Topic

Pharmacologic

Topic Progress:

Numerous types of treatment have been described for the conservative handling of tendon pathologies. Unfortunately, very few have been shown to have any major scientific basis.

Click on the following tabs to learn more about some of the commonly used treatment for tendinopathy.

Non-steroidal anti-inflammatory drugs
The role of non-steroidal anti-inflammatory drugs (NSAIDs) in tendinopathies is controversial. As there is no significant inflammatory component, it is likely that any efficacy is due to an analgesic effect – rather than an anti-inflammatory action.10

In the case of acute tendinopathies, it is debated whether or not it is useful to block the immediate pain response as the analgesic effect can allow the athlete to continue training – potentially making their problem worse. In the acute setting, when there is no bursitis, tenosynovitis or any accompanying inflammatory pathology, treatment with paracetamol seems more appropriate than that with NSAIDs.

With respect to chronic tendinopathy, the role of NSAIDs is similarly uncertain. The analgesic affect may have some value when initiating eccentric exercise.

Corticosteroids
Injections of corticosteroids have been, and are, administrated frequently in the treatment of tendinopathies. This is despite the lack of inflammation. There are a number of issues related to steroid injections. The main issue with intra-tendinous and peritendinous injection is the risk of tendon rupture. Tendon ruptures have been described after infiltrations of corticosteroids (in particular in the Achilles tendon) while studies suggest that corticosteroids reduce the tensile strength of tendons. Studies have shown that while steroid injections can be very effective at the three-month follow-up appointment, at one year they are worse than doing nothing.11

The use of corticosteroids in tendon pathologies depends on careful clinical medical evaluation and must be individualised for each case. It may be an appropriate treatment for some upper limb tendinopathies.

Dextrose
Hyperosmolar dextrose has been used for years as part of prolotherapy treatments for chronic musculoskeletal pain. Prolotherapy is a technique in which a small amount of an irritant solution is injected around the insertion of the tendon or ligament. It is speculated that dextrose induces an inflammatory process that would facilitate the production of growth factors and favouring the proliferation of fibroblasts and increasing the production of extracellular matrix. More data from controlled and randomised studies are necessary before this treatment can be recommended.
Polidocanol
Some clinicians believe that the pain in chronic Achilles tendinopathy is linked to neovascularisation. Sclerosis with polidocanol has been shown to be effective in reducing the pain by, presumably, reducing neovascularisation and sensory innervation accompanying the same. The stipulated period necessary for rehabilitation after receiving an infiltration of sclerosant includes from one to three days of rest. It takes two weeks until the athlete is permitted to load the tendon normally. At present, this technique can be considered experimental for two reasons: the procedure is technically demanding and randomised and controlled studies have not been published.10
Autologous growth factors (platelet rich plasma)
The use of autologous blood and platelet preparations to treat tendinopathy has become very popular. It has been reported that this can promote the healing process through regeneration of collagen and the stimulation of well-ordered angiogenesis. The literature, thus far, has failed to show that these treatments are effective in chronic tendon pathologies.12,13
Stem cells
There is also major research interest in the role that stem cells might play in the treatment of tendon injuries. This is not a widely used treatment currently.
High-volume image-guided injections
In recent years, injections have been described of volumes between 20 and 50ml of a combination of bupivacaine, hydrocortisone and saline as a treatment for different tendinopathies. For both Achilles and patellar pathology, the authors suggest that the injection of these volumes produces a “local mechanism effect” that destroys the neovascularisation, also damaging the accompanying innervations both through direct traumatism and ischemia, which causes an immediate improvement in the patient and permits the initiation of eccentric exercise.14-16

The stipulated period necessary for rehabilitation after receiving a high-volume infiltration includes from one to three days of rest. It will not be until the second week that the maximum load can be applied on a tendon level. At present, this technique could be considered experimental for two reasons: the procedure is technically demanding and randomised and controlled studies have not been published.

While it can be tempting to pursue these “adjuvant therapies”, in many cases it is better to continue with strengthening exercises and careful adjustments of the athlete’s load.

Dr Ricard Pruna

Sport and Exercise Medicine