Various physical therapies
in
TENDINOPATHY
Jakub Jeníček
Objectives
Definition of the clinical condition and diagnostics
Basics of patophysiology
Most common types
of tendinopathy
Goals of treatment
Various treatment approaches –
from conventional up to advanced ones
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Tendinopathy –
definition and diagnostics
primary disorder of the tendons –
common, often chronic, difficult
treatment
diagnosis is in most clinical
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activity-related pain, pain at rest
decreased function, ADL
stiffness of the tendon
localized swelling
palpable crepitations
muscle tone imbalances
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Tendinopathy – pathogenesis
repetitive or excessive mechanical
overloading and subsequent
activation of noxious mechanisms
tendon loses its reparative
capacity
inflammation and degeneration
work together in the pathogenic
cascade
confusion in terminology –
tendinitis / tendinosis /
tendinopathy
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Tendinopathy –
most common types
certain tendons are
especially susceptible to
degenerative pathology:
 rotator cuff in the shoulder
 forearm extensor tendons (tennis
elbow)
 forearm flexor tendons (golfer´s
elbow)
 patella tendon (jumper´s knee)
 Achilles tendon
 small feet muscles tendon
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Tendinopathy –
epidemiology
most commonly diagnosed musculoskeletal
disorders (Forde et al., 2005):
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tendinopathies (19%)
discopathies (18%)
shoulder bursopathies (15%)
carpal tunnel syndrome (12%)
sum of all other disorders (36%)
high lifetime prevalence in sportsmen
 tennis (40%!), volleyball (20%)
 squash, basketball, soccer, running, jumping, cycling
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Tendinopathy –
therapeutic intervention
in many cases remains uneffective –
especially when treatment is only analgesic
or anti-inflammatory monotherapy!
choice of adequate therapy:
 phase of disorder
- acute / chronic
- more inflammatory / degenerative nature
 goals of treatment...
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Tendinopathy –
Goals of treatment
analgesia
reducing inflammation
elimination of the swelling
tendon structure recovery (elasticity)
muscle normotonia, trigger points elimination
detection of primary causes of the disorder:
 muscle imbalance in segment, hypertonia
 incorrect movement stereotypes
 overloading activities, ergonomics
 other individual factors
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Tendinopathy –
range of treatments
numerous different types of treatment in literature
poor evidence base – mostly empirical findings
from clinicians
Conventional treatment
Advanced treatment
Non-steroidal anti-inflammatory
drugs, corticosteroids
Biomechanical alterations – braces,
taping, Kinesio-taping
Cryotherapy, Rest
Manual therapy techniques
Low-intensity laser therapy
Shockwave therapy
Therapeutic ultrasound
Electrotherapy, Iontophoresis
Stem-cell or gene therapy
Platelet-rich plasma
Sclerosant injections
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Tendinopathy –
treatment in acute stage
distinguish acute x chronic tendinopathy!
predominance of inflammation
pain, swelling, redness, crepitations
typically occurs after prolonged stereotypical work
(e.g. screwing)
treatment
 rest, cryotherapy
 orthotics – supportive braces, Kinesio-taping
 drugs – NSAId, antiphlogistics, corticosteroids
injections
 manual therapy techniques
 analgesic physical modalities – electrotherapy
– TENS, DD, interferential currents
 myorelaxant physical modalities – ultrasound
or combined therapy ultrasound + electro
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Tendinopathy –
clinical suggestions
most effective combination of physical modalities for
patient with acute tendinopathy:
analgesia
 electrotherapy – DD currents – sequence of DF (1 min.) +
CP (5 min.) x LP (6 min.), polarity reverse in the middle
myorelaxation
 ultrasound – subaqual application from the distance of 10
cm (1 MHz, 1 W/cm2, 20% duty factor)
 combined therapy (electro + ultrasound) for trigger points –
1 cm2 ultrasound head (3MHz, 0,5 W/cm2, 50% duty factor) +
large electrode (TENS, f 100 Hz, motor treshold intensity)
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Tendinopathy –
treatment in chronic stage
predominance of degeneration
pain, structural changes in tendon, stiffness,
dysfunction
typically occurs after long-term overloading and
microtraumatization (incorrect sport load, work
position)
treatment
 manual therapy techniques
 physical modalities to modify the structure
and promote healing of affected tendon:
 laser therapy (anti-inflammatory,
analgesic, biostimulation)
 shockwave therapy (analgesic,
reparative)
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Tendinopathy –
clinical suggestions
most effective combination of physical modalities for
patient with chronic (degenerative) tendinopathy:
analgesia and biostimulation, reparation
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laser therapy – focused with laser probe
1. dose 20 J/cm2, continuous frequency do deliver energy to
the tissue
2. dose 10 J/cm2, pulsed frequency to modulate desired
effect
structure modification and healing
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shockwave therapy – optimum 2 bar in pathologic spot,
2000 pulses with frequency 10 - 15 Hz
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Thank you for your
attention!
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