JPMER

10.5005/jp-journals-10028-1259
Tendinopathy and Sports
REVIEW ARTICLE

Tendinopathy and Sports: Understanding the Problem and

Options of Management-perspectives from Physiotherapy,
Sports Medicine, and Orthopedics
1
Himmat S Dhillon, 2Sidak Dhillon, 3Vikas Bachhal, 4Mandeep S Dhillon

ABSTRACT physiotherapy too have benefited, and through various

Tendinopathies are perhaps the leading cause of sports- computer programs and wearable equipment, we now
related overuse injuries necessitating visit to an expert. have the means for efficient injury prevention and man-
Increased general public participation in sports and growing agement. However, there are still a significant number of
intensity of elite level sport had further warranted more atten- ailments that lack adequate understanding, and where
tion and research into pathophysiology and management of
tendenopathies. As a result, its management has seen enor- clinicians and researchers have failed to reach a common
mous changes in the last few decades. The newer research consensus over fixed pathophysiological processes that
methodologies applied to diagnostic and therapeutic aspects may underpin them; tendinopathy is one such disorder,
have generated a plethora of literature, which has helped which even in the 21st century eludes a well-defined
sports medicine experts. However, these newer modalities
management protocol.
have also added to the confusion among many. This review
aims to present current understanding of pathophysiology of Tendinopathy has been used as an umbrella term to
tendinopathies and evidence of success or failure of several describe a spectrum of changes that occur in damaged or
modalities in current use. diseased tendons in the upper and lower limbs.1 Tendi-
Keywords: Exercise, Management, Orthobiologics, Sports, nopathy or tendinosis is a common, yet highly debated
Tendinopathy. disorder of the tendons, seen in individuals of all age
How to cite this article: Dhillon HS, Dhillon S, Bachhal V, groups, most frequently in the active adult population.
Dhillon MS. Tendinopathy and Sports: Understanding the The disorder is characterized by localized tenderness and
Problem and Options of Management-perspectives from Physio- pain, which is significantly exacerbated when the load
therapy, Sports Medicine, and Orthopedics. J Postgrad Med Edu on the tendon is increased, resulting in loss of function
Res 2017;51(4):175-181.
and performance.2 Despite its frequent occurrence, the
Source of support: Nil exact etiopathogenesis of the pathological process is still
Conflict of interest: None not crystal clear, and researchers and clinicians continue
to debate the presence or absence of an inflammatory
component in tendinopathy at all sites.3
INTRODUCTION
Cook and Purdam4 proposed the occurrence of tendon
Over the past few decades, advancements in technology pathology in a continuum, describing it as occurring in
and research methods have allowed researchers from three overlapping phases. Their theory describes the
various fields to answer questions that may have eluded first phase as reactive tendinopathy, a noninflammatory
their predecessors. The fields of sports medicine and response to acute overload or unaccustomed activity in
young individuals, who usually experience pain with
increased tendon loading. Reactive tendinopathy is fol-
1
Consultant, 2Junior Resident, 3Assistant Professor 4Professor lowed by tendon dysrepair/failed healing occurring as a
and Head result of chronic overloading of the tendon. The authors
1
Department of Physiotherapy, Medwest Health Care, Melbourne
report collagen separation and matrix disorganization
Victoria, Australia, accompanied by neovascular ingrowth. The pathology
2
Department of Sports Medicine and Arthroscopy, Sri
progresses to degenerative tendinopathy, exhibiting
Ramachandra Medical College and Research Institute, Chennai areas of cell death, which, if severe enough, may evolve
India to tendon rupture. It is a well-documented fact that
3,4
Department of Orthopaedics, Postgraduate Institute of Medical degenerative tendinopathy is more prevalent in the older
Education and Research, Chandigarh, India population, where it has little capacity for reversibility. As
Corresponding Author: Vikas Bachhal, Assistant Professor a clinician, especially in a sports setting, it is important
Department of Orthopaedics, Postgraduate Institute of to understand that pathological tendons are not always
Medical Education and Research, Chandigarh, India, Phone: painful and pain can occur anywhere on the tendon
+917087008664, e-mail: vikasbachhal@gmail.com
pathology spectrum.1
Journal of Postgraduate Medicine, Education and Research, October-December 2017;51(4):175-181 175
Himmat S Dhillon et al

