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Re: Tendinopathy
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Re: Tendinopathy - February 6, 2005 10:53:00 PM
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erehab
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From: San Diego
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Matthias, you stated: "During eccentric exercise the muscle uses fewer motor units than during concentric exercise;
I am thinking back to my exercise phys days to try to understand. If I recall, with an eccentric contraction, the external force is greater than the force generated by the motor units; therefore, using the knee extensors as an example, it would be forced into flexion by an eccentric quad contraction because the external load is greater than the force generated by the muscles. Does this seem correct?
Also, for a given force, say 50 kg, to concentrically move the load, you would have to overcome this force with x motor units. If the muscles were eccentrically contracting with this load, then it the motor units used would be >x. Is this also correct?
Finally, assuming the force is constant, why would an eccentric load be harder on a tendon than a concentric load? The force is the same with each. I can see that it would be harder on the muscle cells since there are fewer working but why the tendon(s)?
BTW, great discussion. I am very interested in how eccentric work effects tendinopathy.
Any ideas where I can hear the above referenced speakers lecture? Do they do any con-ed?
Dave
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David Straight, MPT, OCS
President
E-rehab, LLC
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Re: Tendinopathy - February 7, 2005 7:08:00 AM
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Bournephysio
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"I am thinking back to my exercise phys days to try to understand. If I recall, with an eccentric contraction, the external force is greater than the force generated by the motor units; therefore, using the knee extensors as an example, it would be forced into flexion by an eccentric quad contraction because the external load is greater than the force generated by the muscles. Does this seem correct?"
This is partially correct. Remember F=ma or more appropriately torque=moment of inertia x angular acceleration. Therefore if the external torque is the same as the torque generated by the muscles (or the muscle moment) there is no acceleration. The muscle could still be doing eccentric or concentric work. If the joint angle is starting from a static position, for an eccentric contraction to start the external torque has to be greater than the muscle moment but once the movement has started the muscle moment can be the same as the external torque. If the movement is at a constant speed they have to be the same.
"Also, for a given force, say 50 kg, to concentrically move the load, you would have to overcome this force with x motor units. If the muscles were eccentrically contracting with this load, then it the motor units used would be >x. Is this also correct?"
A muscle can produce more force eccentrically than concentrically. To do that the muscle needs to be able to generate more force per motor unit eccentrically. Therefore, for a given force you need less motor units.
"Finally, assuming the force is constant, why would an eccentric load be harder on a tendon than a concentric load? The force is the same with each. I can see that it would be harder on the muscle cells since there are fewer working but why the tendon(s)?"
There may be more strain at the mt junction but you would expect the midsubstance strains to be the same. This is the big question I have. Maybe Matthias's experience sheds some light on this.
"Any ideas where I can hear the above referenced speakers lecture? Do they do any con-ed?"
Alfredson, Kahn and Cook are the most internationally recognized names mentioned in this thread. Alfredson is in Sweden I believe. Kahn is at the University of British Columbia. I think he does cont-ed but he speaks a lot internationally. I've seen him at IFOMT and the combined orthopaedic research society meeting. The combined ORS talk was about bone and osteoporosis though. Cook is at La Trobe University in Australia. I saw her speak at IFOMT as well.
Doug
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Re: Tendinopathy - February 8, 2005 6:10:00 AM
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Matthew
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From: Regensburg, germany
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Dave: I haven`t seen any studies yet that looked at the rate of strain in concentric vs. eccentric exercise.
As for tendon strain: it doesn`t necessarily have to be more stress - but the stress it has to withstand might be more focused. If fewer motor units are active less tendon "units" are active too. I have no way to prove this - but it`s the only (big) difference (apart from CNS issues) I can think of. Concentric contractions are quite painful and lead to no improvement whereas eccentric exercise works like a charm - at least in my case.
Why the results are so different when it comes to midportion vs. attaching site is still beyond me.
If the problem occurs at the site of attachement maybe the underlying cause is too much stress; whereas the midportion needs exactly that go get better.
