Nonpharmacological management for tendinopathy
Assess people with tendinopathy for modifiable predisposing factors and biomechanical abnormalities that may be amenable to correction. Predisposing factors include:
- high-level athletic activity
- repetitive occupational activities
- adiposity
- diabetes
- use of medications including oral corticosteroids, quinolone antibiotics, aromatase inhibitors and statins.
Discuss with the person the natural history of tendinopathy, avoiding terms such as ‘degenerative’ and ‘inflammation’. Emphasise the concept of temporary overload of the tendon(s). At a population level, tendinopathy usually resolves spontaneously with time; however, on an individual level, recovery is unpredictable, and the associated pain can be prolonged. Encourage the person to discuss their concerns, goals and expectations, and include them in proposing a management plan that includes self-management.
People with chronic pain and sleep disturbance associated with pain may require regular review of their mental health. Encourage them to maintain their general physical fitness.
Advise people to temporarily avoid or modify activities that increase discomfort by more than 2 points on a 10-point pain-score scale and activities that have the potential to place particularly high loads on the affected tendon.
For most tendinopathies, complete rest is not recommended because complete unloading of the tendons leads to poorer outcomesCook, 2018. Evidence for the efficacy of rehabilitation programs is limited and may vary between different tendons affected. Referral to an appropriate physical therapist (eg a physiotherapist) for institution of a progressive-loading program may assist in treatment and rehabilitation. See Features of a progressive loading program for tendinopathy for features of a progressive loading program for tendinopathy. Other loading programs have insufficient evidence to support their use in treatment plans for tendinopathies. If a person with tendinopathy does not respond to a well-supervised, 6-month progressive-loading program, refer them to a specialist.
A progressive loading program should involve:
- Gradual return to physical activity
- Gradual return to physical activity may reduce the risk of reinjury and prevent deconditioning.
- This may not affect long-term outcomes of tendinopathy.
- For example, if a person has a lower limb tendinopathy, advise them to start with a slow-walking program and gradually build towards reintroducing the desired physical activity (eg running).
- Start an eccentric-concentric loading program [NB1]
- An eccentric-concentric loading program may promote positive effects on the tendon’s structural integrity and load-bearing properties.
- Other forms of reduced-loading programs that do not cause tendon damage may also be appropriate.
- Monitor and adjust the tendon loading.
- If pain after exercise increases by at least 2 points on a 10-point pain-score scale, reduce the load on the tendon for several days.
- Return to exercise at a lower load when pain improves.