Tendon pain is one of the most frequent conditions all physiotherapists will rehabilitate on a daily basis and it is no different here at West London Physiotherapy. There is clear and strong evidence that physiotherapy incorporating a progressive heavy loading exercise regime reduces tendon pain and improves symptoms in the medium to long term. These exercises however may make no difference if a patient is still “in season” with one study reporting a worsening of symptoms. There are few researched interventions, an exception being an invasive steroid injection, which reduces tendon pain in the short term, but I will discuss in a later blog why we tend to encourage patients to avoid steroid injections if possible. Could a specific form of exercise help in decreasing tendon pain in the short term? A study with which I have been familiar with for some time now has recently been published in the British Journal of Sports Medicine and you can find the link here. As such I had the opportunity to review the article in full for our team and our patients here at West London Physiotherapy.
This study contained six subjects with a diagnosis of patellar tendinopathy. Pain was self-rated on a scale of 0-10 while doing a single leg decline squat (see figure 1) before, immediately and 45 minutes after interventions. The interventions were undertaken on consecutive weeks at the same time to ensure that participants had similar levels of stress through their patellar tendons at the time of testing and intervention. The intervention consisted of two separate exercise protocols, which you can see in the table below.
The isometric exercise involved subjects contracting their quadriceps against an immovable resistance with the knee at an angle of 60 degrees flexion. This angle did not change throughout the exercise and was performed on a biodex isokinetic machine. The isotonic exercise involved movement of the knee throughout range on a leg extension machine. This involved a three-second concentric (muscle shortening) and four-second eccentric contraction (muscle lengthening) with 4 sets of 8 repetitions repeated.
Results of this study
The graph below clearly demonstrates the drastic and significant reductions in pain immediately and 45 minutes after isometric exercise (6.8 point reduction in pain). Isotonic exercise also resulted in a decrease in pain immediately afterwards (2.6 point reduction) but this was to a much lesser degree than isometric exercise as well as not being maintained at 45 minutes.
Clinical implications of this research
Combined with our use of shockwave therapy, isometric exercise is a very useful strategy to help decrease symptoms rapidly in patients with irritable tendon pain. It may also help in keeping patients active in their sport throughout a competitive season or indeed in training for an upcoming event. A simple and easy method I use to ensure the isometric hold is of sufficient intensity is to use the below chart (Figure 2). Research has shown a strong association between maximal voluntary contraction and self-reporting of perceived exertion. For isometric exercise patients should aim to perform the exercise at a self-reported intensity of 6-7/10.
Although this research is on a small scale and specifically for the patellar tendon, similar results may be achieved for rotator cuff and Achilles tendinopathy, which we commonly encounter in our clinic. Future research will aim to investigate if this holds true.
David Wynne BSc (Physio) MSc (Sports and Exercise Medicine) MCSP MHCP
Musculoskeletal and Sports Physiotherapist, Research Lead at West London Physiotherapy
For any other questions regarding this topic please do not hesitate to contact West London Physio on 0207 937 1628 or email David at david@westlondonphysio.co.uk
