy.. quite often than not after being diagnosed by a consultant come to you for therapy/rehab. ... by this time the case has lapped into the chronic phase.... so now ask your self... cryotherapy is used is acute or chronic cases?... you will get your answer.
now comming to using ice/cryo in the first place itself... when in the acute phase of injury.... it will work!... like our friend neurospast has said it.... ice will incerase the flow of blood to that area by a phenomenon called "lewis hunting response/ reaction" the means by which it reduces pain is by the pain gate mechanisim and by simple wash out of pain causing neurotransmitters /substance P by vasodialatation.
And the answer to you last query: "Do you guys use ice as a means of decreasing pain in patients with tendinopathys?"
is : YES i do use cryo for all ACUTE conditions, it gives me immidiate response wrt pain releif and reduced soreness
thus more comfort to the patient.but when a chronic one rolls in i prefer the good old U.S. and some warmth for relieving the reflexive spasm i see around the damaged tissue.
and last but not the least the golden rule says never use prolonged cryo...esply in acute cases ... you will worsen the whole thing! and probably never get your patient back!
i hope i have not been too long and boring.....

[kripag]

P.S : i think the following link will be usefull to you:
www.clinicalsportsmedicin...endon.html
or
clinicalsportsmedicine.com

[marj]

I agree with the others. Tendinopathy merely means pathology of the tendon. The true debate is tendinitis vs tendinosis. Karim Khan of UBC has posted a chapter re same on the internet, from his sports medicine book. I don't have the link. He has written extensively re tendinosis, which is the condition that was described in the first post. Karim is quick to point out inflammatory cells have never been found in human tendons without inflammatory conditions such as rheumatoid arthritis.

In my clinical experience, some people do present with an acute inflammation related to a specific incident.

His primary point is that chronic tendon pain is not likely to be tendinitis. Hope this helps. Marj

[alophysio]

Hi.

Firstly, in defence of 21st Century Physio, Alfredson and his researchers have found the presence of increased new blood vessels in cases of mid tendon tendinopathy. They (I think) have also found that glutamate and not prostaglandin E2 is predominate in tendinopathies. Glutamate is a central sensitiser.

The thought behind eccentric exercise is that perhaps it stretches these new blood vessels and their accompanying neural supply - they found less vascularity after a programme of eccentric exercises in the Achilles Tendon.

Secondly, stretching changes the mechanical properties of both the tendon and muscle and in a muscle like the gastrocs, the length changes can be x4-10 more than the length change in the muscle (see Kubo et al various studies). So it is possible that the stretching effect of eccentric exercises via the various soft tissues changes the tendon.

In response to 21stCPhysio's question about using ice, i do use ice but not to assist the tendinopathy - more for the other muscles and tissues that are strained during the exercises and for pain relief!

That's my 2 cents worth, I hope it helps