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Tendinopathy
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Tendinopathy - January 5, 2005 4:17:00 AM
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ericm
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In the last decade a shift occurred in which we no longer automatically conclude chronic tendon problems represent tendonitis but rather more likely a condition called tendinosis. Presumably, for most this has also meant a shift in how these problems are managed. For example, modern thought now widely promotes eccentric strengthening exercises.
I can think of alot of questions here, but for now I'd just like to ask, how's this shift in thinking working for you? For those of you who began practicing in the 'itis' era, are you now getting better results? What have we learned about the deep model of pain in chronic tendon conditions?
eric
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Re: Tendinopathy - January 5, 2005 5:21:00 AM
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bravocosta
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Hello Eric,
Try this weblink which questions some of the commonly held assumptions and beliefs about RTC retraining.
http;//www.aptei.com/articles/pdf/Rotator_Cuff.pdf
This fellow (Bahram Jam) has a host of insightful articles on his website.
Cheers.........Thomas
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Re: Tendinopathy - January 6, 2005 5:10:00 AM
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PTupdate.com
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I do not believe my treatment changed that much, as I have alwasy provided a mix of anti-inflammatory treatment, and mechanical treatment.
While much of the literature points out that histological analysis of extracted tissues (from ECRB in tennis elbow, Achilles, etc) reveals few inflammatory cells and more granular/degenerated tissue, we have to look at how the patient presents.
If a chronic lateral epicondylitis patient responds to a corticosteroid injection and/or NSAID therapy, I have to assume there is still an inflammatory component, and treat accordingly.
I still perform my mechanical treatments, via TFM and exercise. There is always the chance that the soft tissue techniques tear, or release, the damaged tissue (similar to the surgical release) and thus the positive response. This may be why the Mill's manipulation for the elbow is successful.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: Tendinopathy - January 6, 2005 6:54:00 AM
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Bournephysio
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Tendinopathy is not an inflammatory process by definition, since there are no inflammatory cells present. I don't think that you can call inflammation an all or nothing response. Dr. Hart talks about endogenous vs exogenous inflammation. While there isn't exogenous inflammation (no inflammatory cells present) The tenocytes themselves do produce and respond to inflammatory mediators such as cytokines (endogenous inflammation). Even if there was no inflammation present, we can't assume that antiinflammatories only effect inflammation.
After seeing Karim Kahn speak at my old school, new school and at IFOMT and seeing Cook speak at IFOMT and seeing Curwin speak here, I was under the assumption that it was pretty clear that eccentric exercises were better than concentric exercises for treating tendinopathy. So for a paper in my course last semester I decided to look at why that might be. I was suprised to see that there has only been one rct looking at concentric and eccentric exercises and it was very flawed. Besides not blinding anyone the groups were doing vastly different exercises.
Doug
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Re: Tendinopathy - January 6, 2005 1:54:00 PM
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ericm
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Doug, I've also been under the assumption eccentric exercises were better than concentric. I believe the theory is that eccentric load stimulates the tenocyte to produce collagen. The increase in pain often experienced as one begins eccentric exercises has been related to a shearing effect on vasculature which has grown in a disorganized fashion within the tendon. At least that is what a sports med Dr told me.
I am puzzled why an eccentric muscular effort places any different a load on the tendon than a concentric contraction would. Are they not in series? Why wouldn't a forceful concentric contraction do the same thing? I appreciate that eccentric contractions are capable of producing more force, but are these forces actually achieved during the exercies commonly performed? I agree that the lack of standardization in exercise protocol is a problem.
Furthermore if eccentric exercise is beneficial, what does this tell us about the mechanism of injury, a lack of eccentric loading in the period prior to onset of symptoms?
thanks for all your replys,
eric
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Re: Tendinopathy - January 6, 2005 2:20:00 PM
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Bournephysio
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"I am puzzled why an eccentric muscular effort places any different a load on the tendon than a concentric contraction would."
That is exactly why I wanted to look at this. The exercise program advocated by Alfredson involves slow eccentric exercises over a step (achilles tendonopathy). At a constant speed the muscle only needs to resist body weight which is the same for eccentric and concentric exercise. The tension has to be the same.
Others have recommended faster eccentric contractions such as drop squats or dropping over a stair. Curwin presented data in class that the tension developed in the heel drops was still less than that developed while running. Stanish, somebody and Curwin is probably the earliest record I have seen recommending eccentric exercise and probably the most widely cited.
There are a few different theories why eccentric exercises may be better but if they are not better the theories are pretty useless.
Doug
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Re: Tendinopathy - January 6, 2005 3:09:00 PM
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Jon Newman
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Here's some thoughts of my own...not research based.
