Thoughts of a Chartered Physio on Tendon rehabilitation

Tendinopathy research has rebounded from being one of a non-inflammatory pathology back to being one of a chronic inflammation (Dakin et al. 2018). However, this does not mean that we treat tendinopathies with anti-inflammatories as currently our understanding is that by switching off the inflammatory process we also switch off the resolution of the pathology. Furthermore, recent evidence demonstrated that using anti-inflammatories in addition to rehabilitation has no benefit over rehabilitation alone (Malmgaard-Clausen et al. 2021).

Rehabilitation of the tendon is individualised; is it a chronic degenerative tendon? is it an acute tendon pain? is it a forelimb or hindlimb tendon? is it an energy storing tendon or a positioning stabilising tendon? what age is the dog and what activities does the dog do? There's no one rehabilitation approach! Also, tendon rehabilitation takes longer with progress being slower. Rehabilitation appointments need to be stretched out over 3-6 months, depending on the individual, as tendons respond slowly. Furthermore, tendons are mainly made up of collagen fibres which do not regenerate but they are extremely metabolically active and are highly responsive to load. It is the healthy part of a degenerative tendon that when loaded collagen synthesis can be achieved (Cook et al. 2016). However, it is important to leave at least 36 hrs after loading before reloading as otherwise the tendon becomes vulnerable to injury and pathology may be accelerated.

It is important not to rely on clinical investigations such as an ultrasound scan to measure functional improvement as these may remain unchanged when the patient doesn't have any pain and so may serve as being complementary to the clinical examination (Drew et al. 2012: Rabello et al. 2020).

References:

Dakin et al. (2018). https://bjsm.bmj.com/content/bjsports/52/6/359.full.pdf

Malmgaard-Clausen et al. (2021). No Additive Clinical or Physiological Effects of Short-term Anti-inflammatory Treatment to Physical Rehabilitation in the Early Phase of Human Achilles Tendinopathy: A Randomized Controlled Trial - Nikolaj M. Malmgaard-Clausen, Oscar H. Jørgensen, Rikke Høffner, Peter E.B. Andersen, Rene B. Svensson, Philip Hansen, Janus D. Nybing, S. Peter Magnusson, Michael Kjær, 2021 (sagepub.com)