Tendinopathy – Does corticosteroid injection aid or hinder our rehabilitation process?

 

When physiotherapy treatment for tendinopathy fails, have you ever thought ‘Where did I go wrong?’ Assuming you have applied contemporary evidence informed protocols that incorporate load management and appropriate exercise therapy (e.g. avoiding compressive loading for insertional tendinopathies), there are a number of factors that may influence your success, including patient beliefs and compliance, systemic illness and psychosocial issues. Have you ever considered though that prior medical treatment may have had you fighting an uphill battle from the start?

If a patient with symptomatic tendinopathy presents first to a medical physician, the first line of treatment is generally a corticosteroid injection (CSI), due to their known effects on early pain reduction. Hopefully the patient is then also sent off to the physiotherapist or this may be delayed until the problem is demonstrated to be recurrent. A second or third CSI may then be provided to help the patient through the impending rehabilitation process. The physician is practising within the current evidence base and is trying to do the best by patient and the therapist, because surely a patient whose pain has been lessened with CSI will be more easily rehabilitated. Right?? Hmmm, maybe not…

 

Effects of exercise and CSI on tendon structure

Let’s consider the effects of both exercise and CSI on the intrinsic structure and function of a tendon. Khan and Scott (1) describe in detail the process by which exercise, via mechanical shearing of tenocytes between collagen fibrils, initiates a biochemical cascade that forms new collagen and matrix proteins, a process referred to as ‘mechanotransduction’. Kongsgaard and colleagues demonstrated both clinical improvements and positive structural changes within patellar tendons in response to heavy, slow resistance exercise (2). While rehabilitative exercise appears to have a positive effect on tendon structure, the same cannot be said of the effect of CSI.

The conclusions of a systematic review of the effects of local glucocorticoid on tendon (CSI) were as follows:
‘Overall it is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro, including reduced cell viability, cell proliferation and collagen synthesis. There is increased collagen disorganisation and necrosis as shown by in vivo studies. The mechanical properties of tendon are also significantly reduced. This review supports the emerging clinical evidence that shows significant long-term harms to tendon tissue and cells associated with glucocorticoid injections’ (3).

 

Effectiveness of physiotherapy intervention post CSI

Coombes, Bissett and Vicenzino (4) have found through their high-quality trials on lateral elbow tendinopathy, that while CSI engenders short-term pain relief, longer term recovery is delayed and outcomes reduced compared to a wait-and-see approach or physical therapy management. Perhaps even more relevant for our discussion here is the fact that the application of this same physical therapy intervention to participants who were first given a single CSI, did not have the same positive benefit. The physical therapy intervention did not manage to overcome the delay in recovery and recurrence observed after CSI. ‘For these reasons’, these researchers ‘do not advocate corticosteroid injection as a first-line intervention for lateral elbow tendinopathy’.

For lateral hip pain, a treatment review highlighted that in those surgical studies that reported prior treatment, patients that failed conservative management and progressed to surgery had all received at least one CSI, mostly 2-5 and some more than 20 injections (5). Were the injections provided because physiotherapy interventions failed or did physiotherapy intervention fail because patients were not referred for physiotherapy until after CSI and the CSI hampered the ability of mechanical loading to induce positive change within the tendon and improvements in pain and load tolerance? Too simplistic? … yes, probably, pain and the effect of any intervention is complicated, as is the relationship between pain and tendon structure. While the presence of tendon pathology is commonly noted in painfree individuals, structural change within a tendon is a strong risk factor for pain and links between tendon mechanical properties and pain have been established (2, 6).

From a clinical perspective, I have noted that of the hundreds of patients with gluteal tendinopathy treated within our clinic, there appears to be a pattern of diminishing returns from a load management and exercise therapy approach, apparently correlating with the number of CSIs a patient has undergone prior to treatment – the more injections, the more difficulty in achieving early and optimal outcomes (in patients who have no other known systemic or psychological drivers). There may possibly be pre-conceived bias in my observations; much further research is required to establish the interaction between mechanical and pharmaceutical interventions. The type of medication – long or short acting glucocorticoid and method of injection – intra vs extratendinous and blind vs ultrasound guided may impact on these effects. For now, despite some early effects on pain, considering the known potential negative effects of CSI on tendon health and longer term rehabilitative outcomes for certain tendons, Coombes et al’s stance on avoiding CSI as a first line intervention may be wisely adopted as a general principle in the management of tendinopathy, particularly in the case of chronic, degenerative tendinopathy.