REVIEW OF LITERATURE improvements in pain and function in the management

of patellar tendinopathy.9 In a recent review of 11 RCTs
Tendon pain has the potential to be highly debilitating,
reviewed, Ortega-Castillo and Medina-Porqueres 10
especially in elite athletes, who tend to exhibit deteriora-
concluded that there was moderate evidence in favor
tion in their athletic function and performance.5 Evidence-
of eccentric training for reducing pain and improving
based management encourages clinicians to treat patients
strength in upper limb tendinopathies, recommending its
with the best possible protocols and, therefore, it is
inclusion in rehabilitation programs. In an RCT involv-
extremely important for a sports physiotherapist to be
ing 120 patients suffering from chronic lateral elbow
aware of optimal treatments in order to ensure high-
tendinopathy, Peterson et al11 compared eccentric with
quality athletic performance.
concentric loading. They discovered that patients in the
To determine the optimal treatment protocols avail-
eccentric training group exhibited significantly superior
able, an extensive literature search was conducted
results compared with the concentric group in terms of
in PubMed, Cochrane Library, Google Scholar, and
pain reduction and muscle strengthening after a 3-month
Medline using the following key words: tendinopathy,
intervention. Moreover, these improvements were main-
tendinosis, conservative, management, physical therapy,
tained at a 1-year follow-up.
sports, exercise. The search was restricted to randomized
As evidence suggests, tendon loading has proven
controlled trials (RCTs), systemic reviews, reviews, and
highly beneficial in managing chronic tendinopathies
meta-analysis between the years 2009 and 2016.
in the upper and lower limbs. On the contrary, tendon
Tendon Loading loading in acute or reactive tendinopathy should be
avoided and management should aim to reduce tendon
Literature search revealed that tendon loading through load.5 Isometric exercise is an emerging form of loading
various forms of exercise is being employed as the favored that has been experimented with in painful tendons,
management and is backed by strong evidence dem- especially during in-season rehabilitation where eccentric
onstrating significant improvements in pain, function, training would potentially aggravate tendon pain and is
athletic performance, and patient satisfaction in patients not a viable option. An RCT of 29 athletes with patellar
suffering from chronic tendinopathy. Additionally, tendon tendon pain concluded that both isometric and isotonic
loading through eccentric training has shown to have exercise programs were capable of significantly reducing
structural benefits including improved collagen produc- tendon pain at a 4-week follow-up.12 Rio et al13 assessed
tion, which has positive short- and long-term effects of the immediate effects of isometric and isotonic training in
the tendon structure.4 six athletes with patellar tendon pain and their random-
Malliaras et al6 conducted a systemic review to deter- ized cross-over study demonstrating significant reduction
mine the optimum loading programs for patients suffer- in pain immediately after one bout of exercise in favor
ing from Achilles and patellar tendinopathy. Their review of isometric training.13 Furthermore, these results were
of 32 RCTs demonstrated improved clinical outcomes sustained even 45 minutes following the exercise bout. In
as a result of improved neuromuscular performance. another midseason clinical trial, Rio et al14 demonstrated
However, they failed to observe any superior benefits of isometric training to be significantly superior to isotonic
isolated eccentric training when compared with eccen- training which exhibited immediate reduction in pain,
tric–concentric training and heavy–slow resistance which was sustained at 1-week and 4-week follow-up.
(HSR) training. Although further research is warranted
in various forms of tendon loading, a plethora of evi- Electrotherapy Modalities
dence exists regarding the benefits of eccentric training
Shock Wave Therapy
in tendinopathy. A randomized trial conducted by Beyer
et al7 comparing HSR training to eccentric training dem- Shock wave therapy is another area of interest and can
onstrated significant improvement in pain and function potentially be a beneficial modality for conservative
in patients with chronic midportion Achilles tendinopa- management of tendinopathy. In a recent meta-analysis of
thy using both forms of training. However, there was a 13 studies, Mani-Babu et al15 examined the effectiveness of
significant difference in patient satisfaction and exercise extracorporeal shock wave therapy (ESWT) in commonly
compliance in favor of HSR training. A meta-analysis occurring tendinopathies of the lower limb. They found
regarding eccentric training on Achilles tendinopathy, moderate evidence in favor of ESWT over home-based
patellar tendinopathy, and common wrist extensor ten- exercises and corticosteroid injections when treating
dinopathy exhibited beneficial outcomes regarding pain, greater trochantric pain syndrome and Achilles tendi-
function, and return to activity/sport.8 Another systemic nopathy. Interestingly, they also discovered that ESWT
review of 13 RCTs found that eccentric training yields was more effective in managing insertional Achilles

