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Re: Achilles tendinosis
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Re: Achilles tendinosis - March 13, 2007 11:26:00 AM
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nari
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My contribution is that a chronic problem is due to sensitisation of the nerve/s, which can lead to local tissue changes.
Ginger treats differently from the way I would, but the fact that a chronic problem is rarely managed satisfactorily at some local site alone, is paramount.
Referred pain is so common that it would seem logical not to waste time at a locally sore spot.
The spine is always a good starting point.
Nari
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Re: Achilles tendinosis - March 13, 2007 5:40:00 PM
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jlharris
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"...a chronic problem is due to sensitisation...can lead to local tissue changes."
To be clear, is this your personal opinion or have you found literature that shows or implies this. Thanks for the clarification.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: Achilles tendinosis - March 13, 2007 8:28:00 PM
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ginger
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Jason, your success with the patient you mentioned is wonderful ,though much as I would expect.
I'm waiting at the airport using a dodgy coin in the slot killing time and have nearly run out of coins .talk later when I've landed. cheers
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Achilles tendinosis - March 14, 2007 12:53:00 AM
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nari
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When a system or part thereof is sensitive to stress of any kind, there is a volley of nociceptive messages resulting in ongoing pain generation from the brain, even if the tissues have healed.
This results in dysfunction of the local area with likely muscle wasting and disuse; along with the usual emotional effects. An example could be tendonosis, or arthrosis.
What causes a system to become sensitive is still unpredictable, but the factors are clearly complex.
Any books by Shacklock or Butler will explain this process; it is not black and white because of multifactorial reasons why a mild or moderate injury can result in chronic pain, or intermittent pain that arises under some duress.
This is one reason why pain education is so important as a desensitisation process, along with cautious and not too repetitive rehab.
Nari
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Re: Achilles tendinosis - March 14, 2007 1:40:00 PM
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jlharris
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Thank you for your response Nari.
[QUOTE]
...along with cautious and not too repetitive rehab.
[/QUOTE]This is interesting as the Alderson paper uses high load eccentrics 3x15 for rehab. As I recall, the author suggested to push the rehab even with increased pain, and to only back off if the pain caused the inability to walk.
It's an interesting clinical conundrum as his paper showed excellent results, and I have no doubt (in all sincerity) you have excellent results with your patients with the same presentation.
It's the above that'll never allow me to loose interest in this profession and trying to find the best ways to get people the results they need.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: Achilles tendinosis - March 15, 2007 5:52:00 AM
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steve
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Jason,
Interesting discussion. Causing pain does seem counterintuitive to a good outcome but there is some good science to why eccentrics MUST be painful according to Alfredson. He suggests that neovascular and neural ingrowth is why tendonosis becomes painful. The theory is that the eccentrics cause a shearing effect on the nerves and cause pain as the neoneural ingrowth is basically destroyed. Not only do patients have high levels of success with treatment (>90%) consistantly in the studies but they also demonstrate tendon repair at six month follow-up.
Hard to argue with those dramatic results with both functional and observable structural change.
Steve
PS Alfredson said that in one of his trials patients used pain killers during the eccentric protocol and had higher compliance and significantly decreased pain reports through the course of eccentric exercises.
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Re: Achilles tendinosis - March 15, 2007 2:29:00 PM
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ginger
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Jason , on the question of how, it is clear that there must be neural involvement at some level in both normal and abnormal behaviour, in this case of achilles tendinoses, these include swelling , denaturing of proteins, cartilaginous detruction etc. . I can describe the likelihood of autonomic altered neural input being at the core of these changes, though my insights into these relationships are a perspective gained through having observed many cases of resolution. Rather than by having a series of RCT's or the like to quote for you. It seems too obvious that to resolve what may be a neuralgic event , one first attempts to resolve what is most likely to cause it.Protective spinal responses.
While I do not doubt the good results often described for eccentric loading for achilles pain, I can only reiterate the simple logic of my approach . To perform what may be an adventure into extended painful territory for a patient with exercise, rather than a series of relatively painless, gentle , though ( as you have noted with your example of the woman with shoulder pain )immediately effective spinal mobs , would seem like an odd choice. But then of course , not everyone is willing, for reasons unclear to me , to approach a problem spine first. You've seen but a glimpse of the spectacular results this method can provide . Power to you .
