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.

Considering all the available treatment options, above anything else, I always recommend:

• load management, in combination with
• a strengthening program.  

​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:

• Corticosteroid (A strong anti-inflammatory)
• Prolotherapy (An irritant to stimulate new tissue growth, e.g. hypertonic dextrose/glucose)
• Sclerotherapy (An irritant to decrease vascularisation, e.g. Polidocanol)
• Traumeel (A homeopathic preparation derived from arnica)
• Actovegin (derived from calf blood)
• Autologous blood (injecting your own blood into the tendon to promote healing)
• Platelet-rich plasma (blood is taken and PRP is extracted and injected to promote healing)
• High-volume injections (to damage the tissue and encourage new growth)

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 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).  

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.

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.  

​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?..

​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.

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:

• Have you travelled to, or transited through, an affected country in the last 14 days?
• OR had contact with someone with Coronavirus or who is suspected of having Coronavirus?
• AND have any of these symptoms: COUGH / FEVER / SHORTNESS OF BREATH?

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 unwell with a temperature, cough, or shortness of breath, please do not come to your appointment.
• If you have been advised to quarantine or self-isolate, please do not come to your appointment.
• There is hand sanitiser on the front desk and all patients are to use this on entering and leaving the clinic.
• I am leaving space in-between appointments to allow time for cleaning, and to minimise patient interaction in the waiting room.
• I will not be greeting you with hand shakes or other contact hand gestures.
• I am wiping down contact surfaces between appointments with Dettol Surface Cleanser.
• I am continuing with my normal hand hygiene measures of thorough hand washing before and after all patient contact.

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 fergus@fitasaphysio.com, or book online here.

Stay safe and well.

Kind regards,

Fergus Tilt
Sports & Exercise Physiotherapist
Fit As A Physio | MOSMAN

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.

Are you working from home, self-isolating, or practising social-distancing due to COVID-19? Fit As A Physio offers online physio consultations, available via PhysiApp, FaceTime, or Skype.

The most important parts of any physio appointment can easily be done via telemedicine: history taking, diagnosis, advising, supporting, educating, as well as exercise prescription design and modification.
​
The video consultation includes a thorough assessment of your injury, an accurate diagnosis, estimate of timeframe for recovery, and a management plan of the right exercises you need to do to help yourself.

Importantly this includes simple explanations, so you can understand:

• What is it?
• Is it serious?
• Why have you got it?
• Is it something you need to rest, or push through?
• Can you keep training?
• How long will it take to get better?
• Have you done any permanent damage?
• Are you doing something that's making it worse?
• What do I need to do to get it better?​

Video consultations are available on your smart phone, tablet, or a browser on your laptop or desktop.

​Advantages:

• Innovative, secure and easy to use.
• In-call streaming of high quality content.
• Seamlessly integrated with HD-video exercise and education library.
• 3D anatomical images and videos.
• Audio and video are encrypted.
• Instant access to activity prescriptions and outcomes.

Video consultations are booked in 15 minute increments ($39), depending on how long you need.

Email Fergus to discuss. Or book online HERE.

Benign paroxysmal positional vertigo (BPPV) is one of the most common forms of vertigo, affecting 2% of the population at some point in our lives. 

BPPV is caused by a problem with the inner ear, where a small calcium deposit forms and moves with gravity around the different angled canals of the inner ear. BPPV is “positional” as it is triggered by specific head movements, for example, turning your head to the left with rolling over in bed. Symptoms of vertigo are room spinning, disturbed balance, and nausea.

BPPV typically resolves within a few weeks, but can be recurring.

Your GP can give you anti-nausea medication, and Physiotherapists treat BPPV with a sequence of movements and positions, called the Epley Manoeuvre, that uses gravity to re-position the calcium crystals.

A video of the Dix Hallpike test for BPPV is HERE.

Information on the Epley Manoeuvre is HERE.

A video of the Epley Manoeuvre is HERE.

Do you have vertigo? Book a physiotherapy appointment in Mosman to perform the Epley Manoeuvre HERE.