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tendinopathy when compared with eccentric exercise. Its effectiveness in reducing pain in acute and chronic
Additionally, combination of eccentric training with tendinopathies was demonstrated in a systemic review
ESWT was shown to be more beneficial when compared including 446 patients, over seven RCTs, and compara-
with eccentric training alone. In an RCT consisting of tive clinical trials.22 The authors concluded that not only
68 patients with chronic Achilles tendinopathy and a did topical GTN reduce pain in daily activities, it also
history of failed management, Rompe et al16,17 found enhanced tendon strength. Bokhari and Murrell23 con-
that combining ESWT with eccentric training yielded ducted three RCTs to assess the long-term benefits of GTN
significant improvements in pain and function at a patches in noninsertional Achilles tendinopathy, lateral
4-month follow-up in midportion Achilles tendinopathy elbow tendinopathy, and supraspinatus tendinopathy.
and at 1 year in insertional Achilles tendinopathy. These At a 3-year follow-up, only noninsertional Achilles ten-
results should encourage clinicians to administer ESWT dinopathy showed significant improvement whereas
as an adjunct to eccentric training. Despite the increasing no additional benefits where noted in any patient at a
interest in ESWT in the management of tendinopathy, 5-year follow-up. Nonetheless, the authors demonstrated
there is very limited research of its effectiveness in the short-term benefits of GTN patches in reducing pain in
upper limb. Galasso et al18 conducted an RCT to deter- lateral epicondylitis. Owing to the limited evidence and
mine its effectiveness in 20 patients with noncalcifying conflicting results, the treating clinician should make a
supraspinatus tendinopathy, demonstrating significant decision on administering a GTN patch. Patients using
improvements in pain and range of movement compared GTN patches have also reported of significant incidences
with baseline and the placebo group. Although further of headaches and need to be cautioned by the clinician
research is warranted in the area, current management prior to its use.22,24
should incorporate ESWT as an adjunct to eccentric train-
ing, especially in the lower limb. Manual Therapy

Laser Therapy and Therapeutic Ultrasound Soft-tissue mobilization has been a part of management
protocols for tendinopathies. A systemic review and meta-
Low-level laser therapy (LLLT) has been proposed as a
analysis conducted by Desjardins-Charbonneau et al25
management option for tendinopathy. A systemic review
demonstrated low-level evidence for efficacy of soft-tissue
with meta-analysis analyzed 17 RCTs to determine the
mobilization for patients with rotator cuff tendinopathy.
clinical effectiveness of LLLT on pain and function in
Furthermore, an RCT comparing the efficacy of soft-tissue
shoulder tendinopathy.19 The authors concluded that
mobilization with a supervised exercise program con-
LLLT produced clinically significant improvements in
cluded no significant benefits of soft-tissue mobilization
shoulder pain and function when used as an adjunct to
in reducing pain in rotator cuff tendinopathy.26
exercise therapy and even as monotherapy. Tumilty et al20
conducted a double-blind RCT including to study the
Emerging Concepts of Managing Tendinopathy
effect of photomodulation and eccentric exercises in 80
participants with chronic Achilles tendinopathy. Their Tendon Neuroplastic Training
results demonstrated clinically significant improvements
The exact source of tendon pain still eludes us, and this
in pain and function at a 12-week follow-up in favor of
is touted as one of the prime reasons for failed tendon
photomodulation being used as an adjunct to eccentric
rehabilitation by some authors, as they debate over
training twice a week. These studies demonstrate the
local and centrally mediated pain. In a recent narrative
potential of laser therapy as a treatment option in the
review, Rio et al27 proposed a new approach to rehabili-
future as further research in this area is warranted.
tation where they employed an exercise protocol using
Therapeutic ultrasound is commonly used for upper
externally paced strength training. Their new approach
and lower limb tendinopathy. However, there is very
aimed to restore corticospinal control of the muscle
low-quality evidence for its efficacy in improving pain
tendon complex by employing isometric and isotonic
and function as demonstrated by in a systemic review
strengthening in nine athletes, administering external
of 11 RCTs.21
paced resistance using a metronome capable of induc-
ing excitability and inhibition. Even though their results
Glyceryl Trinitrate
demonstrated significant pain reduction with both forms
Although glyceryl trinitrate (GTN) patches are used in of exercise at a 4-week follow-up, isometric training had
the management of tendinopathy by clinicians in man- significant immediate reduction in pain. This trial is the
aging acute and chronic patients, there is conflicting first of its kind and gives direction to future studies in
evidence regarding its long-term and short-term efficacy. this area with larger patient groups.
Journal of Postgraduate Medicine, Education and Research, October-December 2017;51(4):175-181 177
Himmat S Dhillon et al

