By Paul Dijkstra @DrPaulDijkstra & Jill Cook @ProfJillCook
Before we delve into evidence based medicine as it relates to tendons, here are the top 10 short (clinical) pearls from the 3rd International Scientific Tendinopathy Symposium (ISTS) or #Tendons2014:
- Tendinopathy is still not clearly defined
- Do not treat all tendons with the same recipe – what works for the upper limb tendons might not be good for lower limb weight bearing tendons
- Pain is complex – consider central sensitization; psychosocial factors contributing
- Do not rely on (expensive) special investigations – they are often not helpful in diagnosis or follow up
- UTC – (the imaging tool Ultrasound Tissue Characterization) too early to use in private practice or isolation; research setting / big team perhaps OK
- No good evidence for injections into or around tendons yet
- Inflammation poorly defined and not part of the (clinical) equation – no evidence to suggest otherwise
- Load, Load, Load – adjust; sensibly progress; role of isometrics
- Each patient is an individual – own special genetic make-up. Treat them as individuals, do not fall into the trap of ‘individual genetic profiling’ and reject the direct to consumer genetic ‘profiling’ for whatever tendon reason!
- We’re giving the early steps on a long and complex road to understand tendons better!
We don’t have an agreed, consensus definition for tendinopathy; we’re all thinking about tendons and tendon injuries from a biased personal framework, including our interpretation of ‘evidence’.
A question of concern for all clinicians is how effective (and efficient) our approach is to a specific, individual patient with a certain clinical problem. With the best of intentions, we can still do harm. An evidence-based approach helps minimise the potential for harm.
Time for a quick recap on EBM – because folks are overlooking elements. The term ‘evidence-based medicine’ (EBM) was coined by the David Sackett and colleagues at McMaster University in Ontario, Canada in the early 1990s. EBM gained significant ground worldwide since the inception in 1993 of the Cochrane Collaboration, a non-profit body which systematically organizes research information. The central role of the Cochrane Collaboration has been ‘to liberate the results of unpublished clinical trials from their neglect, with the aim of pulling together separate strands of research into a coherent, useful and reliable guide to best outcomes’. (1)
4 pillars of the evidence-based medicine approach in the tendon context
In its broadest form, EBM integrates the best research evidence with clinical expertise and patient values to achieve the best possible patient management.
- The best research evidence (systematic reviews of randomized clinical trials as the top level of evidence). It is important that we all agree on the fact that ‘the plural of anecdote is NOT evidence’.
- Patient expectation, values, concerns:
- elite high jump athlete with an acute flare of PT one week before the Olympics;
- 62yr-old with acute Achilles tendinopathy following a course of quinolone antibiotics for prostatitis going on a cruise with his new wife in 5 days;
- 12yr old keen swimmer with signs of supraspinatus tendinopathy, multi-directional instability and scapula-humeral dysfunction and ‘female tenocytes’…she’s the daughter of a colleague;
- 32yr old national team volleyball player with longstanding anterior knee pain misdiagnosed as patella tendinopathy and a brother who ruptured both Achilles tendons
- Clinician experience and expertise:
- a practitioner with a tool… a junior doctor in a NHS ward with a stethoscope and a pair of hands;
- a private orthopaedic surgeon with a knife and shares in the clinic;
- a radiologist with an expensive 3T MRI… and shares in the clinic;
- a SEM physician with a (brand new) portable US scanner;
- a keen clinician who jumped on the UTC bandwagon;
- A scientist who just bought shares in / founded Genetics4U (and he didn’t hear Malcolm Collins at the ISTS 2014…) and has a multi-million-pound-strong elite footballer with a painful tendon in front of him)
- Environment including concern about litigation:
- school rugby team – parents begging to inject Johnny’s sore knee (patellar tendinopathy) in the change room before the interschool semi-final;
- warm-up track before the Olympic 1500m final;
- NHS GP practice with 5 patients waiting – you only have 6 minutes for this consultation;
- physio room of Queens Diamond Royal Premiership Football Club – manager banging on the door;
- hotel room clinic in Nairobi before the African Games opening ceremony
It’s NEVER simple!
