Management & Treatment

• Advice & Education:

  • explain what is wrong and what the patient can expect
  • address fears and unhelpful beliefs
  • relative rest, encouragement of early and safe return to activity
  • discuss likely frequency/duration of treatment, self management plan
  • discuss patients goals, treatment options and encourages shared decisions
• Symptom control:

  • ask about pain control
  • possible use of passive modalities
  • consider analgesics (via qualified provider)
  • 24 hour pain response
• Build capacity:

  • Address:
  • strength deficit
  • progressive loading
  • Apply clear evidence based principles of exercise dose and progression
• Return to function:

  • Advanced rehab
  • functional/sport specific exercises
  • increase load
  • consider appropriate level and time for return to function (particularly with high performance activities)
  • maintenance programmes
• Management:

  • EXERCISE IS BEST EVIDENCED – no optimal protocol
  • Managing the load – art > science
  • Timing is important – rest v. load
  • Isometric, concentric, eccentric, plyometric
  • Education on load self-management
  • Biopsychosocial factors important
  • Pharmacological agents as adjuncts
  • Other modalities only supportive, low evidence mostly
  • No magic bullet with any treatment, not everyone responds
• Biopsychosocial components:

  • Fear avoidance
  • Catastrophising - will my tendon rupture?
  • Inhibitions - kinesiophobia
  • Individual and personal traits
• Exercises for tendinopathy- is there a best way?

  • GRADED PROGRESSIVE EXERCISE, LOADING, STRENGTH
  • Complete unloading is bad for tendons
• Exercises for tendinopathy- is there a best way?

  • Heavy Isometric in pain free range
  • Eccentric exercise
  • Heavy, slow, Isotonic (concentric-eccentric)
  • Plyometric/power/Stretch-shortening cycle component
  • Appropriate recovery periods
  • Kinetic chain
  • Other adjuncts eg meds, ESWT, education
• Decision making in exercise prescription:

  • if its irritable, the target is pain
  • if its non irritable, the target is function & load capacity
  • if its degenerative, the target is structure
  • if its neuromotor deficits, the target is biopsychosocial
• Decision making in exercise prescription - What stage is it at?

  • Tolerance to loading – volume / duration / frequency
  • Problem is not homogenous
  • Can’t give same to all – but principles are the same
  • Can we address modifiable factors?
• Treatment strategies

  • Early modification of activity then progressive loading
  • Use pain monitoring model to guide:
  • anything from 0 - 2 is safe to do
  • anything from 3 - 5 needs to be monitored carefully
  • anything from 5 - 10 is to be avoided

  
• Summary:

  • Overload trigger, underpinned by possible intrinsic components such as weakness, genes, etc
  • Definitive theory on pathology still uncertain
  • Exercise is best treatment … but not for all
  • Consider biopsychosocial factors in many
  • Prognostic outcomes slow
  • Ensure to re-educate and rehabilitate to completion beyond the relief of pain