Nutritional Intervention healing,30 making Orthopods consider options in sports-

related tendinopathies where the healing processes can be
Nutrition has been studied for many decades, and sports
enhanced.31 The usage of platelet-rich plasma (PRP) has
nutrition has gained significant importance when train-
become relatively frequent, with well-selected indications,
ing and rehabilitating elite athletes. Additionally, as a
in cases that have failed all other physical therapy modali-
team approach to rehabilitation in sports setting may not
ties plus a well-structured rehabilitation protocol. Our
always be an option, it is beneficial for a sports physio-
work on lateral epicondylitis,32 compared a single injection
therapist to be aware of nutritional interventions available
of leukocyte-poor (type-4) with bupivacaine injections, and
to aid the healing process of tendons. However, research
it has shown good improvement in pain and function for
in this area is extremely limited and a systematic review
recalcitrant lateral epicondylitis. This has also been cor-
by Curtis28 suggests that nutritionally supplementing
roborated by other research (Table 1),32-36 although larger
whey protein, protein, glutamine, and amino acids to the
multicentric studies are needed to recommend this as the
diet could promote protein and collagen synthesis in the
best modality of management.
healing human tendon. Although the authors reviewed
Another area of concern for sportspersons is the
110 studies, animal trials were also included. Nonetheless,
rotator cuff, and this is notorious for not healing in the
only results relevant to human trials have been discussed
distal part, which is the area involved in sports-related
in this essay.
injuries. The distal part of the rotator tendon heals
poorly, and PRP with its concentration of growth factors
Orthopedics and Sports Medicine Aspects
has the potential to stimulate tendon healing. Although
It is the opinion of the senior author (MSD) that sports- PRP has been used to augment rotator cuff repairs,
related tendinopathies in the acute phase respond well to the evidence does not support its use in that scenario
a supervised rehabilitation protocol, with limited phar- (Table 2).37-39 Nevertheless, there is some inconclusive
macological interventions.29 The current understanding evidence that PRP as a conservative option may help,40
is that the problem is not of an inflammatory nature, but it may be too early to advocate its routine use at
and hence there is a limited role of pharmacological this stage.
agents; nevertheless, in the acute stage, the judicious Patellar tendinopathy is commonly encountered in
use of nonsteroidal anti-inflammatory medication can jumping athletes and PRP injections may help in cases
help. The best suited under some circumstances could be of refractory pin unresponsive to standard physiothera-
Ibuprofen, probably best suited for the so-called “reac- peutic measures. Many studies have been conducted and
tive tendinopathy” stage, as this can have an inhibitory some are ongoing, and they are grouped in Table 3.41,42
effect on some ground substance proteins responsible for Although used extensively, PRP and other orthobio-
tendon swelling. logical products are still not proven to be effective beyond
Modern understanding of the pathology has made it doubt. Nevertheless, the increasing use and dependence
clear that a majority of the sports-related cases have issues of sports physicians and orthopedicians on this modality
with repetitive overload, and subsequent problems in to sort out what is essentially an overuse phenomenon
healing. We now have a better understanding of the role reflects on the changing paradigms in modern sports
of various growth factors and cells in the process of tendon medicine.

Table 1: Summary of studies using PRP for resistant lateral epicondylitis (modified from Dhillon et al30,31)
Patients PRP
Authors Study type studied Control type Outcome measure Results
Mishra and Cohort study 15 cases vs Bupivacaine 1A VAS, Mayo elbow score 81% reduction in pain in PRP
Pavelko33 5 controls group at 6 months
Creaney et al34 Prospective 80 cases vs 70 Autologous 1B PRTEE Improvement in PRTEE at 6
randomized controls blood months 35.8 in PRP and 46.8 in
trial ABI group with higher conversion
to surgery in ABI group
Thanasas et al35 RCT 14 cases vs 14 Autologous 1A VAS, Liverpool elbow 70.8% improvement in PRP
controls blood score group and 57.8% in the
autologous blood group at 6
months
Behera et al32 Prospective 15 cases vs 10 Bupivacaine 1A VAS, modified Mayo Significant improvement at 6
randomized controls clinic performance index months and 1 year for all scores
trial for elbow, Nirschl score
PRTEE: Patient-rated tennis elbow evaluation; ABI: Autologous blood injection