The dilemma is often (falling back to our own ‘framework’) the media (or coaches / colleagues… patients) creating unreasonable expectations around certain miracle (guru-juice) treatments; treatments that got celebrity player Z back on the track in no time… No evidence, just the report on ‘News at 6’.
Here are some critical reflections on a clinical approach – remembering that tendons are complex and different; patients are individuals with their own unique expectations.
- Always take a thorough and detailed history with particular attention to the onset of symptoms, the type of symptoms, the location of the symptoms, functional deficits and performance goals (‘get to my apartment on the 1st floor’; ‘run in the Olympic final’; ‘go with my new wife on a boat cruise without crutches’ etc.);
- Perform a thorough and tendon-specific examination (make sure the pain is truly a tendon-pain – example patella tendinopathy and not anterior knee pain; red flags include fever, weight loss, signs of inflammatory arthropathy – Sacroiliitis, night pain etc; bilateral thickened Achilles tendons – cholesterol etc; PLANTARIS – medial Achilles / musculotendinous junction calf pain, recurrent soleus strains / failed rehabilitation, don’t like dorsi-flexion – ‘push-off’
- Assess pain and function – perhaps without exception patients want to have less pain and better function. There is good evidence that specific targeted tendon loading (isometrics for instance in PT) reduces pain.
- Consider special investigations. The vast majority of patients around the world will not have access to special imaging – ultrasound, MRI and now UTC. Fear of litigation (missing a partial tendon rupture in an elite Olympic athlete, patient expectation and finances etc. will influence decision). UTC has limited clinical value – perhaps only in a research setting and as part of the toolbox used by medical teams looking after elite athlete teams. Make sure however that you know how to interpret the scan and perhaps how not to react to abnormal findings… especially important is how you communicate these to the patient. Blood tests won’t contribute anything unless of course the tendinopathy is part of a possible inflammatory / rheumatologic disease.
- Management tools. Load, load, load. Load adjustment (when overload in the elite athlete is a problem), load introduction if a sedentary lifestyle is part of the equation and specific loading programs as part of a physiotherapy program. Footwear, including heel raises; technique and functional rehabilitation (the swimmer with rotator cuff tendinopathy dropping her elbow… Scapula Humeral Dysfunction etc); address the psychosocial aspects of pain perception – stress, sleepless nights (just had a baby), long working hours (paying the mortgage), sitting in the car in the London-traffic for 2 hours before a training session – no wonder high hamstring tendinopathy is a problem…); pharmacological agents – inflammation is not part of the tendinopathy equation.
- No evidence for injecting anything into or around the tendon. However high volume injections / hyaluronic acid in sheaths and soft tissue interfaces, dextrose or Platelet Rich Plasma (PRP) for intra-substance ruptures are all being done on a regular basis by clinicians all around the world. Especially practitioners looking after elite athletes might feel pressured ‘to do something’. This is complex and decisions should be made after careful thinking and thorough risk-benefit discussions between performance health and coaching teams. For the purpose of this blog the fact remains that we have no conclusive evidence to suggest that injecting anything into or around a tendon is of any clinical benefit. We only have anecdote, low quality or small epidemiological trials in support. There are however very well conducted Randomised Controlled Clinical Trials against for instance PRP.
- Monitor – discuss with the patient one or two symptoms / loading tests to perform at home or in the gym / rehab room on a regular basis as some objective indicator of progress.
- Follow up – re-asses; discuss progress and set new goals. Tendon palpation has very little value.
Prof Jill Cook is a Physiotherapist, Tendon Clinician-Scientist, Deputy Editor of BJSM @ProfJillCook
Dr. Paul Dijkstra is a Specialist Sport & Exercise Medicine Physician ASPETAR, DOHA, QATAR. UK Athletics Chief Medical Officer Beijing & London Olympic Games. Views are my own. @DrPaulDijkstra
BJSM was an official sponsor of the 3rd International Scientific Tendinopathy Symposium – #Tendons2014. The next conference will be in 2016 at a venue to be determined. BJSM will aim to break the news! “And the winner is….!”