There are multiple potential causes of tendinopathy, so as you can guess, there are also multiple potential treatments. The most evidence-based treatment is progressive loading. There may be many reasons for this. Load may increase the ability or tolerance of the tendon by having an effect on pain mechanisms, tendon tissue function or neuromuscular function. Well thought out and individualised progressive loading is indispensable in the management of most tendinopathy patients. It often does not need to be fancy, but should target patient-specific functional deficits, taking the patient on a progressive exercise journey back to their functional goals.
Other common treatments for tendinopathy include massage, frictions, taping, braces, ultrasound therapy, laser, microcurrent, shockwave therapy, and various injections including blood product injections such as PRP, steroid, prolotherapy, high volume injections and many others. Some treatments are supported by evidence, some are not. If a treatment is not supported by evidence, it should at least be biologically plausible. It is startling how many treatments are used, even though evidence shows they do NOT work! Unfortunately, there are many factors that influence the treatments that patients are offered aside from evidence and biological plausibility, some good reasons, some not so good reasons (e.g. the size of the clinicians mortgage).
Here are some basic do’s and don’ts for managing pain. Remember, this is half of the equation, the other half is loading the tendon and person back to full function
Best ways to settle tendon pain
1) No substitute for reducing abusive energy storage activities such as walking running and jumping – sudden changes in these loads are potentially harmful. Sometimes this needs to be very aggressive eg limited walking completely in someone with Achilles pain related to walking loads. It may also need to be for up to 8 weeks if tendon pain is really flared up.
2) Tendon compression against bone can also be aggravating. A common example is compression of the Achilles insertion against the bone when performing a calf stretch (see photo). Reducing compressive activities may be necessary to manage pain. Top tips for reducing compression include sitting cushions for hamstring origin, knee pillows for gluteal tendon, and heel raises for Achilles and plantar fascia
3) Tape, braces and splints can help to reduce tendon compression and pain. There are great taping techniques for Achilles, plantar fascia, patellar and gluteal tendinopathies.
4) Anti-inflammatories are useful for reducing pain when pain has really flared up. This is when pain flares for days after energy storage activities and/or there is a high level of pain with daily activities such as walking, sitting, going up/down stairs, etc.
4) Modalities and manual therapy. Applying ice can provide short term pain relief, but is unlikely to influence tendon pathology. Manual therapy such as massage and frictions may reduce pain in the short term for some people.
5) What about nutrition? Although green tea and fish oils are recommended, there is no clinical evidence that they do any good. Maybe something in it, or may be placebo.
6) What about shockwave therapy? Although a fantastic pain modulator, shockwave seems much more effective among patents with less irritable/less severe symptoms. It can be counterproductive otherwise.
7) Some forms of tendon load can be very effective in managing pain. It seems counter-intuitive if we are also recommending reducing abusive load. However, mid range isometric loading of moderate intensity sustained for 45-60 seconds seem to have a hypoalgesic effect on tendon pain
Rees J, Maffulli N, Cook J: Management of Tendinopathy. American Journal of Sports Medicine. 2009, 37:1855-1867.
Rio E, Kidgell D, Moseley L, et al: Exercise to reduce tendon pain: A comparison of isometric and isotonic muscle contractions and effects on pain, cortical inhibition, and muscle strength. Journal of Science and Medicine in Sport. 2013, e28
Rowe V, Hemmings S, Barton C, et al.: Conservative management of Achilles tendinopathy: A mixed methods study, integrating a systematic review and clinical reasoning. Journal of Science and Medicine in Sport. 2012, 15:S97-S98
Gaida JE, Cook J: Treatment Options for Patellar Tendinopathy: Critical Review. Curr Sports Med Rep. 2011, 10:255-270.