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Re: Tendinopathy
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Re: Tendinopathy - February 2, 2005 8:10:00 AM
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Bournephysio
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From: Calgary
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Matthias: "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." Which would explain effects at the mt junction but in the achilles its usually mid substance and for the patella tendon you have the whole patella imbetween the muscle and pathology. The forces should be well distributed by then.
"I tend to think that this effect is due to rapid motor relearning." I think that this is one of the more likely explanations.
Those of you with bilat problems. Maybe try concentric on one side and eccentric on the other with the exact same exercise and loading. See if one side gets better faster.
Doug
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Re: Tendinopathy - February 2, 2005 8:24:00 AM
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Matthew
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Hi!
Doug:
[QUOTE] Those of you with bilat problems. Maybe try concentric on one side and eccentric on the other with the exact same exercise and loading. See if one side gets better faster.
[/QUOTE]Absolutely imposssible. Concentric exercise feels like the tendon is being ripped apart from within. The pain is unbearable. When the whole process started a few years ago I wasn`t even able to get out of bed in the morning. I couldn`t take one step.
One thing for those who haven`t tried it yet (and something that doesn`t come across from the studies done by Alfredson): weight. I have no effect when I use bodyweight alone - lowering my body on a staircase for example.
You really need to "overload" the tendon; in a legpress that means around 100-120 kilograms for me using only one leg. Only then do you feel the effect immediately.
Matthias
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Re: Tendinopathy - February 2, 2005 8:42:00 AM
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Bournephysio
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"Absolutely imposssible. Concentric exercise feels like the tendon is being ripped apart from within. The pain is unbearable. When the whole process started a few years ago I wasn`t even able to get out of bed in the morning. I couldn`t take one step."
Interesting! either we have to come up with a good reason why the loading would be different or there must be a difference in pain perception. Maybe too much pain during an eccentric activity is more of a safety concern. Eccentric activity you are usually controlling an external force such as gravity while concentric you are generating force. Not sure if that is a completly sound argument just theorizing.
Alfredson does suggest adding weights as you progress while others progress to more dynamic exercises like drop squats.
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Re: Tendinopathy - February 2, 2005 8:52:00 AM
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Matthew
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From: Regensburg, germany
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Hi!
I haven`t found any study yet that looked at activation patterns concerning motorneurones during these two types of exercise.
The clue as to why and how it works is definitely inside the brain. Somehow the brain associates concentric with pain. Maybe because it has some internal value for (damaging) muscle force comparable to body temperature?
Yes - Alfredson does add weight - but for people who don`t have that much experience: pack it on! The more the better. Took me some time to figure that one out.
Matthias
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Re: Tendinopathy - February 2, 2005 11:26:00 AM
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srcase
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From: Michigan
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I was wondering if anyone has heard of or used the ASTYM system of augmented soft tissue mobilization for tendinosis (among other things) and what you think of the theory behind it? The website is [URL=http://www.astym.com.]www.astym.com.[/URL]
The theory is that by reinitiating the inflammation cycle with external forces (specially designed tools)directed in parallel to the fibers, one can effectively stimulate the body to reorganize the collagen and resolve the degenerative effects of chronic inflammation. They seems to have a lot of research to back up the claims (I took the course a couple of years ago, but don't have the research in front of me now). I was getting good results with it (resolution within 4 to 9 treatments on average!) but haven't had access to the tools at my new job due to logistics of leasing them. Just curious if anyone out there has heard of this. There is also something called the Graston system that I heard about, which sounds similar.
Just a thought about eccentric exercise versus concentric from my recent grad brain...isn't eccentric exercise more effective due to the lengthening of the filaments, the recruitment of more motor units, and longer contraction time? In my basic understanding it promotes dynamic flexibility of the muscle, which leads to greater ability of the muscle to produce powerful concentric contractions.
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Re: Tendinopathy - February 2, 2005 4:17:00 PM
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Jon Newman
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Here's some links that may be worth looking at. One of them has free access to the full text.
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12381833]link 1[/URL]
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11897860]link 2[/URL]
Matthias, you stated: "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."
If a muscle produces x newtons of force, wouldn't x newtons be transmitted via the tendon regardless of the type of contraction that produced x newtons? I think that is what Eric was asking. This must be the case.
Perhaps, people are willing/able to produce more force across the tendon for a given contraction as our task demands are rarely graded exactly to the minimal needs of the task. For example, something that weighs 50 N requires 50+ whatever is needed to perform the task (taking into consideration external and internal counterforces). But we may use 60 or 70 or 150, etc based on affect, past experience, misperception of force required, etc.