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Table 2: Summary of studies using PRP for rotator cuff injury (modified from Dhillon et al30,31)
Study Patients
Authors type studied Control Outcome measure Results
Randelli et al37 RCT 26 cases vs Nonapplication SST, UCLA score, Constant
PRP positively affected cuff rotator
27 controls of PRP score healing of grade I and II tears
38
Rha et al RCT Dry needling Shoulder pain and disability
Clinical effect of the PRP injection was
index, passive ROM superior to the dry needling from 6
weeks to 6 months after initial injection
Weber et al39 RCT 30 cases vs Nonapplication UCLA score, VAS, SST, No significant difference in VAS scores
30 controls of PRP ASES score between groups and no statistically
significant differences in recovery of
motion, SST, or ASES scores
ROM: Range of motion; SST: Simple shoulder test; ASES: American shoulder and elbow surgery; UCLA: University of California, Los
Angeles shoulder scale

Table 3: Studies using PRP for patellar tendinopathy (modified from Dhillon et al30,31)
Authors Study type Patients studied Control Outcome measure Results
Filardo et al41 Case–control 15 cases vs 16 Physical Tegner, EQ VAS, Statistically significant improvement in all
study controls therapy and pain level scores at the end of the PRP injections and a
further improvement was noted at 6 months
Gosens et al42 Prospective 36 patients – VAS, VISA Statistically significant improvement in VAS
case series and VISA scores in patients receiving PRP
injections

Table 4: Pain provocation tests for lower limb tendinopathy for tendon-related pain.44 On the contrary, Rio et al45
Tendon Low-load tests High-load tests have proposed a more centrally mediated response with
Achilles tendon Single leg heel raise Hop multiple potential contributors to pain.
Patellar tendon Decline squats Single leg highjump,
landing from height Optimum Tendon Loading
Hamstring Single leg bent knee Single leg dead lift
tendon bridging Although the pathology of tendinopathy is still elusive,
Gluteal tendon Single leg stance Hop it is known that unaccustomed tendon loading is respon-
sible for development of tendinopathy. However, the
Areas of Clinical Uncertainty amount of load that induces tendon pathology is still
unknown.4 Therefore, sports physiotherapists need to
The Pathology of Tendinopathy
develop exercise programs with sufficient rest intervals
To make good clinical decisions regarding management, between bouts, especially during trainings in season. The
the understanding of the pathological process of a dis- sports physiotherapists need to construct programs that
order is essential. The exact mechanisms underpinning ensure systemic progression of load in order to achieve
tendinopathy have eluded medical professionals with enhancement of the muscle–tendon unit capacity. Studies
some authors proposing an inflammatory component4 have shown type-1 collagen takes up to 3 days to respond
and others opposing this notion and claiming that acute to high-load training, and daily bouts of high-load train-
tendinopathy is a noninflammatory response.43 This ing place excessive strain on the tendon, eventually
debate has resulted in experimentation with various leading to injury.46 As per discussions during the lecture
physiotherapy and medical interventions, majority of on management of tendinopathy by Mr David Spurier,
which have been successful in determining an effective sports physiotherapists should consider employing an
concrete solution to the most effective management of approach of high-load training, followed by days of
tendinopathies (Table 4). low-load training followed by medium-load training to
ensure optimum rest to allow tendons to accommodate
Pain in Tendinopathy
to the loads.
Pain is the primary limiting factor in regard to function
and performance. Interestingly, a tendon can be pain-free Clinical Practice in Sports Physiotherapy
even with the presence of pathology leading to specula-
Quantification of Tendon Function and Symptoms
tion on whether the pain is a locally or centrally medi-
ated response. Neovascular ingrowth following collagen • Victorian Institute of Sport Assessment (VISA): The
disorganization is proposed to be locally responsible questionnaire has shown to have good test–retest,
Journal of Postgraduate Medicine, Education and Research, October-December 2017;51(4):175-181 179
Himmat S Dhillon et al

