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Achilles tendinosis
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Achilles tendinosis - March 6, 2007 3:32:00 AM
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proud
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Does anyone have a protocol they are willing to share for treating Achilles tendinosis that is in tune with the work of Khan et al?
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Re: Achilles tendinosis - March 6, 2007 4:24:00 AM
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PTupdate.com
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Not familiar with Khan et al. What is his tune?
Duffy
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Re: Achilles tendinosis - March 6, 2007 4:56:00 AM
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proud
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Duffy,
Karim Khan. He has done a fair amount of work in the area looking into the histopathology of things. Much of the work has resulted in the current paradigm shift in the treatment of tendons. I think most PT's employ the knowledge but without knowing where some of the research came from.
A pubmed search brings him up. Some of the work describes treatment guidelines however I was looking to see if someone here has formulated a protocol consistent with that work that they find effective. Basic guidlelines include: neovascularization and the use of ice/laser/high-voltage galvanic stimulation; Biomechanical unloading, eccentric strengthening; acceptable timeframes for return to sporting activities etc.
Regards,
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Re: Achilles tendinosis - March 6, 2007 5:57:00 AM
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PTupdate.com
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I just covered an article titled: ULTRASOUND GUIDED ELECTROCOAGULATION IN PATIENTS WITH CHRONIC NON-INSERTIONAL ACHILLES TENDINOPATHY: A PILOT STUDY. British Journal of Sports Medicine, June 2006
Your question reminds me to print the references at the end with regards to the above treatment and also use of sclerosing agents for a guy at the gym with chronic tendinosis.
My typical routine includes: Manual therapy to adhesions/thickening, GSC stretching without agitation, eccentric strengthening, heel lift for relief, control of pronation and thus "wringing" of the tendon, iontophoresis with either dexamethasone, or acetic acid and ice. The above mentioned guy is one of the few that I could not get resolved. I also used focal pulsed US.
Not sure if any of the above could be traced back to Khan.....Khan.....KHAN!! (Trekkies will know what I mean there)
John Duffy, PT OCS
[URL=http://www.PTUpdate.com]www.PTUpdate.com[/URL]
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John M. Duffy, PT
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www.PTupdate.com
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Re: Achilles tendinosis - March 6, 2007 6:49:00 AM
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ptim
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Khan's protocol is.
Eccentric Heel drops on a step, 3X15 2X/day for 12 weeks.
Pain on/Pain off, increase/decrease the loading with bilat-unilat and add weight (backpack).
Look at Alfredson et al, he has done alot of work on achilles tenopathy.
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Re: Achilles tendinosis - March 6, 2007 7:12:00 AM
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mcap56
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KHAN!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
I have always struggled with this one clinically. While I could certainly view most tendinopathies as tendinosis instead of tendonitis and I see the need for x fiber massage, and eccentric loading to address the non inflammatory degeneration.......the achilles always spooked me for some reason.
I have always been hesistant to move ahead of eccentric loading or any heavy loading in achilles tendinopathy because of the possibility of a tear or rupture. I know you probably wouldn't cause a rupture but who knows the state of the tendon and how much pathology there is there. Anyone else have the same dilemna? I know it may not be totally rational but......
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Re: Achilles tendinosis - March 6, 2007 8:00:00 AM
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proud
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mccap56,
Khan has an article out that discuses the tendinosis and tendonitis debate. If you like reading about ground substance, vascularity, cellularity, fibroblasts and myofibroblasts... it is a pretty decent read. Dry information but I think important to understand.
I know it is available online but I cannot seem to find it.
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Re: Achilles tendinosis - March 6, 2007 8:24:00 AM
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ptim
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Khan tells the story of how Alfredson became interested in eccentric loading. Alfredson is a keen runner and developed an achilles tendonosis and wanted surgery, but the ortho wouldn't do surgery unless it was ruptured. So he started doing heel drops (aggressive eccentric load to the achilles) in an attempt to rupture it!!! and much to his supprise over a period of a few weeks it improved and resolved.
Alfredson's study of chronic achilles tendonopathy using eccentric loading had a 90% success rate at 12 weeks in a population of patients that had failed everything else.
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Re: Achilles tendinosis - March 6, 2007 10:16:00 AM
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chunkypuffin
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Hi all,
Just thought I'd add my 2 pence worth (coming to you from across the pond, hence not cents :-)). The recent work by Alfredsons group indicates that the success behind their protocol may lie in its effect on the neovascularity present in some degenerate mid-tendon tendinopathies (1). Similar effects were noted with the an injection of anaesthetic + adrenaline targeting these structures in 'tennis elbow' patients. The protocol appears to be less successful with insertional tendinopathies, possibly due to differing pathological mechanisms. Interestingly, the regime of eccentric work often utilised by therapists uses higher reps or lack of load progression, yet is reported to have success. This has recently been pointed out on my masters course and may be due to changes in the viscoelastic properties of the tendon and a reduction in hysteresis loss (3). As always with peripheral symptoms, somatic referral and neural referral/involvement need to be cleared.