It is more common to have "muscle pain" after eccentric exercises than concentric exercises if I'm not mistaken. Perhaps the nature of the contraction has the ability to trigger an inflammatory reaction in the local tissues. How I don’t know.
Tendonopathy describes issues in the tendon and does not speak directly to how the nerves that send pain signals become involved. Thus a lack of inflammation, the normal way we view nociception coming into play, is not what is going on to cause pain. Perhaps the pain is "asking" that something be done differently as the normal biological process has become short-circuited.
Perhaps eccentric exercises autogenically cause the missing inflammatory reaction needed to heal the tendon. This would account for both more pain in eccentric contractions in normal conditions and its relief in a tendinosis (as an inflammatory reaction is what is missing to heal the tendon). This also may be why some people get relief using cross friction massage. The big problem with cross friction is the externally applied forces also causes the chance for all kinds of inflammation where it is not needed not to mention the bizarre orthogonal stresses one would be asking a compromised tendon to endure.
Just thinking out loud on a non-whole person level.
jon
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Re: Tendinopathy - January 6, 2005 4:41:00 PM
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ericm
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Links to some of the articles Doug mentions can be found here [URL=http://www.clinicalsportsmedicine.com/rroom.htm]Clinical Sports Medicine[/URL]
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Re: Tendinopathy - January 6, 2005 5:21:00 PM
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steve
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Eric,
Good to see a fellow islander here! For me, the tendinosis helps explain why chronic lateral epicondylitis fail to improve quickly where as you would expect an inflammatory condition to resolve much sooner. It wasn't that I was missing some magical facilitated segment or thoracic sympathetic input - although I'm sure that on occassion this is the case, rather that the half life of collagen is around 180 days and requires a substantial period of time to reorganize itself as stress is applied. Interesting comment by Jon regarding pain and eccentric exercises, I attended a lecture by Alfredson and he stressed that the eccentric exercises should be painful when performed. He also provided a similar explanation as to why they are effective as the one Eric proposes. There is also some interesting research on monkeys forced to perform repetitive tasks and changes in their brain organization.
Doug - Dr. Kahn is an excellent speaker and perhaps one of the best advocates of physiotherapy that I have seen, I have heard him on a couple of occassions and quite impressed.
Steve
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Re: Tendinopathy - January 6, 2005 5:57:00 PM
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ericm
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Steve, that's interesting information regarding the half life of collagen. I think we can conclude that tendon healing follows a linear, therefore predictable path, albeit prolonged. In my experience however, the pain associated with a tendinopathy may actually leave well before, or not until well after 180 days of eccentric training has passed. It's far less predictable. To me this suggests another model of pain must be at work. I hope others can add to this discussion so we can get to the bottom of it.
eric
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Re: Tendinopathy - January 6, 2005 6:05:00 PM
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nari
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OK, I am going to ask a dopey question...
why is there always assumed there is tendon injury? and inflammation as a result? What proof is there that the tendon is damaged?
Or that there is any muscle injury?
Why do these tennis elbows/tendonoses/itises respond so quickly to neural mobs if we are looking at 'tendon pain?' or 'muscle pain'.
Just curious
nari
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Re: Tendinopathy - January 6, 2005 6:46:00 PM
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steve
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Eric,
I agree that sometimes the pain may disipate well before the 180 day mark but tendinopathies do tend to have a prolonged recovery patterns and likely pain leaves well before (And sometimes after) the tissue has finished its remodelling process. My point was simply that there is an explanation as to why they have prolonged recoveries.
Nari,
I would agree with you that we often don't know what tissue or central mechanism is responsible for an individuals pain experience based on a physical assessment. Certainly there is some evidence to suggest that neural tension tests are positive for a significant number of individuals with "Tennis elbow". There is also research to say that psychosocial factors are a strong predictor of repetitive strain injuries in the upper quadrant. I believe that Eric has basing his line of questioning on the analysis of surgical tendonosis that found no signs of inflammatory cells but rather disorganized collagen patterns and vascular ingrowth.
I think that likely the difficulties with the management of tendinosis is that there causes are multifactorial - collagen/tissue breakdown, psychosocial factors, neural tension, ergonomics, central mechanisms...
Steve
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Re: Tendinopathy - January 7, 2005 8:47:00 AM
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Bournephysio
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Steve, Karim is a great guy and an amazing speaker.
Nari, there is histological proof that tendons become damaged. A strong correlation between neovascularization of the tendon and pain has been found. A decrease in pain has also been shown to correlate with a decrease in neovascularization and improvement of tendon structure. That is not saying that all diagnosed "tendinopathies" are do to tendinosis.
