Remedies For Hurt Tendons

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Two time-honored remedies for injured tendons seem to be falling on their faces in well-designed clinical trials.

   The first, corticosteroid injections into the injured tendon, has been shown to provide only short-term relief, sometimes with poorer long-term results than doing nothing at all. And resting the injured joint is supposed to prevent matters from getting worse, but may also fail to make them any better. Rather, working the joint in a way that doesn’t aggrevate the injury but strengthens supporting tissues and stimulates blood flow to the painful area may promote healing faster than “a tincture of time.”

   And some researchers suggest that counterintuitive remedies may work just as well or better.

   A review of 41 “high quality” studies involving 2,672 patients, published in November in the The Lancet, revealed only short-lived benefit from corticosteroid injections. For the very common problem of tennis elbow, injections of platelet-rich plasma derived from patients’ own blood had better long-term results.  

Still, the authors, from the University of Queensland and Griffith University in Australia, emphasizes the need for more and better clinical research to determine which among the many suggested remedies works best for treating different tendons.

   Jane E. Brody, a renowned writer on health, had a problem which was precipitated one autumn by eight days of pulling a heavy suitcase through six airports. Her shoulder hurt nearly all the time, not a happy circumstance for a daily swimmer and trying to retrieve sometimes even slightly behind her produced a stabbing pain. Diagnosis: tendonitis and arthritis.

   Two months of physical therapy did help somewhat, as did avoiding motions that caused acute pain. The therapist had some useful tips on adjusting her swimming stroke to minimize stress on the tendon while the injury gradually began to heal.

   The following spring, though she still had some pain and feared a relapse, she attacked her garden with a vengeance. Much to her surprise, she was able to do heavy-duty digging and lugging without shoulder pain. Could the intense workout and perhaps the increased blood flow to her shoulder have enhanced her recovery? Her friend, Richard Erde, had an instructive experience.

   An avid tennis player at 70, he began having twinges in right shoulder while playing. Soon, simple motions like slipping out of a shirt sleeve caused serious pain. The  diagnosis was injury of the tendon that attaches the biceps muscle of his upper arm to the bones of the shoulder’s rotator cuff. He as advised to see a rheumatologist, who decline to a corticosteroid injection and instead recommended physical therapy and rest.

   Erde stopped playing tennis for a month, and it didn’t help at all. The physical therapist found he had very poor range of motion and had him do a variety of exercises, which improved his flexibility and reduced the pain somewhat. After two months, he stopped the therapy.

   Then several weeks later, after watching the Australian Open, he thought he should do more to strengthen his arm and shoulder muscles and decided to try playing tennis more vigorously. The pain started to drop off dramatically and in just 10 days the pain had eased more than 90 percent.

   Tendonipathies, as the injuries are called, are particularly vexing orthopedic problems that remain poorly understood despite their frequency. “Tendinitis” is a misnomer: Rarely are there signs of inflammation, which no doubt accounts for the lack of lasting improvement with steroid shots and anti-inflamatory drugs. They may relieve pain temporarily, but don’t cure the problem.

   The underlying pathology of tendinopathies is still a mystery. Even when patients recover, their tendons may continue to look awful, say therapists who do imaging studies. Without a better understanding of the actual causes of tendon pain, it’s hard to develop rational treatments, and even the best specialists may be reduced to trial and error. What works best for one tendon, or one patient, may do little or nothing for another.

   Most tendinopathies are precipitated by overuse and commonly afflict overzealous athletes. With or without treatment, they usually take a long time to heal: many months, even a year or more. They can be frustrating and often costly, especially for professional athletes and physically active people. 

   In a commentary accompanying the Lancet report, Alexander Scott and Karim M. Khan of the University of British Columbia noted that though “corticosteroid injections does not impair recovery of shoulder tendinopathy, patients should be advised that evidence for even short-term benefits at the shoulder is limited.” Like the Australian reviewers, the commentators concluded that “specific exercise therapy might produce more cures at 6 and 12 months than one or more corticosteroid injections.”

   The question is: What kind of physical therapy gives the best results? Most therapists prescribe eccentric exercises, which involve muscle contractions as the muscle fibers  lengthen – for example, when a hand-held weight is lowered from the waist to the thigh. Eccentric exercises must be performed in a controlled manner; uncontrolled eccentric contractions are a common cause of injuries like groin pulls or hamstring strains. 

   Marilyn Moffat, professor of physical therapy at New York University and president of the World Confederation of Physical Therapy, prefers “very protective” isometric exercises, at least at the onset of treatment until the tendon injury begins to heal. Those exercises involve no movement at all, allowing muscles to contract without producing pain.

    The stronger the shoulder muscles are when the tendinopathy calms down, the better shape the shoulder is in to take over movement without further injury. Dr Moffat said, “You don’t want the muscles to weaken, which is what happens when you rest and do nothing. That leaves you vulnerable to further injury.”

(NYT)