The whole discussion about what to call it - tendinosis, tendinopathy, ... has missed the point somewhat. Maybe a clinical categorization in "overstrain" and "dysfunctional strain" (?) might be better.
Matthias
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Re: Tendinopathy - February 8, 2005 4:00:00 PM
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srcase
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Doesn't eccentric activity recruit more motor units, not fewer? I am confused about this current line of discussion.
Jason, good luck on your experiment. I personally would not push through tendon pain, and I WOULD stretch it like crazy. Am I just backwards here in my approach to tendonitis?
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Re: Tendinopathy - February 8, 2005 11:56:00 PM
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Matthew
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Hi!
It recruits fewer motor units but at higher firing rates.
As for your question: what do you base your treatment on? What`s the rationale behind it? (and is it supported by evidence)?
Matthias
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Re: Tendinopathy - February 9, 2005 7:50:00 AM
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JLS_PT_OCS
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I actually am pushing through some tendon pain and noting some pleasant results.
Maybe about 5-6/10 pain rating during exercise.
Hurts like hell the same day as the strengthening, but paradoxically, much better one day later.
I am continuing to stretch my quads as well, as I am prone to tightness there which can alter my exercise performance.
However, the pattern is still the same - during the eccentric contraction, I feel no pain, but when I switch to concentric contraction, I feel the pain immediately.
I have to say, since discovering this thread, I have totally changed my approach to patellar tendonitis. I was doing this with my achilles people like Matthias had mentioned, but not for my patellar or lateral epicondylitis folks.
Now I realize that by not keeping up on the research, I was providing suboptimal care...scary to think of all those folks I had seen before and not treated right...
Well, that's EBM, I guess...
_____________________________
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 9, 2005 7:57:00 AM
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Matthew
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Hi Jason!
Glad to hear it works for you.
But don`t forget that you`re not over "the hump" yet - that`s the point where you won`t feel pain at all - not during the day and not during training.
That`s when most people stop doing their exercises. You have to continue for at least 3 months - otherwise the tissue hasn`t got enough time to adapt.
Matthias
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Re: Tendinopathy - February 9, 2005 10:00:00 AM
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JLS_PT_OCS
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I hear you there...thanks for the reminder. I know I have only just begun the process...
I appreciate your insight.
J
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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 10, 2005 11:58:00 AM
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bravocosta
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Hello Jason,
Here's a link for patellar tendinosis and volleyball players (abstract)... hope it helps.
[URL=http://bjsm.bmjjournals.com/cgi/content/abstract/39/2/102?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexacttitle=or&titleabstract=patellar+tendinosis&andorexacttitleabs=or&andorexactfulltext=or&searchid=1108076100906_3728&stored_search=&FIRSTINDEX=0&sortspec=relevance&resourcetype=1,2,3,4,10&journalcode=bjsports]http://bjsm.bmjjournals.com/cgi/content/abstract/39/2/102?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexacttitle=or&titleabstract=patellar+tendinosis&andorexacttitleabs=or&andore xactfulltext=or&searchid=1108076100906_3728&stored_search=&FIRSTINDEX=0&sortspec=relevance&resourcetype=1,2,3,4,10&journalcode=bjsports[/URL]
and
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10384993
Cheers...Thomas
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Re: Tendinopathy - February 11, 2005 5:24:00 AM
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JLS_PT_OCS
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Thanks, Bravo....these were the ones i used in designing my program.
I appreciate the links.
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 12, 2005 2:02:00 PM
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ericm
Posts: 171
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From: Nanaimo, BC
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So it's not looking at tendons, but here's another interesting study just published comparing concentric and eccentric exercise
[URL=http://www.thieme-connect.de/ejournals/abstract/sportsmed/doi/10.1055/s-2004-817892]Effects of Eccentric versus Concentric Training on Thigh Muscle Strength and EMG[/URL]
eric
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Re: Tendinopathy - April 20, 2005 5:20:00 PM
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ericm
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From: Nanaimo, BC
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I'd like to revisit this topic. I've got some burning questions I'm hoping maybe someone can help me with.