Best regards
Craig
(1) Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis. Ohberg and Alfredson, 2004. Knee Surgery, Sports, Traumatology and Arthroscopy, vol.12, pp465-470.
(2) Extensor origin vascularity related to pain in patients with tennis elbow. Zeisig, Ohberg and Alfredson, 2006. Knee Surgery, Sports, Traumatology and Arthroscopy, vol.14, pp659-663.
(3) Effect of stretching training on the viscoelastic properties of human tendon structures in vivo. Kubo, Kanehisa and Fukunaga, 2002. Journal of Applied Physiology, vol. 92, pp595-601.
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Re: Achilles tendinosis - March 6, 2007 6:31:00 PM
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Geert Jeuring
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That´s how myths are created. I posted to mr. Alfredson personally as one of my students asked what the idea behind eccentric loading is. He answered rather dryli that there wasn´t a real hypothesis to start with, more like trial and error (as far as I remember the email). If the discovery was as hilarious as described above, I´m rather sure he would have told me so because it makes a good story.
But you can ask him yourself:
hakan.alfredson@idrott.umu.se.
Greetings Geert
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Re: Achilles tendinosis - March 7, 2007 2:12:00 AM
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PTupdate.com
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It looks like I have read the Khan stuff...including the backpack idea.
But, I rarely have or need 12 weeks to resolve this problem, but rather get 12 visits, so have to make the best of my time.
mcap: I never worried about a tear/rupture, as the eccentric program is so controlled and slow, and ruptures occur with a rapid subconscious event.
I would be interested in seeing a study that details how the tissue changes with a course of deep tissue work, be it TFM, ASTYM or whatever.
Just finished up a rupture repair patient....ref at the PSU game where Paterno broke his leg. Blew his out in the first series of downs, and when his wife saw him bent over with the other refs on TV, was wondering why he'd puke on national TV!
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
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www.PTupdate.com
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Re: Achilles tendinosis - March 7, 2007 6:17:00 AM
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certMDT
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Craig -
I was at a conference where Dr. Khan was speaking, I asked him about the neurovascularization theory, as he had not mentioned it when pressed about the reason for success with the program. If I understood him correctly, he indicated that he more or less disagreed with the neurovascularization as the primary cause. His explanation was thorough, elegant, and convincing, and I wish I had recorded it, because I really can't remember it now.
He emphasized the importance of load and focus on eccentric exercise, and discussed how the same parameters are bearing out for patellar tendinosis (and I've read at least one pilot study for supraspinatus tendinopathy).
During his talk he spoke at length about the chemical changes involved in tendinopathy. If anyone else was at the last McKenzie conference, maybe they can fill in the gaps for me.
Charlie
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Re: Achilles tendinosis - March 7, 2007 8:48:00 AM
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jlharris
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Duffy,
No matter the visits you "have" with them. The treatment is straight forward and works. Of course it only takes 1-3 visits to teach them how to do it, so you wouldn't even get those 12 you were talking about.
I have 2 articles from Alfredson on eccentrics for Achilles tendonosis, 1 from Shalabi showing decrease in tendon girth after the 12 weeks of eccentrics shown through MRI, and an article by Roos that reproduced Alfredson's work and included a 1 year follow-up.
It's hard early on to trust the pt to do their exercises as home, but in the case of Achilles Tendonosis these research articles show that it's the way to go. I tend to just make f/u calls monthly to check how they are doing. Can't charge for that, but if they are struggling, I can get them back in.
Also, in my limited experience, pt's feel better early (< 3 weeks) but need the full 8-12 weeks to return to running, soccer, etc.
I'll try to do article reviews and submit them @ PTupdate for you.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: Achilles tendinosis - March 7, 2007 8:58:00 AM
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ptim
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Charlie
Khan talked about 'mechanotransduction'
The shearing of the tendon cells produced with eccentric loading produces a biomechemical signal that triggers the tendon cells to regenerate
Khan explained it beautifully, a very entertaining guy to listen to.
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Re: Achilles tendinosis - March 7, 2007 10:43:00 AM
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chunkypuffin
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Hi again,
thanks for the info Charlie and ptim. Always interesting to hear differing opinions from the leading authorities. As far as the mechanotransduction theory goes I've not heard of this before. The immediate question that springs to mind is - if the symptoms are purely due to the degeneration of the tendon why does the recovered tendon still display characteristic hypoechogenic regions on ultrasound scan? Have biopsy results been taken pre and post regime to qualify this theory? It's interesting to note that the neovascularisation is also associated with degenerative discs. Could it be that this neovascularisation and associated innervation are in part responsible for low back pain? I think another interesting aspect of this is the assumption that the painful tendon is a weak tendon. This has been refuted by Alfredsons group with a case study on an Olympic weightlifter who underwent sclerosing injection for patella tendinopathy pain relief and resumed heavy training 2 weeks later. As always these results should only be applied to similar patient groups so extrapolation to Achilles tendinopathy would be ill-advised. Mid-body and insertional tendinopathies should likewise be differentiated as teh insertional tendinopathies appear to rspond less successfully to eccentric programs.
Interesting topic, look forward to any more views and info on it.
