Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Treatment Principles

The management of tendon injuries depends on the diagnosis. The treatment varies according to the different stages of the healing process.
Tendon strength is a direct function not only of the number and size of collagen fibers, but also of their orientation. These fibers respond favorably to tension and motion and it is therefore important to stimulate protective motion of a tendon as early as possible. Early mobilization should therefore be initiated; it may be limited by protective bracing to decrease tensile loading on the tendon. Motion should start within two weeks of the injury.

Exercises

The pain level is often the guide for the exercise program, and dictates the degree of function in chronic tendon injuries. Pain differs depending on whether it is caused by inflammation or degeneration. Pain can
be classified in terms of athletic performance.
A period of vulnerability to re-injury exists. In chronic injury it is the history of pain that allows the proper recommendation and adjustment of activity. If an exercise program is carried out correctly, the pain threshold may be reached and surpassed during the last set of 10 repetitions; if there is no pain, the athlete is not working hard enough. As the tendon strengthens, the pain should diminish.
Isometric and concentric exercises have a place in the rehabilitation program, but it is mainly through eccentric exercise that it is possible to have a clear effect on a chronic tendon condition. Eccentric exercises can enhance the efficacy of treatment of overuse tendon injuries and stimulate healing
(although more research is needed to verify this), and they seem to be effective in the treatment of chronic tendon disorders so that surgery often can be avoided.

The following program was designed to strengthen the tendons to withstand the greater stresses caused by eccentric loading:
1. Stretch—hold stretch statically for 15–30 seconds, and repeat 3–5 times.
2. Eccentric exercise—progress from slow on days 1 and 2, to moderate on days 3–5, and fast on days 6 and 7. Then increase external resistance and repeat the cycle.
3. Stretch statically.
4. Use ice for 5–10 minutes to reduce swelling and moderate pain.

Stretching

Stretching is used extensively and probably has a major role in the treatment of overuse injuries. The theoretical basis for stretching is well defined, but the epidemiological and scientific evidence to support it is somewhat scanty. Studies of the biomechanical effects of stretching show that it will result in greater flexibility and increased strength of the muscle-tendon unit. There is, however, a concern as to what stretching techniques or procedures should be used for optimal gains in flexibility. Experimental evaluation of stretching techniques shows that the ‘contract, relax, and antagonist contract’ method is generally better than ‘contract, relax’ or ‘hold relax’ techniques, but the difference is small.

Surgery

The indication for surgery is often persistence of pain and loss of athletic performance. The rationale for surgical treatment of tendon injury is to reactivate the wound repair cycle or remove pathologic tissue. A surgical incision is the most powerful stimulus to local tissue to release the biologic cell mediators of repair. The result is not a regenerated, but a remodeled tendon. There is a lack of scientific evidence about when and how to perform surgery on overuse tendon injuries. The primary reason for operative treatment is still its apparent success in many well-documented cases, and the frequent failure of conservative treatment.

Summary

Treatment of athletes with chronic tendon injuries requires long experience and also cooperation with the physical therapist. Successful treatment of tendon injuries depends on the correct diagnosis. The cause of the injury should be treated. Correction of training errors is often the key to a successful treatment program. Orthotic correction of malalignments is often helpful. Shoes with posterior support in patients with ankle tendon problems may be helpful. Overuse tendon injuries must be carefully managed.

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