I look forward to further examples , if you have them.
Cheers
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Achilles tendinosis - March 15, 2007 2:38:00 PM
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proud
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Well lets bring this discussion full circle. Thank you everyone for the input.
Steve(or anyone really),
Do you know the protocol used in Alfredson's work? How many reps? frequency, duration. And was eccentric work the only aspect?
Thanks
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Re: Achilles tendinosis - March 15, 2007 4:21:00 PM
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steve
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Proud,
If I remember correctly, the protocol was once a day, 3 sets of 15 reps (Someone can correct me if I am wrong - this is what I use clinically and cant remember the exact numbers). Start with two legged progress to single leg and then back pack loaded eccentrics. He only used eccentrics in the trials and they had to evoke some pain while being performed.
Ginger,
Is "Odd Choice" synonymous with "Highly effective proven treatment"? Perhaps there is a latin saying that could clarify this comment...
Steve
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Re: Achilles tendinosis - March 15, 2007 11:11:00 PM
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nari
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Hi Jason
There we go; you and I get great results by different methods. I'm sure there is a moral of sorts there; or another theory. In the meantime, I prefer non-nociceptive methods. That doesn't mean I don't believe you get good results; I'm sure you do.
Nari
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Re: Achilles tendinosis - March 16, 2007 9:13:00 AM
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jlharris
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Alfredson et al. Heavy Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis. A. J. Sports Med. Vol 36(3) 1998
BID - 7x week - 12 weeks total
Knee straight eccentrics 3 x 15
Knee bent eccentric 3 x 15
-Muscle soreness told to be expected
-Running allowed if no or mild discomfort only
-Continue ex with pain but stop if pain becomes disabling
-Add wt via backpack when ex can be performed with mild or no pain
Results in re: to pain:
eccentric group: Week 0 pain 81.2/100 avg - Week 12 4.8/100 avg
Surgery group: Week 0 pain 71.8/100 avg - week 24 (not a typo) 21.2/100 avg.
Roos et al suggested a progression of:
Days 1-2 = 1 x 15
Days 3-4 = 2 x 15
Days 5 on = 3 x 15
Roos used the same knee straight and knee bent eccentrics and gradual addition of resistance as ex became easier to perform.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: Achilles tendinosis - March 18, 2007 8:51:00 PM
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ginger
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Jason, it would appear from this eccentric group that it may take up to 12 weeks for resolution of Achilles tendinosis . Just wondering what period you would expect , as an average for resolution using eccentric ex's.
Cheers
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Achilles tendinosis - March 19, 2007 2:14:00 AM
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proud
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Thank you everyone for the information. Now, would you ice immediately after the eccentric loading?
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Re: Achilles tendinosis - March 19, 2007 5:19:00 AM
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PTupdate.com
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A very similar discussion has been taking place over on MyPhysicaltherapyspace.com regarding explaining pain, and it has funnelled down to tendinitis/tendinosis/tendinopathy.
I just recently abstracted two articles regarding this problem, and two treatment ideas, especially for those that fail the traditional methods:
SCLEROSING INJECTIONS TO AREAS OF NEO-VASCULARISATION REDUCE PAIN IN CHRONIC ACHILLES TENDINOPATHY: A DOUBLE-BLIND RANDOMISED CONTROLLED TRIAL. Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 13, 2005.
ULTRASOUND GUIDED ELECTROCOAGULATION IN PATIENTS WITH CHRONIC NON-INSERTIONAL ACHILLES TENDINOPATHY: A PILOT STUDY. British Journal of Sports Medicine, June 2006
It appears that neo-vascularization, and the nervous tissue that occurs with it correlates to pain. Destroy those vessels and the nervous tissue (either by ischemia, or by direct death) and pain goes away.
Perhaps Ginger's methods provide the same alteration in neural input by working proximally. However, longer term studies are revealing that getting of the neovascularization results in reduced thickening of tendon, and improved collagen make up. I am not sure if the manual techniques to the spine would have the same effect
Perhaps the next step is to identify which PT treatments, be it modality based, local manual based (including ASTYM), or central manual based (ginger) affect this vascularization and pain. The article I read for today uses laser, but it was not very well performed, even though prostaglandin concentrations were changed. For those who belong to my site, stay tuned..I hope to get it done tonight or tomorrow morning.