Jon, your theory of how eccentric exercise could cause tendinopathy is interesting. The only problem is that if the inflammatory mediators from the muscle were causing the problem, you would expect more musculotendinous tendinopathies and very few mid substance or insertional tendinopathy.
The half life of collagen will be much different in a diseased tendon.
Still, if the tendon is exeriencing the exact same mechanical enviroment, what difference could there be between eccentric and concentric exercises?
Doug
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Re: Tendinopathy - January 7, 2005 2:47:00 PM
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Jon Newman
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Hi Doug,
I have little doubt that there are plenty of flaws with my theory. If not, I'm brilliant because I essentially just made that up. Just to be clear. I wasn't claiming that eccentric exercises cause the tendinosis. I was claiming that the pain associated with eccentric exercises was likely inflammatory by nature and that this inflammatory response may trigger healing of the tendinosis assuming both the muscle and tendon have a similar vasculature.
The neural mechanisms associated with tendinosis is where the real work needs to be done though. If no inflammatory mediators are around to trigger a chemical sensitization of the nerves, what's left? I presume mechanosensitive neurones must come into play. Or perhaps a lack of certain chemical creates antidromic activity in the nociceptors supplying the area which is subsequently responsible for a pain experience.
It's so easy to speculate. Anyone with some facts as it pertains to neurovasculature of tendons? If something actually needs to heal, and is not, I would think it is reasonable to assume a blood flow problem (not taking into account nutrition, systemic pathology, etc).
jon
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Re: Tendinopathy - January 21, 2005 2:30:00 PM
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ericm
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A new study in the BJSM has found that eccentric single-leg squats on a 25 degree decline offered greater clinical gains than those performed on a level surface for treating patellar tendinopathy.
http://bjsm.bmjjournals.com/cgi/content/abstract/39/2/102?etoc
I don't have access to the whole article. If anyone out there does and can post here the specifics of the protocol they used and the reason they gave to account for the observed difference I would greatly appreciate it.
cheers,
eric
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Re: Tendinopathy - January 21, 2005 5:07:00 PM
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nari
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jon
I'm glad to see that link you posted. Anterior knee pain, without accompanying mechanical defects and rampant pathology, is neural in origin as far as I can work out.
I suspect tendinopathy is along the same lines, for the number of so-called tendinopathies and 'itises' that respond well to neural mobilisations is surprising. Same with carpal tunnel and so on, and those isolated conditions are the focus of quite a lot of work around the traps at present. No absolute conclusions yet..
Nari
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Re: Tendinopathy - January 22, 2005 2:28:00 PM
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cneup
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Quick question: What do you people read to learn histology etc and implications for practice in such detail????? I'm a still a newbie and trying to figure out what I need to learn next.
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Re: Tendinopathy - February 2, 2005 5:01:00 AM
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Matthew
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Hi!
I haven`t read all the postings - so forgive me if I repeat something already said.
Eric - you write:
[QUOTE] I am puzzled why an eccentric muscular effort places any different a load on the tendon than a concentric contraction would. Are they not in series? Why wouldn't a forceful concentric contraction do the same thing? I appreciate that eccentric contractions are capable of producing more force, but are these forces actually achieved during the exercies commonly performed? [/QUOTE]During eccentric exercise the muscle uses fewer motor units than during concentric exercise; this means a far higher amount of stress for the muscle tendon complex involved.
I´m suffering from bilateral achilles tendonitis myself and have found the eccentric program to be excellent. The pain is gone after a few repetitions, gait improves markedly and the whole leg feels a lot less "tight" and cramped up.
If I keep repeating the exercise every day (takes only a few minutes on a leg press) I´m fine; however - as I don`t have the opportunity right now they start acting up again.
I´ve asked myself repeatedly why the pain is gone so quickly; I tend to think that this effect is due to rapid motor relearning. Eccentric exercises are totally different from concentric ones (Distinct brain activation patterns for human maximal voluntary eccentric and concentric muscle actions., Fang Y, Siemionow V, Sahgal V, Xiong F, Yue GH, Brain Res. 2004 Oct 15; 1023(2): 200-12).
Matthias
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Re: Tendinopathy - February 2, 2005 6:17:00 AM
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JLS_PT_OCS
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Good discussion of a difficult problem.
Nari, could you go into detail about tendonosis being neural in origin and the neural glides you use?
I am interested because I have had a raging case of Bilat patellar tendonitis/tendonosis since playing a lot of volleyball about 4 mos ago. It's really killing me, and I'm feeling rather impotent that I can't get it better. I have done TFM, just started some eccentric work, and even done Ultrasound (if that's not desperate, what is?). What type of neural glides would you use with a patient with patellar tendonosis and what is the theory underlying that approach?
Thanks.
Jason
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"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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