Best regards
Craig
Is the chronic painful tendinosis tendon a strong tendon? Gisslén, Öhberg and Alfredson, 2006. Knee Surgery, Sports Traumatology, Arthroscopy, vol.14 no.9, pp897-902.
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Re: Achilles tendinosis - March 7, 2007 4:28:00 PM
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ginger
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Hello Craig and others. Some of you have been included in similar topics where I have discussed treatment methods and likely outcomes regarding various "tendonopathies"and "tendonoses" . Those familiar with an approach that seeks cause , or rather , seeks to direct attention to the likely cause of mystery tendon pain and dysfunction will have considered the role played by the nervous system in the aetilogy of such ailments. Personally , since turning my therapeutic attentions away from limbs at the sight( site for those in the US ) of pain and treating the spine a priori , I have found much to enjoy about a considerable improvement in results.
Most examples of the so called achilles tendinosis, is dealt with most effectively by attention , using continuous mobs ( and certainly other methods related to the spondyl/nerve ) to the joint/ nerve that relates to the dermatome . It can be repeatedly observed , that a full and lasting resolution to "tenonoses", can be obtained within one to three treatments. This is without any attention to distal structures .
For those still probing the leaves of the forest and unable or unwilling to step back and view the forest , let me say once again. If you have not first comprehensively and skillfully , with appropriate method and application of that method , eliminated the central spine, including facet joint and nerve as cause, you are just wasting time.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Achilles tendinosis - March 10, 2007 7:02:00 AM
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Geert Jeuring
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Hello Ginger, although I haven´t been on this forum for a while with you the song remains the same. Obviously I´m still (after I´ve completed two complete courses in manual therapy) tugging at the leaves. Personally I would like to see some studies to accompanie such bold opinions.
Geert
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Re: Achilles tendinosis - March 10, 2007 9:17:00 AM
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VagusX
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Ginger
I would agree that your statement is bold without research, but I would agree that a thourough examination is needed to rule out the spine.
Im curious as to how you would mobilize the S1-S2 nerve root being at least part of the dermatomal pattern affecting the triceps surae unit?
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Re: Achilles tendinosis - March 12, 2007 5:19:00 PM
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ginger
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hello Geert and vagusX. I don't mobilise nerves at all . At least it is not my intention as I go about the business of mobilising facet joints to be concerned ( as some are ) about "flossing" or manoevering nerves per se at all . The method I employ is to restore normal pain free movement to spinal facet joints, with attention paid to those that relate to the distal pain/dysfunction . In order to assert by noting change to those distal structures, the cause of those distal ailments. In doing so I almost invariably find , and have done so for nearly twenty years now , that MOST musculoskeletal pain /dysfunction not directly trauma related, are shown to have been referred events. Obviously nerve involvement is taking place. This is best understood ( acc to my model ) as referred events occasioned by temporary inflammatory neural irritation. By resolving the , for instance, L5S1 facet hypomobility , I would expect to relieve achilles pain/ swelling and calf tightness. This is reliably seen to be the case in the vast majority of so called achilles tendonosis cases that come my way. This method is not confined to me , I have been teaching it to hundreds of post and undergrads here in Melbourne for many years. It rather fits with a culture of manual therapy that is quite strong here in Australia. Not unusual or considered so. It does seem that these methods are considered unusual in those countries where PT is rather more an exercise rehab style of intervention, such as in the US.
Not to pretend or assert some dominant position of authority in these matters , I simply tell the story as I regularly see them played out in my rooms. To not share them would seem to be private where public interests are served, I'm sure you would agree.
As to the need to "mobilise" S!1/S2, I have never found this necessary, even if I knew how.
Excellent results that are lasting in the resolution of a range of achilles/calf /heel / foot pain/dysfunction is achievable with atttention to L5 L4 facet joints , with some needing sciatic nerve stretches ( which I do ballistically , with instant and excellent responses )
There really is a wide gap in the likeihood of good lasting results in those who still employ only exercise in their attempts at resolving musculoskeleta problems, with those who consider the spine first.
Cheers
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Achilles tendinosis - March 13, 2007 7:23:00 AM
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jlharris
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Ginger,
Does the nervous system cause the tendon hypertrophy seen with MRI in these "tendonosis" patient's? The Alfredson articles are fairly dramatic in terms of pt decrease in pain and increase in function (and the Roos article shows this remains over time) with eccentric exercises vs surgery or non treatment. Obviously this hasn't been compared to a "neural" treatment, but it's hard to ignore it and turn to something that (apparently) hasn't been shown effective except trough anecdotal evidences.
BTW, off topic, but had a patient the other day with a diagnosis of "adhesive capsulitis". She'd been having shoulder pain for almost one year with limited AROM after a fall onto the ipsilateral out stretched hand. Treated her TWICE with unilateral C5-6 TP AP continuous mobs and she had FULL reduction in her shoulder pain and return of her AROM. Felt bad that she had pain that long. Glad you and Nari have "bold" opinions that allowed me to not just treat her with ROM, ROM, ROM.
Look forward to your answer regarding the tendon hypertrophy.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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