intrarater, and interrater reliability and is used as a tool 4. Cook JL, Purdam CR. Is tendon pathology a continuum? A
for functional assessment and severity of symptoms pathology model to explain the clinical presentation of load-
induced tendinopathy. Br J Sports Med 2009 Jun;43(6):409-416.
in patients with tendinopathy.47,48
5. Cook JL, Purdam CR. The challenge of managing tendinopa-
• Loading/pain provocation tests: Tendon loading and thy in competing athletes. Br J Sports Med 2014 Sep;48(7):
pain provocation tests used with visual analog scale 506-509.
(VAS) to monitor pain summarized in Table 3 assist 6. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and
the sports physiotherapist to monitor the athlete’s patellar tendinopathy loading programmes: a systematic
review comparing clinical outcomes and identifying potential
tendon response to training loads.5
mechanisms for effectiveness. Sports Med 2013 Apr;43(4):
Managing in-season acute tendinopathy and progres- 267-286.
sive loading in sports persons: 7. Beyer R, Kongsgaard M, Hougs Kjaer B, Øhlenschlaeger T,
• Minimize tendon compression and tension at various Kjaer M, Magnusson SP. Heavy slow resistance versus eccen-
sites in the tendon that have a potential to overload, tric training as treatment for achilles tendinopathy: a random-
ized controlled trial. Am J Sports Med 2015 Jul;43(7):1704-1711.
especially the enthesis.2
8. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendi-
• Progressive loading in the form of isometric exercises nopathy: effectiveness of eccentric exercise. Br J Sports Med
should be initiated as they have the potential to inhibit 2007 Apr;41(4):188-198, discussion 199.
pain immediately and can be repeated several times 9. Larsson ME, Käll I, Nilsson-Helander K. Treatment of
a day.14 patellar tendinopathy–a systematic review of randomized
• Depending on availability, ESWT, laser therapy, and controlled trials. Knee Surg Sports Traumatol Arthrosc 2012
Aug;20(8):1632-1646.
soft-tissue mobilization can be delivered for manage-
10. Ortega-Castillo M, Medina-Porqueres I. Effectiveness of the
ment of pain.15 eccentric exercise therapy in physically active adults with
• Modification of training in order to avoid heavy symptomatic shoulder impingement or lateral epicondylar
tendon-loading exercises on consecutive days.46 tendinopathy: a systematic review. J Sci Med Sport 2016
Jun;19(6):438-453.
11. Peterson M, Butler S, Eriksson M, Svärdsudd K. A random-
Management of Chronic Tendinopathy ized controlled trial of eccentric vs. concentric graded exercise
in chronic tennis elbow (lateral elbow tendinopathy). Clin
• From the physiotherapist’s point of view, the literature
Rehabil 2014 Sep;28(9):862-872.
review suggests that eccentric training should the 12. van Ark M, Cook JL, Docking SI, Zwerver J, Gaida JE, van
treatment of choice for managing chronic upper and den Akker-Scheek I, Rio E. Do isometric and isotonic exercise
lower limb tendinopathies and administering ESWT programs reduce pain in athletes with patellar tendinopathy
as an adjunct can potential yield long-term clinically in-season? A randomised clinical trial. J Sci Med Sport 2016
Sep;19(9):702-706.
significant improvements in function and pain.
13. Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ,
• As mentioned previously, the sports physiotherapist Cook J. Isometric exercise induces analgesia and reduces
needs to monitor the tendon response to loading and inhibition in patellar tendinopathy. Br J Sports Med 2015
training modifications should ensure that high-load Oct;49(19):1277-1283.
training is not repeated on consecutive days. 14. Rio E, van Ark M, Docking S, Moseley GL, Kidgell D,
• Interventions by sports physicians or orthopedic Gaida JE, van den Akker-Scheek I, Zwerver J, Cook J. Isometric
contractions are more analgesic than isotonic contractions for
surgeons are limited to the use of injections. As stated
patellar tendon pain: an in-season randomized clinical trial.
previously, lateral epicondylitis reacts well to PRP Clin J Sport Med 2017 May;27(3):253-259.
injections when other noninterventional methods 15. Mani-Babu S, Morrissey D, Waugh C, Screen H, Barton C. The
have failed. The debate still rages about the platelet effectiveness of extracorporeal shock wave therapy in lower
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2015 Mar;43(3):752-761.
of injections. Nevertheless, this is a procedure more
16. Rompe JD, Furia J, Maffulli N. Eccentric loading compared
frequently incorporated by the sports physician in with shock wave treatment for chronic insertional achilles
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