It could be that when performing eccentric work, one typically over exerts for the effort required. Why this reduces your pain is beyond me but may have something to do with the articles I posted.
jon
I should add that I understand that we are quite capable of grading our total effort to a task. I'm not so sure about a single muscle's instantaneous contribution and I think our ability worsens with eccentric contraction (verus concentric).
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Tendinopathy - February 2, 2005 5:09:00 PM
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ericm
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From: Nanaimo, BC
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Matthias, thanks for sharing your thoughts, you've given me some things to think about. I will have to track down that article. What importance do you think the pea-like nodule palpated in the achilles tendon has?
Eric
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Re: Tendinopathy - February 2, 2005 11:15:00 PM
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Matthew
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From: Regensburg, germany
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Hi!
[QUOTE]Matthias, you stated: "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."
If a muscle produces x newtons of force, wouldn't x newtons be transmitted via the tendon regardless of the type of contraction that produced x newtons? I think that is what Eric was asking. This must be the case. [/QUOTE]Let me clarify: a muscle never uses 100% of it`s muscle fibers at the same time. Let`s say that during a concentric contraction 50% are active producing a force high enough to lift 100 pounds. If you create the same force by an eccentric contraction only 40% of fibers are active - thereby increasing the amount of force the individual fibre has to endure. The overall amount of force is the same - but the key lies in how it`s distributed in the muscle itself - it`s a completely different pattern.
I´m speculating here of course.
[QUOTE] What importance do you think the pea-like nodule palpated in the achilles tendon has? [/QUOTE]Well - I can send you a photograph of my tendon. On bad days it`s more like one huge pea. After a few days/weeks of training it`s getting smaller and smaller. Right now you can see it even when I´m wearing socks.
Alfredson`s group has found a reduction of tendon size and thickness after the training regimen (Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up., Ohberg L, Lorentzon R, Alfredson H, Br J Sports Med. 2004 Feb ; 38(1): 8-11).
They think that one of the biggest problems is neovascularisation (Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis?, Ohberg L, Alfredson H, Knee Surg Sports Traumatol Arthrosc. 2004 Sep ; 12(5): 465-70) - and the sprouting of new nerve endings.
Matthias
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Re: Tendinopathy - February 3, 2005 1:58:00 AM
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JLS_PT_OCS
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Great info, everyone.
And to imagine I thought I knew all about the eccentric contraction -- turns out we don't know as much as we'd like to.
Matthias - that is an interesting idea, in that fewer motor units are involved in eccentrics...would certainly help explain some soreness/local damage issues!
As far as the day to day treatment goes-
Something I found interesting in the study that Eric posted was that the subjects were encouraged to exercise into tendon pain, and not see it as a limitation.
I usually tell everyone I work with that pain is to be avoided during strengthening - feel it in the muscle, not the joint/tendon, or something like that. Perhaps I have been giving bad advice where tendonosis is concerned?
Do any of you treat your achilles or patellar people this way (ie exercising into the pain)? What is your guidance to them on how much pain to expect, and how much is too much?
Do you also use supportive treatments such as TFM/friction massage, stretching, ice, etc?
Thanks.
Jason
_____________________________
Jason Silvernail DPT, OCS, CSCS
"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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Re: Tendinopathy - February 3, 2005 2:34:00 AM
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Matthew
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From: Regensburg, germany
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Hi!
About exercising into pain: in my case I don`t feel pain during the exercise at all. It`s the exact opposite - it feels "heavenly".
I think that the advice to "disregard" pain is another way of saying "pack on as much weight as you can bear".
Supportive treatments consist of mobilizing all the joints of the affected foot; in most cases the movement of the subtalar joint is nonexistent. I don`t know if that is a cause for the problems or an effect.
After the eccentric training I used to apply ice for about 5-10 min to prevent post-exercise pain.
Stretching: (in my opinion) is absolutely forbidden! The tendon has lost all "springiness" anyway (meaning it can no longer store energy and rebound afterwards) - why elongate it even more?
Matthias
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Re: Tendinopathy - February 3, 2005 3:10:00 AM
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JLS_PT_OCS
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Thanks, Matthias.
How about in your patients who are chronic and do have pain, regardless of whether it's patellar or achilles?
What is your guidance to them regarding pain and exercise?
My patellar tendonitis actually feels worse when I exercise it, but I'm thinking maybe that my approach to find ways to strengthen without pain in the tendon may be the wrong way to go about it... what does everyone think?
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"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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Re: Tendinopathy - February 3, 2005 3:22:00 AM
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Matthew
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From: Regensburg, germany
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Hi!
In my clients I start with their own bodyweight - either by using stairs or a leg-press. If they tolerate that they can start adding weight pretty fast.