 

Our challenge as physiotherapists

Our challenge as physiotherapists is to provide optimal, evidence informed management that delivers early change in pain and function, reducing the need for that early CSI. We must provide the medical profession with evidence that we can provide good early outcomes, without CSI. More high quality randomised controlled trials are required, but within your own multidisciplinary network you may be able to convince your referring physicians to give physiotherapy a try first with CSI as a backup, and see if you notice differences in your own outcomes.

 

Further Information

If you would like further information on the management of tendinopathies of the hip and pelvis, browse our online learning section and enrol on Understanding Tendinopathies of the Hip & Pelvis . There are also multiple opportunities around the world this year to attend the associated practical workshop. Alison has been involved in a large multicentre RCT on gluteal tendinopathy, with outcomes paper due out this year. Stay tuned for updates here on the website or on Linked In or twitter @alisongrimaldi

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Upcoming Practical Workshops
Click on the links below for further information and registration
Understanding Tendinopathies of the Hip & Pelvis:

Falkirk, Scotland: 4th September www.vitalpm.com
Leeds, England: 5th September www.vitalpm.com
Paris: 18th-19th September www.agence-ebp.com
Brussels: 21st September http://www.mathera.be/en/content/ecmt-2017-european-congress-manual-therapy
Sydney: Sunday 12th November www.dralisongrimaldi.com

 

About Dr Alison Grimaldi BPhty, MPhty (Sports), PhD:
Alison is Principal Physiotherapist at Physiotec, an Adjunct Research Fellow at the University of Queensland, and international speaker, presenter and workshop facilitator. With over 25 years of clinical experience, Alison is committed to supporting physiotherapists and allied health professionals by providing access to cutting-edge research, new products, and professional development opportunities. She is one of the few practitioners who combine ongoing scientific research with continued clinical practice, ensuring that physiotherapy research and treatment methods remain relevant to patient needs.

References
1. Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med 2009;43:247–251. doi:10.1136/bjsm.2008.054239
2. Kongsgaard M, Qvortrup K, Larsen J et al. Fibril morphology and tendon mechanical properties in patellar tendinopathy – effects of heavy slow resistance training. The American Journal of Sports Medicine 2010; 38 (4): 749-56. doi: 10.1177/0363546509350915
3. Dean BJS, Lostis E, Oakley T et al. The risks and benefits of glucocorticoid treatment for tendinopathy: A systematic review of the effects of local glucocorticoid on tendon. Seminars in Arthritis and Rheumatism 2014;43:570–576.
4. Coombes BK, Bisset L, Vicenzino B. Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. J Orthop Sports Phys Ther 2015;45(11):938-949. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5841
5. Lustenberger DP, Ng VY, Best TM, et al. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. 2011;21(5):447–53.
6. Lee WC, Zhang ZJ, Masci L et al. Alterations in mechanical properties of the patellar tendon is associated with pain in athletes with patellar tendinopathy. Eur J Appl Physiol. 2017;117:1039–1045. doi 10.1007/s00421-017-3593-1

Have you asked a patient to recruit their iliocapsularis recently? Ilio…what?

Yes, this is a real muscle and it may have an important function in joint and capsular protection. There is a rapidly growing evidence base for understanding function and dysfunction of the complex layered muscle synergies around the hip. The development of safe fine wire EMG techniques and reliable dynamic ultrasound imaging around the hip has seen an explosion of research into this fascinating area. We have recent information on deep gluteal and external rotator function, and now for the first time we have fine wire information on normal function of iliocapsularis. Early EMG findings for iliacus and iliocapsularis have been released today in our paper in Gait & Posture1. The landscape in this field is undergoing substantial change and is it important that physiotherapy assessment methods and exercise prescription reflect contemporary understanding in this field.

