The most entertaining session at last month's Canadian Academy of Sport and Exercise Medicine conference was the closing debate on tendinopathy treatments. Six eminent doctors and therapists took the podium to argue in favor of six different treatments--and to ridicule the arguments of their opponents. It was very funny stuff, but there was also plenty of serious debate and insight. I can't reproduce the jokes, but I did try to convey the key pros and cons of five of the treatments in my Globe and Mail column this week: eccentric exercise, nitroglycerin patches, dry needling, cortisone, and platelet-rich plasma.

The "winner" of the debate was the exercise program, because pretty much everyone agreed that it's the first thing to try, and you ultimately need to address whatever weakness is present to get a long-term solution. For nitroglycerin patches, dry needling, and cortisone, the key advantage may be reducing pain enough that you can actually do the prescribed exercises. Of course, that assumes you actually follow through. Studies of cortisone seem to show initial improvement followed by worse outcomes after six or 12 months, possibly because patients feel better and assume they're cured then return to sport without doing the exercises. (Alternately, cortisone may directly weaken the tissue--that question remains unresolved.)

With or without cortisone, the most important point about exercise programs is that, well, you actually have to do them. Ian Shrier of McGill University, the sports doc who made the case for exercise, pointed out that patients often arrive at his clinic claiming that they've been doing exercises prescribed by their doctor every day for months with no effect. But when he asks to see the exercises they've been doing, they have to look at their sheet to remember them.

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Final point about exercise: does it have to be "eccentric" (i.e. with the muscle lengthening as it contracts)? That's the dominant protocol for Achilles tendon problems: you do heel drops (eccentric) and not raises (concentric). Greg Lehman, a therapist and biomechanics researcher, pointed out that recent evidence has called that assumption into question, including a 2013 systematic review that didn't find any benefit to exclusively eccentric protocols. Instead, the key may simply be to load the tendon and increase the load progressively.

What's the bottom line? Tendons are tricky, unfortunately. None of the methods presented had particularly awe-inspiring results, and there are numerous other potential treatments backed by equivocal evidence that could have been included in the debate. One possibility is that "tendinopathy" isn't one single condition--it's a wide continuum of possible problems, and the appropriate treatment will depend on the details of the injury. Another possibility is that we're earnestly debating the merits of a bunch of placebos. The truth is probably somewhere in the middle.

If you've got a stubborn tendon injury, my advice (in the absence of any slam-dunk evidence) is to be open to trying various different treatment options--but don't lose sight of the fact that, for a long-term solution, you're eventually going to need to strengthen the tissue.


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