Category: Tendinopathy

Injections for Tendon Pain

1/12/2020

I’ve been frustrated this week by a couple of patients with Achilles problems that I thought should recover well. They’ve disappeared to go and have an injection, against my recommendation. It’s made me think about whether or not I should have made the referral myself? What are our options for injections, and do they work?

TENDON PAIN

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:

load management, in combination with
a strengthening program.

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:

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

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).

"The best systematic review evidence shows that local corticosteroid injections are not effective for tendinopathies after the first few weeks, and produce worse long-term outcomes compared to other treatments" (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)

HIGH-VOLUME INJECTIONS

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.

SO…

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?

NATURAL HISTORY

Some conditions are self limiting and will just get better by themselves. Did the injection work, or was it about to get better anyway?

PLACEBO

Injections are a powerful way to administer a placebo effect. You need to see a specialist to receive it. You need to pay more money. There’s some high-tech equipment spinning the blood. Everything is set up for you to expect improvement and, in a decent percentage of cases, that’s all it takes to get better. If you believe the injection will help you then it is much more likely to work. However, the research tells us it doesn’t really matter what substance is injected, it is your belief in whether or not it will help that is the variable more likely to determine the outcome.

SUMMARY

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.

TL;DR

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.

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Health News 06/12/18

6/12/2018

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Load Management

9/5/2016

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Injuries that begin gradually, without an acute incident or trauma, are one of the common presentations I treat. I often refer to them as overuse type injuries, or injuries that result from excessive loading.

Adaptations to Training

When we “use” our bodies, our bodies adapt to the activity we are doing. The more we do, the more we are able to do. The less we do, the less we are able to do. This is essential in eliciting a training response.

When we train we want to cause stress to our body. (This may be our muscles, bones, cardiovascular system, etc.) We want to overload the system, which causes a degree of damage or micro-trauma. The body then responds by growing bigger / stronger / faster / fitter, so it can cope with that load in future. We cause stress to force adaptations.

Stress/load => damage => rest/recovery => adaptation/growth.

Load

A lot of common gradual-onset injuries result from a failure to adapt to load.

There are a number of variables that can be multiplied to determine the total load:

Number of sessions per week
Length of session
Intensity of session
Novel activity
Bio-mechanical or environmental variables (eg, footwear, hills, ground surface)

The intensity of the activity is the most powerful multiplier in this list.

When we are considering total load, we also need to consider variables that make it harder for our bodies to adapt to load.

Variables that can be multiplied to determine how well we adapt to the load:

Time between sessions
Nutrition
Hydration
Stress
Sleep

Recent research found that getting less than 8 hours sleep a day almost doubles the injury rate in athletes.

Injuries

The two most common over-loading, or over-use type injuries are:

Tendon pain
Stress fractures

Tendon pain is a failure of soft tissues to cope with muscular loading.

Stress fractures are a failure of the boney architecture to adapt to impact loading.

Load Management

Our bodies like a consistent workload, i.e., doing the same things every day. If we need to do more, we have to make gradual changes to avoid overloading. Increases in total load need to be slow and steady. Increasing load by not more than 10% a week is commonly recommended.

We get in trouble when we have spikes of excessive load.

We may rapidly increase training levels in preparation for an event. This is a common cause of injury during pre-season training.

Or it could be a resumption of “normal” training after a period of rest. Unfortunately, the body quickly adapts to the lower levels, so what was normal is now excessive. This is a common mechanism of a new injury, having spent some time rehabbing a previous injury.

An otherwise normal load may become excessive if we are not eating, drinking, or sleeping well, or are stressed. It’s very common to see regular runners breaking down in December when they’ve been going to Christmas parties.

Injury Management

Load management is an essential component of injury management.

Of the total volume of work, I get patients to dial down the load by about a quarter, and stop the most aggravating activities – most likely the more demanding / explosive activities: hopping, skipping, jumping, sprinting, hills, plyometrics. So usually total rest isn’t required.

Patients can keep going with their cardio, but possibly trial a lower impact, cross-training option.

Have you had an injury from excessive load?
What was your experience?...

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Sever's Disease

29/4/2016

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My kids play a lot of sport. When they over-train they get heel pain. Heel pain in kids is called Sever’s disease, or calcaneal apophysitis (which means inflammation of the growth plate of the heel bone - which is the calcaneus).

HEEL PAIN IN CHILDREN

Sever’s is most common in 9 - 12 year olds. It’s sore to squeeze the bone at the base of the Achilles where it attaches onto the heel. It’s not something that can be seen - it never seems to look red or swollen. It’s worse after sprinting, jumping, and hopping. It settles with rest. It is an overuse injury so it’s common in pre-season, or anytime training loads increase too quickly. My kids get it when they do extra sessions in running spikes or footy boots, without the normal heel support of their running shoes. It’s an overuse injury from excessive loads.

OVERUSE INJURY

When we talk about excessive loads it can be “external” load such as:

number of sessions
length of sessions
pace of running
hills
novel activity
footware
ground surface

I think the running pace is the more powerful multiplier in this list. Extra sprint sessions will do it. My kids got sore once when we did a boot-camp session with a novel plyometric exercise - split jumps.

There are also “internal” variables that determine our ability to cope with the training load:

nutrition
stress
sleep
growth spurts

My kids definitely are more prone to Sever’s if they’ve had a couple of late nights that week. And, if they’re having a growth spurt, their bodies are busy spending resources on growing rather than recovering from the stress of a training session.