Iliocapsularis sits beneath the rectus femoris and has a substantial attachment to the anterior hip capsule. This anatomical relationship has led to suggestions from the available literature that this deep muscle may be important in joint stability and preventing capsular impingement during deep flexion tasks. Ongoing work at the University of Queensland will be able to shed more light on this over the next couple of years. Clinically, we find that working on activation of this muscle, together with the deep joint protection portions of iliacus can be very useful in the management of anterior hip pain. While iliacus is able to be palpated with careful hand position and awareness of surface anatomy, iliocapsularis is too deep to reliably palpate due to the overlying rectus femoris and sartorius. Real time ultrasound provides a perfect tool to visualize, assess size and recruitment and retrain iliocapsularis and all the deep joint protectors of the hip.

Further Information

In my online course, Dynamic Stabilisation of the Hip & Pelvis, we explore in detail the functional anatomy, patterns of dysfunction and implications for therapeutic exercise for the hip flexors, including the iliocapsularis. In the accompanying practical workshop, specific assessment and exercise techniques for the hip flexor group are taught. Real time ultrasound is used as a tool to visualise and retrain the deep hip flexors. This course does not require access to real time ultrasound in your clinical practice but uses ultrasound as an advanced teaching tool – great for your freshening up your anatomy and palpation skills!

I also run ultrasound focussed workshops, with one 4-hour workshop focussed on ultrasound assessment and muscle retraining around the hip

Enrol here

Visit    www.vitalpm.com  for information on my upcoming UK tour

Twitter: @alisongrimaldi for further infobytes

 

  1. Lawrenson P, Grimaldi A, Crossley K, Hodges P, Vicenzino B, Semciw A. Iliocapsularis: Technical application of fine-wire electromyography, and direction specific action during maximum voluntary isometric contractions. Gait & Posture 2017; 54: 300-303. http://dx.doi.org/10.1016/j.gaitpost.2017.03.027

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Are you still prescribing ITB stretches and clams for lateral hip pain?

It might be time for a knowledge update!

Painful tendinopathies are one of the most frequent musculoskeletal conditions with which patients present to physiotherapy clinics. Diagnosis can often be challenging, with hip and pelvic tendinopathies often masquerading as lumbar-referred or hip joint pain. A missed diagnosis or incorrect management plan can lead to delayed outcomes for our patients and loss of confidence & patronage for the physiotherapist.

How can I be confident of making the correct diagnosis for hip & pelvic tendinopathies?

The best solution is to keep your knowledge up to date! There has recently been substantial progress in the area of diagnosis for gluteal tendinopathy. In fact, I recently co-authored a paper on this topic in the British Journal of Sports Medicine! (include link to this) You can experience first-hand the practical application of these learnings at my May workshop: Understanding Tendinopathies of the Hip & Pelvis.  During the workshop, you will learn to skillfully perform the latest diagnostic tests for gluteal tendinopathy as described in the BJSM paper as well as a battery of clinical tests for proximal hamstring, iliopsoas, and adductor tendinopathies. These have been extensively road-tested in clinical practice.

 

Update your hip & pelvic tendinopathy management plans

Did you know prescribing ITB stretches & clams for lateral hip pain can often worsen symptoms and hinder progress?

The impact of hip tendinopathies can be profound: gluteal tendinopathy can have an impact equal to severe hip osteoarthritis; while proximal hamstring tendinopathy and groin pain can end sporting careers. Through ongoing research, we now know that some of the more traditional management approaches lack evidence base and can potentially be detrimental to a patient’s outcomes. Advances have been made in the general principles of tendinopathy management & these principles provide faster and better outcomes for our clients.  The Understanding Tendinopathies of the Hip & Pelvis workshop provides a step-by-step approach to implementing the latest evidence-informed and effective management strategies.

 

Find out more

Through my role as an adjunct research fellow with the University of Queensland, I’ve had the immense pleasure of being a key member in a major study involving the development of education and exercise strategies for the management of gluteal tendinopathy. This involved extensive testing in a large randomised controlled trial and we are excited by the outcomes. The results are due for publication in the coming months so be the first to know by subscribing for further updates.