Full article: http://dx.doi.org/10.1136/bjsports-2019-101611
Tendinopathy (tendon pain) is very common. They are the most common type of overuse injury (ref). Achilles tendinopathy affects the majority of runners (ref) and is the reason 16% of athletes have to stop sports participation (ref).
There are a range of commonly prescribed treatment options for tendinopathy, but very few are supported by quality, randomised, prospective, placebo-controlled trials.
SO WHAT DO I DO?
Considering all the available treatment options, above anything else, I always recommend:
WHAT ABOUT INJECTIONS?
Having mapped out a management plan, patients will routinely ask my opinion on getting an injection. They may have had a friend for whom an injection worked well, or the GP has suggested it as an option, or they’ve had one before and it worked.
There are a range of drugs to inject into or around a tendon, depending on who you are referred to:
Corticosteroids are an anti-inflammatory medication injected around the tendon to decrease pain that is caused by inflammation (although it is now thought that inflammation does not play a significant role in tendon pain). Corticosteroid injections have historically been commonly prescribed but more recently their use is controversial. Repeated corticosteroid injections can weaken the tendon and increase the risk of rupture. Corticosteroid injections are good at relieving pain in the short term (2-6 weeks) however, there is strong evidence that long-term outcomes (> 6 months) are worse than other conservative treatments or no treatment at all (ref).
PROLOTHERAPY / SCLEROTHERAPY
Prolotherapy injections act as an irritant causing an inflammatory response then scarring of the nerves that transmit pain. There is no solid support in the medical literature for this procedure for the treatment of tendinopathies. A randomised controlled trial of polidocanol injections showed the potential to reduce tendon pain in patients with chronic painful mid-portion Achilles tendinopathy (ref). However, a systematic review found limited results for use of prolotherapy in sports related soft tissue injuries (ref).
AUTOLOGOUS BLOOD INJECTIONS
The rationale of autologous blood injection consists of enhancing tendon healing through collagen regeneration and the provision of cellular mediators. Good experimental models are lacking, and clinical application is anecdotal. A 2013 randomised controlled trial investigating the efficacy of autologous blood injections as a treatment for mid-portion Achilles tendinopathy concluded they did not reduce pain or improve function any more than a strengthening program. (ref)
The suggested mechanism of high-volume injections is the mechanical disruption of local tissues then stimulates a healing response. One study (ref) has shown that high-volume injection of normal saline solution, corticosteroids or anaesthetics reduces pain and improves short and long-term function in patients with Achilles tendinopathy. However, more research is required.
PLATELET RICH PLASMA (PRP)
Platelets are naturally occurring in your blood, where they play an important role in healing damaged tissue, so superficially it’s inherently appealing to just add more of them to the sore spot. PRP injections are particularly trendy at the moment and it’s easy to find someone who will tell you they work well. Unfortunately, research concludes there is no benefit to PRP injections. This study found PRP injections do not improve plantar fasciopathy pain or function. This study concluded there is insufficient evidence to support the use of PRP for treating musculoskeletal soft tissue injuries. This systematic review found strong evidence against platelet-rich plasma injections for tennis elbow. This study found PRP did not improve tendon structure. This meta-analysis found no greater clinical benefit of PRP over placebo or dry needling for tendinopathy.
Would I have any of these injections, or would I recommend them to my patients, friends, or family? Well it depends. In my experience some people get some benefit some of the time. HOWEVER, these injectables are not consistently effective and their use is mostly not supported by research. I suggest that patients try the strengthening program and the results will be overall better in the long term.
WHY DO THE INJECTIONS WORK FOR SOME PEOPLE?
I’ve been frustrated with a couple of patients that cancelled their follow-up appointment and, when I phoned and asked what had happened, they’ve had an injection and now feel fine. My conclusion is the injections don’t work, but if you were sore and now you’re not, your conclusion would be they do work. So what is it?..
REGRESSION TO THE MEAN
Most people seek treatment when they are at their worst. By definition the only possible change from being as bad as at can be, is an improvement. Was it the injection working, or was it getting better anyway?
