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.
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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Understanding Tendinopathies of the Hip & Pelvis:
Falkirk, Scotland: 4th September www.vitalpm.com
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Brussels: 21st September http://www.mathera.be/en/content/ecmt-2017-european-congress-manual-therapy
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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.
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