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 19, 2007 7:09:00 AM
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jlharris
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@ Ginger
For actual histologic changes, I would assume 12 weeks. This is only because the research I've read that showed tissue change was done over that 12 week period. As I stated earlier the few (read 3 pts) I've done this protocol with had decreased pain complaints with activity after about 3 weeks (not necessarily improved function). They were asked to continue for the full 12 weeks.
@ Proud
Good question. I did(do) not as there is some thought that you want an inflammatory response and blunting it may result in diminished outcomes. Of course that is just my clinical opinion.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: Achilles tendinosis - March 19, 2007 8:01:00 AM
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proud
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Jason,
The work of Khan...suggests ice because the intent of the eccentric work is to "strip" the neo-vascularization effect. I assumed then the ice was to avoid any inflammation...
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Re: Achilles tendinosis - March 19, 2007 11:58:00 AM
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ginger
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Jason , thanks, you will no doubt be surprised when I say that my approach requires only one to three treatments. I consistantly see resolution to about 70 to 80 percent after one sesssion of about twenty five minutes of CM to L5S1, with the sweeling gone after about twenty four hours. Further attention to L5S1 clears up the rest along with any dural stretches to sciatic tissues that are indicated , over the following treatment , with some requiring a third .
This is a permament resolution in as much as the function is restored , pain gone , swelling gone and any other indicators available to me ( no path lab ). The condition sometimes returns after several months depending on how that persons back behaves. It becomes clear that the primary involvement is at the low back , after seeing this occur many times over many years.
I realise this may seem somewhat controversial or even unbelievable to those who don't consider musculskeletal problems this way . All I can repeat to you though jason is the mentod is safe , immediately effective and available to anyone with skill and determination.
All the best.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Achilles tendinosis - March 19, 2007 1:29:00 PM
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proud
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ginger,
I have read your post in the past reference continous mobs. Can you go through it again?
Really it is unbelievable those results you describe. Surely at some point you will get that published or something...
Anyway. Can you walk me through like I was a two year old how you are doing that? Approximately what grade of mob...etc.
I will not lie, I had a few recalcitrant cases and as a last resort attempted to replicate your continous mobs theory. No luck.
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Re: Achilles tendinosis - March 19, 2007 3:05:00 PM
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ginger
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From: Melbourne Victoria
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Time doesn't always allow an immediate or lengthy response Proud, so I'll have to refer you back to my notes in the manual therapies section . There is no doubt I have developed both strength and sensitivity in my thumbs by mobilising day after day year in year out. I do find that my students are able to reproduce my results, provided they don't give up when thumbs become sore. This will change over a period of months, provided you stick with it.
L5S1.
patient prone , pillow under pelvis to put spine into flexion. approach L5s1 at the junctions of illium,sacrum and spinal landmarks, with thumb oriented tip towards sacrum. Use the flat of your thumb, hyperextend if necessary, though better to lay the hand flatter along the spine so that the broadest fleshy part of the thumb is able to take weight.
Mobilise till pain is felt by your patient at or near L5S1, rate of 2/sec. be consistent this way for however vlong it takes for the pain associated with this mobilising movement reduces, continue till it is gone or considerably better. Do the same for the other side and L4.
Ballistic dural stretches are also described in the manual therapy section. If indicated by sciatic tightness , use the ballistic method, it works immediately with lasting results.
Do no work on the achilles.
retest achilles discomfort/change/improvements at any time by squeezing it.
gotta go
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Achilles tendinosis - March 20, 2007 6:40:00 AM
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allenbr4
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Ginger,
I'd be interested to hear if you have any background/experience with Applied Kinesiology or any opinions on the techniques.
I ask because of the location of the "Neurolymphatic" reflexes which correlate to the peroneii muscles and flexor hallucis (amongst others). Those specific reflexes are in the same location that you contact for the mobilization and are treated with digital stimulation.
Just another example of how a treatment form with a different intent can potentially end up in the same result.
Thanks!
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