Some conditions are self limiting and will just get better by themselves. Did the injection work, or was it about to get better anyway?
I understand that getting an injection seems like a much easier option than doing 12-weeks of strengthening exercises, but in the long run, a strengthening program is the thing that actually works.
If treating tendon pain was as easy as getting an injection then that’s what everyone would do first. Unfortunately it’s not as easy as that.
Have you had an injection for your tendon?
COVID-19 is presenting an unprecedented challenge. Australians are being asked to take measures that we’ve never had to before.
You may be wondering how this affects your physiotherapy treatment?
The Prime Minister has confirmed specifically that physiotherapy is deemed an essential service. In addition, the Health Minister also encouraged private practices to remain open, as it will reduce demand on general practice and the hospitals if patients can still see their physiotherapist for their musculoskeletal and acute care management.
As such, Fit As A Physio is currently staying open to continue offering quality care to my clients.
There are many things I am doing as a registered health professional to minimise risk of exposure, through rigorous hygiene practices, and patient screening to keep you safe. So, you are welcome to come in for your treatment, subject to the following screening process:
If you answer “yes” to any of the above:
PROTECT YOURSELF AND OTHERS BY STAYING HOME AND CONTACTING YOUR LOCAL GP.
I have recently completed the Department of Health's "COVID-19 Infection Control Training". I have reviewed all clinic hygiene practices, to ensure optimal safety and care for every person who attends the clinic and have made the following changes:
If you are in self-isolation or would prefer to minimise contact in any way, you may like to consult with me via video. "Telehealth" uses technology that’s readily available on your computer or phone to receive assessment, diagnosis, and rehab prescription. FaceTime, Skype, or PhysiApp are easy options. The standard consultation via telehealth is $39/15mins.
If you would like to talk to me about commencing or continuing your physio through Telehealth, please phone 9969 6925, email email@example.com, or book online here.
Stay safe and well.
Sports & Exercise Physiotherapist
Fit As A Physio | MOSMAN
THE PROBLEM WITH SCREEN TIME
Around 30% of patients I treat have a complaint that is caused by prolonged sitting, commonly in front of a screen. This is mostly neck and back pain caused by things like; getting stuck at the desk too long, long commutes, long-haul flights, binge watching Netflix on the lounge, or looking at the iPad in bed.
This is a relatively new activity for humans and we're just not used to it. From an evolutionary point of view, we're just not adapted to sitting still all day. We've had 100,000 generations of hunting and gathering, moving around, doing different things all day. We've had 50 generations of agriculture, and only 10 generations of industry, where we're expected to sit and do the same repetitive task for prolonged periods of time. We're just not used to staying still from 9-5. Our bodies have evolved to move and be used. Staying still makes us sore.
NOW, WORSE THAN EVER
COVID-19 has caused a unique moment in time, with unprecedented social and workplace disruption. Never before have so many people been required to work from home. People are working at the dining table or kitchen bench. People are on their laptops on the lounge or in bed. The home set-up isn't ideal.
Also, some of the usual workplace activities that might get you away from the screen, like getting into the boardroom for a meeting, are now happening online too, so there are less reasons to get up and move away from what you're doing.
My workload has decreased with people self-isolating, but every new patient I've had in the last two weeks has been someone with neck pain or back pain caused by working from home.
So remember, if you're getting a sore neck, or a pain next to your shoulder blade, get up and more around more. It's time to take a break.
If you're getting a sore back, or an ache into the top of your buttock, get up and move around more. It's time to take a break.
It should be very simple. Motion is lotion. Rest is rust.
I CAN HELP
If you need help, come in for an assessment and treatment. Physiotherapy is deemed an essential service, and we are still open. Phone 99696925, or book online HERE.
Alternatively, if you're self-isolating, or practising social-distancing due to COVID-19, you can book a video consultation HERE.
Stay safe and well.
VIDEO CONSULTATION AVAILABLE THROUGH