I've got a patient now with what appears to be an insertional achilles tendinopathy. I think this is also referred to as an enthesopathy. I've read that eccentric training programs are less successful that this compared with problem found mid-tendon.
A brief history of this case;
there is no tendon thickening,
no signs of inflammation,
no pain with running or after,
no history of change in training patterns,
LL biomechanics are unremarkable,
She experiences pain only when attempting a 'downward dog' yoga posture, during which she finds she is unable to extend her knee so that the heel rests on the floor
Pain is over the lateral aspect of the tendon insertion and it is sore on palpation,
Neurodynamic tests such as slump and SLR are non-provocative.
Am I on track in thinking this could be an insertional tendinopathy?
Are there other signs I should be looking for?
How would you treat this?
Thanks,
Eric
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Re: Tendinopathy - April 20, 2005 6:06:00 PM
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srcase
Posts: 551
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From: Michigan
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Sounds like nerve tension. Try a standing straight-leg raise test with ankle dorsiflexion and inversion, or better yet attempt to provoke it while bowstringing the sciatic in the popliteal fossa and peroneal branch by the fibular head in the down-dog position with the knee slightly flexed.
Do a thorough lumbar screen including repeated motions. Yoga involves a lot of lumbar flexion if not done properly (flex from the hips with spine neutral)
Sarah
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Re: Tendinopathy - April 20, 2005 6:10:00 PM
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pablo w
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From: Canberra
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Eric,
I doubt an enthesopathy in this case. You cleared the SLR and lump test, but the position requires a lot of dorsiflexion in a straigh leg position with the hands straight and on the floor. Does she have the dorsiflexion range of motion to achieve the position? Have yo tried looking at the position and altering hip but not ankle position? I'm thinking of a stretched cranky nerve here, i don't think slump would pick it up.
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Re: Tendinopathy - April 20, 2005 6:36:00 PM
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ericm
Posts: 171
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From: Nanaimo, BC
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I agree with the cranky nerve hypothesis, I just haven't been able to confirm it for myself yet. Thanks for the ideas, I'll try them out.
Eric
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Re: Tendinopathy - April 21, 2005 1:04:00 PM
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JLS_PT_OCS
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From: USA
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All cranky nerves aside...
Does she perhaps have a calcaneal bursitis?
Perhaps a heel cup and stretching or local modalities? Surely that is a more physiologically likely scenario than a neural tension issue?
No pain with running makes me suspicious...
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 - April 21, 2005 2:14:00 PM
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dosrinc
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From: Bonita Springs
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Just read both pages, great stuff. My Question:
My understanding of the eccentric contractions ability to generate more force than that of the concentric contraction was that it had to do with the fact that when the muscle responds eccentrically to loading, the elongation of the muscle is resisted by both the contractile component (actin and myosin fibers) and the elasticity of the noncontractile components found in the muscle tendon (SEC) and in the connective tissue sheathes and sarcolmma (PEC) while during concentric contractions, only the contractile elements function to generate tension because the SEC and PEC are shortening. Is this incorrect?
Jason - I was once shown and have since successfully used many, many times a taping technique for patellar tendonitis that is very simple and also very effective. Not McConnel in any way, not trying to affect patellar tilt, but instead it seems to act in a way similar to a Cho-Pat strap, takes away the pain so that you can then eccentrically load away and reorganize those collagen fibers. Maybe it has an effect on the neural tension? (that was for Nari) Have you tried any such taping? Good Luck!
Rick
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Re: Tendinopathy - April 22, 2005 4:38:00 AM
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JLS_PT_OCS
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I have been remiss in my updates...
About 6 weeks after the eccentric exercise regiment began, I had a complete resolution of all my symptoms.
I am now exercising with no tendon pain to include back squats and deadlifts, and brazilian jui-jitsu...no pain.
Needless to say, I am now using eccentrics with all my tendonopathy folks, noting great success with patellar and achilles, less success with lateral epicondylagia people.
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 - April 22, 2005 4:49:00 AM
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Matthew
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Hi Jason!
I´m happy for you.
Just remember: keep it up for at least another 6 weeks!
Matthias
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