Massage Therapy for People with Tendon Pain

Tendinopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading (Scott et al., 2020). In addition to a local tendon pathology a biopsychosocial approach to tendinopathy acknowledges and addresses the biological, psychological, and social contributions to pain and disability (Ackermann et al., 2022; Edger et al., 2022).

• Medial or lateral elbow tendinopathy refers to persistent medial or lateral elbow tendon pain and loss of function related to mechanical loading.
• Gluteal tendinopathy refers to persistent lateral hip tendon pain and loss of function related to mechanical loading.
• Patellar tendinopathy refers to persistent patellar tendon pain and loss of function related to mechanical loading.
• Achilles tendinopathy refers to persistent Achilles tendon pain and loss of function related to mechanical loading.
• Peroneal (fibularis) tendinopathy refers to persistent peroneal (fibularis) tendon pain and loss of function related to mechanical loading.

A Framework for Evidence-Based Massage Therapy

For people with tendon pain a multidisciplinary approach including exercise therapy and load-management are first line treatments. In addition, manual therapy may be a useful adjunct to help manage pain and other associated symptoms (Irby et al., 2020; Jayaseelan et al., 2022).

Informed Consent

Informed consent will include a discussion about natural history and the effects of no treatment, as well as the possible risks and benefits of receiving treatment. The therapist and patient will then work together to develop a plan of care based on the individualized goals and needs of the patient. This approach gives people the opportunity to be engaged in their own health through the process of shared decision making.

Comprehensive Assessment

A comprehensive assessment assists the clinician come up with a treatment plan that is best suited to each individual. It may involve a physical examination and detailed health history intake to gather information about patients' limitations, course of pain and can help identify those with a higher likelihood of red flags (serious underlying pathologies) or yellow flags (prognosis factors for delayed recovery). This may also help establish therapeutic alliance and identify the biological, psychological, social and contextual factors contributing to pain and disability.

• Physical Examination - A physical examination could include palpation, observing gait, neurological screening tests, assessing mobility and/or muscle strength. Interpret examination results in the context of all assessment findings and implement an individualized treatment plan that is based on the assessment findings and goals of the patient.
• Red Flags (serious underlying pathologies) - Red flags are signs and symptoms that raise suspicion of serious underlying pathology, if a serious pathology is suspected a clinical decision should be made to refer the patient to an appropriate healthcare practitioner. For the general population there are several red flags to be mindful of such as, substantial motor/sensory loss or progressive neurological deficits, fractures or osteoporosis risk/fragility fracture, acute infection, joint dislocation, and venous thromboembolism.
• Yellow Flags (risk factors for delayed recovery) - This assessment process could also include screening questionnaires, such as the Orebro musculoskeletal pain questionnaire or Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) to help identify yellow flags or identify patients at risk of poor prognosis. If the patient develops worsening physical or psychological symptoms consider a referral to counseling or an appropriate healthcare professional for further evaluation.

Outcome Measurements

Clinicians should use appropriate tools and strategies to monitor and evaluate the effectiveness of the treatment plan and adapt care accordingly. This could include incorporating one or more of the following outcome measurements when assessing and monitoring patient progress:

• Self-Rated Recovery Question
• Patient Specific Functional Scale
• Brief Pain Inventory (BPI)
• Visual Analog Scale (VAS)
• Wearable Activity Tracker

Education & Reassurance

Focus on the concept of a person-centered approach that addresses biopsychosocial influences and empowers people with shared decision-making. Provide reassurance and facilitate an evidence based understanding of treatment options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms. Reassess the patient’s status at each visit for new or worsening symptoms, or satisfactory recovery.

Multidimensional Treatment Plan

• Manual Therapy - A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. There may be times that focal irritability (i.e., nerve irritation, trigger points, nervous system sensitization) co-exists with tendon pain. Gently stretching the muscles, neurovascular structures, and investing fascia activates endogenous pain modulating systems that help to modulate neuro-immune responses.
• Self-Management Strategies - Clinicians managing tendon pain should be thoughtful and skilled in managing the load on the tendons and supporting structures through a number of rehabilitation considerations. Self-management strategies such as isometric exercises, hydrotherapy, and relative rest may be useful for people with tendon pain.

Reassessment and Reevaluation

Reassess the patient’s status at each visit for new or worsening symptoms, or satisfactory recovery. Then the patient is discharged, treatment is continued, or treatment is escalated based on response to the initial treatment plan, risk/benefit assessment and shared decision making.

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