If someone has an adverse reaction - usually (severe) DOMS in their calf muscles - I reduce the weight till no such reaction occurs after training.
Pain a few hours after a session is normal - but it should resolve overnight.
Have you tried mini-squats? and ice afterwards?
Matthias
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Re: Tendinopathy - February 3, 2005 4:58:00 AM
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bravocosta
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Hello Jason,
Try this link below, it gives a brief overview of tendinosis and outlines a training regimen on a total gym with variable loads. Perhaps your exercises are overstressing/overloading the tendons in your knees perpetuating the cycle.
With the incline board you can control the amount of force more easily. This guy is an expert on tendon/cartilage issues.
http://sportscenteraustin.blogs.com/the_view/tendonitis/index.html
Hope this helps...........cheers.....thomas
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Re: Tendinopathy - February 3, 2005 5:40:00 AM
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JLS_PT_OCS
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From: USA
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Thanks, bravo. That was helpful.
Matthias-
Sorry if I seem to not be getting it, but I'm still uncertain about your opinion. I'm kinda dumb sometimes, so that may be it...
I never have soreness in my quads, I am unable to work them in a painfree way such that they can get an overload. The limiting factor is the tendon pain. My question would be, then, should I exercise into and through tendon pain, and if so, how much is too much?
I have a total gym at home, and perhaps I need to get on that.
Right now I am doing barbell squats with an eccentric focus, but I just recently started, so can't say I see a lot of results yet.
My concern is just what bravocosta mentioned...how do you know when to stop? How much tendon pain is good for remodelling and how much tendon pain is bad and perpetuates the cycle?
I am sure no one is positive they know for sure, but any guidelines for me to try?
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"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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Re: Tendinopathy - February 3, 2005 5:57:00 AM
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Matthew
Posts: 41
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From: Regensburg, germany
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Hi!
(Un)fortunately I can only write about the experience of achilles tendonitis. And at least in my case the training doesn`t hurt at all.
My clients too haven`t reported any such thing.
As for patellar tendinitis - yes - it is distinctly different - although I´m not yet sure why.
If you feel that the pain makes the training impossible - then reduce the loading to a level that let`s you still perform a complete session (approx. 15-20 reps, 3-4 sets).
And keep in mind that you must not mix concentric and eccentric contractions!
I´d try this for one week to see if the muscle/tendon/brain is adapting.
I don`t think that there is such a thing as a bad tendon pain; mine hurt most when I´m doing nothing. Focus on eccentric movemenst, don`t sit too much with your knees bent, "use the force", ...
Matthias
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Re: Tendinopathy - February 3, 2005 6:18:00 AM
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Yogi
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From: San Antonio, Tx., USA
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For the Augmented soft tissue mob., maybe the new web sit is [URL=http://www.performancedynamics.com]www.performancedynamics.com[/URL] I don't know if [URL=http://www.sastm.com]www.sastm.com[/URL] is similar, or related, or and enhancement.
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Re: Tendinopathy - February 3, 2005 8:09:00 AM
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bravocosta
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Hello Jason,
Per the article you are looking for the threshold, ie- at what level of loading is it not painful, so that after the routine is completed there is an overall low level of pain. The problem of course is not the loading of the quads, but at what point your tendons object to the load. To really "feel it" in the quads may be more than your tendons need. Try it mate.
Cheers....Thomas
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Re: Tendinopathy - February 3, 2005 8:35:00 AM
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Matthew
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From: Regensburg, germany
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Hi!
I´ve just received this article:
Knee Surg Sports Traumatol Arthrosc (2003), 11:327–333, Chronic Achilles tendon pain treated with eccentric calf-muscle training
They found that only mid-portion tendinosis reacts very good to the treatment and that in the group with insertional tendinosis only 30% benefited from it.
They also add that it is absolutely necessary to find out why and how it works - because every tendon seems to react differently. Only if we know what the "magic ingredient" is can we properly and confidently apply the same training to the shoulder and elbow.
Matthias
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Re: Tendinopathy - February 3, 2005 9:45:00 AM
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JLS_PT_OCS
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From: USA
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Thanks, everyone.
I will try eccentric loads with barbell squats and total gym leg press type thing, 3 sets of 10-12.
I'll let you know how it goes in our little study here, N=1.... :)
I'll push through as much tendon pain as I can and see how it goes.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"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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Re: Tendinopathy - February 3, 2005 10:58:00 AM
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Jon Newman
Posts: 1707
Joined: April 24, 2004
From: Amherst, WI
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The following may be of interest:
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15118032]link 1[/URL]
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15262655]link 2[/URL]
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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