NATURAL RECOVERY

Text books say that Sever’s disease is self-limiting because the growth plate eventually fuses by the age of 15 or 16. But I don’t think there’s anyone who would be happy to just let it run its course until then. It is usually sore enough to stop you participating in sport, so it needs treatment.

WHAT DO WE DO?

I used to put kids with heel pain in orthotics, until I read this research which confirms that a simple heel wedge is more effective than orthotics for Sever’s disease. Cheaper and easier.

I get them to do an isometric Achilles strengthening program which also helps with pain control.

But ultimately recovery comes down to load management.

Load management means reducing the excessive loads. So this could be:

less sessions/week
shorter sessions
less sprint work
run in joggers rather than spikes or footy boots
less hills
heel wedges in shoes
stay in shoes - no bare feet / thongs / flats. I really like them to stay in some sort of shoe with a heel all the time. Even if they’re getting up to use the bathroom I want them to slip their joggers on.

And aid recovery with:

plenty of sleep
massage calf muscles
ice and Ibuprofen for pain relief when sore

HAVE YOU HAD A CHILD WITH SEVER’S DISEASE?

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Isometric Exercise for Tendinopathy

23/6/2015

9 Comments

Tendon pain is the most common gradual-onset, overloading injury. Mechanotherapy / exercise is the most beneficial treatment option.

Eccentric exercises have been commonly prescribed over the last decade, following the pain-provoking Alfredson programme of 3 x 15 reps, twice/day. It sometimes works very well.

The last few years I’ve favoured isometric exercise as an initial treatment - partly because of personal experience with Achilles, patellar, and lateral elbow tendon issues, & recommendation from Jill Cook & Craig Purdham at the AIS.

New research adds some support to isometric exercise as a treatment for tendinopathy, concluding it reduces tendon pain and improves strength. The authors delve in to all the “hows” & “whys” of how it works in their discussion, and to be honest it’s a bit technical for my understanding.

The research protocol uses 5 reps of a 45 second contraction, at a 70% effort. I prefer a more gentle contraction of 50% effort, but a longer hold of at least a minute, and I like a larger total volume of at least 10 minutes/day. Obviously it’s hard to define what the perfect dosage is for exercise, & volume could be adjusted depending on results.

I like isometrics because:

you don’t need any equipment / you can do them anywhere
they're easily done for all the common tendinopathies
they can be started straight away, even in the most painful cases
they work well

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Blog

Injections for Tendon Pain

TENDON PAIN

SO WHAT DO I DO?

WHAT ABOUT INJECTIONS?

CORTICOSTEROIDS

PROLOTHERAPY / SCLEROTHERAPY

AUTOLOGOUS BLOOD INJECTIONS

HIGH-VOLUME INJECTIONS

PLATELET RICH PLASMA (PRP)

SO…

WHY DO THE INJECTIONS WORK FOR SOME PEOPLE?

REGRESSION TO THE MEAN

NATURAL HISTORY

PLACEBO

SUMMARY

TL;DR

Health News 06/12/18

Load Management

Adaptations to Training

Load

Injuries

Load Management

Injury Management

Have you had an injury from excessive load?
What was your experience?...

Sever's Disease

HEEL PAIN IN CHILDREN

OVERUSE INJURY

NATURAL RECOVERY

WHAT DO WE DO?

HAVE YOU HAD A CHILD WITH SEVER’S DISEASE?

Isometric Exercise for Tendinopathy

Archives

Categories

PHYSIO MOSMAN

Blog

Injections for Tendon Pain

​TENDON PAIN

​SO WHAT DO I DO?

​WHAT ABOUT INJECTIONS?

​CORTICOSTEROIDS

​PROLOTHERAPY / SCLEROTHERAPY

​AUTOLOGOUS BLOOD INJECTIONS

​HIGH-VOLUME INJECTIONS

​PLATELET RICH PLASMA (PRP)

​SO…

​WHY DO THE INJECTIONS WORK FOR SOME PEOPLE?

​REGRESSION TO THE MEAN

​NATURAL HISTORY

​PLACEBO

​SUMMARY

​TL;DR

Health News 06/12/18

Load Management

​Adaptations to Training

Load

​Injuries

​Load Management

​Injury Management

Have you had an injury from excessive load? ​What was your experience?...

Sever's Disease

​HEEL PAIN IN CHILDREN

​OVERUSE INJURY

​NATURAL RECOVERY

​WHAT DO WE DO?

​HAVE YOU HAD A CHILD WITH SEVER’S DISEASE?

Isometric Exercise for Tendinopathy

Archives

Categories

​PHYSIO MOSMAN

TENDON PAIN

SO WHAT DO I DO?

WHAT ABOUT INJECTIONS?

CORTICOSTEROIDS

PROLOTHERAPY / SCLEROTHERAPY

AUTOLOGOUS BLOOD INJECTIONS

HIGH-VOLUME INJECTIONS

PLATELET RICH PLASMA (PRP)

SO…

WHY DO THE INJECTIONS WORK FOR SOME PEOPLE?

REGRESSION TO THE MEAN

NATURAL HISTORY

PLACEBO

SUMMARY

TL;DR

Adaptations to Training

Injuries

Load Management

Injury Management

Have you had an injury from excessive load?
What was your experience?...

HEEL PAIN IN CHILDREN

OVERUSE INJURY

NATURAL RECOVERY

WHAT DO WE DO?

HAVE YOU HAD A CHILD WITH SEVER’S DISEASE?

PHYSIO MOSMAN