A Brief Synopsis of AFP's "Management of Chronic Tendon Injuries"

A brief synopsis of:

Management of Chronic Tendon Injuries

MARC A. CHILDRESS, MD, Fort Belvoir Community Hospital, Fort Belvoir, Virginia

ANTHONY BEUTLER, MD, Uniformed Services University of the Health Sciences, Bethesda, Maryland

Am Fam Physician. 2013 Apr 1;87(7):486-49

http://www.aafp.org/afp/2013/0401/p486.html

     Most chronic tendon injuries tend to be from overuse (and I have a left elbow to prove it). These areas typically have a poor blood supply with collagen separation and degeneration.  Rather than bleeding and inflammation, the pain is mediated by glutamate and non-prostaglandin pathways. NSAIDs are considered first line medication but there is little evidence to support this, and the side effects (GI, renal, and cardiovascular issues) outweigh the benefits. In general, steroid injections may provide short term pain relief, but long term benefit has not been proven.
     There are two types of Achilles tendinopathy; midsubstance and insertional.  Midsubstance tendinopathy is located approximately in the middle of the Achilles tendon. First line treatment is eccentric strengthening of the gastrocnemius and soleus. This article has a nice table and picture of the exercise, which appears to be a modified calf raise. The classic therapies (ultrasound, electric stimulation, massage, surgery and stretching) have not been shown consistently to improve long term function. Insertional tendinopathy is located distal to the midsubstance injury, near the insertion of the Achilles. Eccentric stretching is not as helpful, but has shown benefit in about 30% of these injuries. The patient should also be in a walking boot for 4-6 weeks.
     Eccentric exercise is a first line treatment for patella tendinopathy, which consists of a type of slow knee bend (please see figure 3 of this article). This has been shown to be of greater benefit than surgery or injections of sclerosing agents.
     Lateral epicondylitis is pain that can be reproduced by forearm extension and pronation against resistance. The best therapy here is wrist extensor strengthening and stretching. Steroid injection provide short term pain relief, but may affect long term cure rates. Studies have shown benefit with autologous blood and platelet-rich plasma injections, as well as nitroglycerin patch.
     Rotator cuff tendinopathy can be caused by repetitive actions of throwing, lifting, and overhead motions. Imagining is helpful to determine the extent of the injury and to rule out a possible tear. The main therapy is strengthening the rotator cuff, stabilizing the scapula, and increasing range of motion  Steroid injections can be used to help relieve pain during therapy, but the location of injection may not be important.
     Prolotherapy is the injection of irritants to induce healing. Examples are dextrose, autologous blood and platelet-rich plasma. Other therapies  such as lasers, phonophoresis, ultrasound and iontophoresis have had mixed results and are not a substitute for first line therapy.