Why the double standard in tendinopathy research?

  • Friday 16 January 2015

I think the BJSM is on a warpath against platelet-rich plasma or PRP injections for the treatment of tendinopathy. Recent tweets by the editor of BJSM suggest that PRP won't be on his shopping list for next Christmas. There are a plethora of sports doctors and physiotherapists who are lining up to knock PRP off it's position as credible treatment for tendinopathy. And quite rightly so in my opinion. While there has been an abundance of case reports and animal studies shining a positive light on the benefits of PRP, more powerful research in the form of double-blinded randomised controlled trials has consistently shown no benefit compared to placebo. We still have much to learn about the positive effects, if any, of PRP in tendinopathy.

However, there is almost a deathly silence when the topic of discussion turns to rehabilitation and, in particular, tendon loading programs for tendinopathy. I keep hearing that we've moved on from the traditional Alfredson eccentric program but I'm not sure the results have moved with it. Silbernagel et al used a loading program consisting of body-weight concentric and eccentric exercises for Achilles tendinopathy. After 6 months, 60% of cases had an improved VISA-A, hardly an earth-shattering result. Kongsguard et al used a heavy loading program for patella tendinopathy consisting of four compound exercises. They had a comparison arm performing the traditional eccentric loading program. After 6 months, VISA P scores were the same in both groups but patient satisfaction was higher in the heavy loading group. Is improvement in a patient satisfaction outcome measure a sign of success? And finally we have the tendinopathy continuum (Cook et al) that attempts to rationalise treatment of tendinopathy based on staging of the disease into reactive or degenerative tendinopathy. While the basis of the model makes sense and is supported by an excellent extrapolation of good basic sciences, there is very little 'hard' clincial evidence backing this theory. I know of one case series (an excellent study nonetheless) demonstrating improvement in pain with isometrics compared to isotonics but know of no others.

We have three alternative loading programs that have tenuous evidence for efficacy compared to the traditional Alfredson program. Yet, this is not the impression you get when you read the BJSM or sit through lectures on tendinopathy. One gets the impression that an optimal rehabilitation program has already been defined; but this is just not the case. We need more 'hard' clinical evidence before we can definitively say that one loading program is superior to another. And that means more studies.

So, I have to ask the question: Where are the howls of protest (like with PRP) at the lack of 'hard' clincial evidence for an optimal rehabilitation program? Why are we so quick to condemn PRP but we don't seem to question the validity of specific tendon loading programs? Why the double standard in tendinopathy research?

Tags: researchtendinopathy

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