Is there anything that really works for tendonitis?

Change the column: why almost everything works for tendonitis at four weeks and almost nothing at twelve months

Is there anything that really works for tendonitis is a question asked by a reader who has tried several things, each of which worked for a while, and the honest page's answer is not a new thing to try but a change in the column the reader has been reading, because the reason everything seemed to work and nothing lasted is that the reader was reading the four-week column, and the four-week column for tendonitis is full of winners that mean nothing. A tendon with tendinopathy is a tendon whose load has exceeded its capacity for long enough that its matrix has disorganised, and when it is painful it is usually in a reactive state as well, swollen and sensitised on top of its structural disorganisation. Almost anything that drops the load or changes the pain calms the reactive state within a few weeks: rest does it, a brace does it, a new insole does it, a course of tablets does it, an injection does it, a change of shoe or bar or technique does it, and so does any treatment at all delivered by a confident person, since tendon pain, like all pain, is suggestible and responds to attention. So at four weeks a trial of almost anything against nothing shows a benefit, and a reader who tries almost anything feels better, and the four-week column has twenty winners in it. The structural disorganisation and the lost capacity are untouched by all of them, because capacity is changed only by remodelling under load, which takes months, and so when the reader returns to the load that found the tendon out, the pain returns with it, and the reader concludes that the last thing stopped working and looks for the next; the two lists, the fast one that relieves and the slow one that heals, are separated on the heals tendonitis fast page. The things that really work are the ones still ahead in the twelve-month column, measured against waiting or against an honest comparison in trials that followed people for a year, and that column is short, which is the good news, because a short column is one a reader can act on. Progressive loading heads it. The heavy slow resistance programmes and the older eccentric programmes, three slow repetitions at loads near the heaviest manageable every second or third day for the former, slow lowering on a step for the latter, are ahead at twelve months against wait-and-see, against corticosteroid injection, against platelet-rich plasma and against the other comparators in every trial that ran that long, with the gains holding or growing as long as the loading continues, and that durable lead is the reason progressive loading is the first-line treatment in every clinical guideline for tendinopathy and the reason a physiotherapist's programme looks, at four weeks, like the slowest thing on the list. It is slowest at four weeks because it is the only thing on the list that is doing the work the other things skip.

The twelve-month column read entry by entry, the one adjunct inside the thing that works, and the worked example

The twelve-month column read entry by entry gives each option its verdict. Corticosteroid injection is the clearest reversal in sports medicine: the winner at four weeks, with the largest and most reliable pain relief of anything on the page, and the loser at six and twelve months in the meta-analyses, where those injected were worse than those who waited or did physiotherapy and relapsed more often, because the injection relieved pain without changing capacity and suppressed collagen synthesis in the tissue around it, so the reader returned to full load on a silent, weaker tendon; the loop that feeds is on the quickest way page. Platelet-rich plasma, in which the reader's own blood is spun down and the concentrated platelets injected into the tendon, has a mechanism that sounds like it should work and a trial record that says it does not: in the well-run blinded trials for Achilles and elbow tendinopathy, platelet-rich plasma did no better than an injection of saline, which suggests that whatever good followed the procedure came from the needle, the attention and the rest and loading afterwards rather than from the platelets, and the unblinded trials that favour it are the ones whose patients knew what they had been given. Shockwave, pulses of pressure delivered through the skin, has modest evidence for a few tendons, calcific tendinopathy of the shoulder most clearly and some plantar and lower limb cases, as an adjunct beside a loading programme rather than instead of one, and little for others. Surgery, which for tendinopathy means removing the degenerate tissue and stimulating a healing response, did no better than a structured exercise programme in the randomised trials that compared the two for patellar and Achilles tendinopathy, with the exercise group reaching the same place without an operation, which is why surgery is held for the few whose loading programme has failed after many months. Dry needling, acupuncture, laser, ultrasound, taping and the various braces sit in the four-week column with evidence that is small, short or absent at a year. And collagen has one small six-month trial, 2.5g a day beside six months of calf strengthening for Achilles tendinopathy, ahead of placebo beside the same calf strengthening, which places it as an adjunct inside the one thing that works rather than as a thing that works on its own, with a synthesis marker trial, 15g gelatin with vitamin C an hour before loading in healthy men, as the mechanism behind it; it is read for exactly what it is on the collagen and tendonitis page. The honest shape of the answer is therefore that one thing really works, progressive loading, that a few things are adjuncts beside it, isometrics for pain, a heel raise or grip change to keep the day under capacity, shockwave for a few tendons and collagen's protocol beside the heavy session, and that the things which looked like they worked were working on the four-week problem while the twelve-month problem waited. The worked example is the adjunct at habit scale, stated on its true terms: two capsules, 1200mg hydrolysed type 1 marine collagen with 12mg vitamin C at 15% of its reference value plus zinc, 120 for £16.99 at 28p a day, lab tested and UK made, below the 15g protocol dose, carrying vitamin C's collagen formation sentence for cartilage and bones and no tendon claim. Is there anything that really works for tendonitis: yes, the slow one, and the way to see it is to stop reading the four-week column.

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