POTENTIAL NERVOUS SYSTEM SENSITIZATION IN PATIENTS WITH PERSISTENT LOWER EXTREMITY TENDINOPATHIES: 3 CASE REPORTS

BACKGROUND & OBJECTIVE

Tendinopathy research is currently growing, increasing our knowledge on tendon structure, adaptations from different stressors, usefulness of clinical interventions, and changes in function in these pathologies. Traditionally, tendinopathy has been viewed as a local tissue pathology, whereas there is growing evidence of peripheral and central nervous system changes in this condition. Individuals with tendinopathic changes may experience central sensitization, altering the person’s pain modulation and threshold for varying senses. This may be why interventions such as aerobic exercise and pain neuroscience education (PNE) can reduce individual’s pain levels with tendinopathy. Currently, evidence varies in demonstrating this phenomenon, suggesting more research is needed.

METHODS

This was a retrospective case series examining three patients with persistent lower extremity tendinopathies with self-reported disability of one or more years. Each patient had been treated multiple times with therapy ranging from strengthening (eccentrics, isotonics, isometrics), modalities (laser, ultrasound, dry needling), manual treatments (mobilizations, transverse friction massage), corticosteroid injection and had MRI findings suggesting tendinopathic changes.

The patients ranged from 27-42 years old with symptoms lasting 18-48 months. Two cases were Achilles tendinopathy and one was patellar tendinopathy. Functional limitations were primarily activities involving running, stairs, or walking in high heels. Examination consisted of static posture, gait analysis, red flag screening, neurodynamics, AROM/PROM, joint mobility, bilateral/unilateral squats, heel raises and hop testing. Pain pressure threshold testing for nociceptive processing was done on the tendon, contralateral tendon, and contralateral thenar eminence. The numeric pain rating scale, VISA-A or VISA-P, and central sensitization inventory were completed.

Treatment in this study differed from what the patients has experienced previously, and focused on joint mobilizations, self-stretching, PNE, and aerobic exercise. PNE was simply introduced in the first session, but was focused on during the second session with 45 minutes of PNE. Impairment-based manual therapy was meant to reduce tendon strain and reduce pain. Self-stretching was instructed for a home-exercise program. Treatments were approximately every two weeks with re-evaluation of varying tests across a two-month period.

RESULTS

The patients had clinically significant changes in tendon pain, self-reported function, and pain pressure threshold testing. Improvements were maintained at a 1-year follow up.

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