Tendinopathy TOP TEN By Jill Cook PhD
Tendon pain and dysfunction are the presenting clinical features of tendinopathy. Research has investigated many treatment options, but consistent, positive, clinical outcomes remain elusive. We know that treatment should be active (eg, exercise-based), and that a consistent and ongoing investment in rehabilitation is required. It is important to maximise this investment by understanding (and conveying to patients) treatments that do not help. The following 10 points high- light treatment approaches to avoid as they do not improve lower limb tendinopathy.
1. Don’t rest completely.
Rest decreases the load tolerance of tendon, and complete rest decreases tendon stiffness within 2 weeks.1 It also decreases strength and power in the muscle attached to the tendon and the function of the kinetic chain,2 and likely changes the motor cortex, leaving the person less able to tolerate load at multiple levels. Treatment should initially reduce painful, high tendon load (point 2) and intro- duce beneficial loads (eg, isometrics3). Once pain is low and stable (consistent on a loading test each day), load can be increased slowly to improve the capacity of the tendon.4
2. Don’t prescribe incorrect exercise.
Understanding load is essential for correct exercise prescription. High tendon load occurs when it is used like a spring, such as in jumping, changing direction and sprinting.5 Tendon springs must be loaded quickly to be effective, so slow exercises even with weights are not high tendon load and can be used early in rehabilitation. However, exercising at a longer muscle tendon length can compress the tendon at its insertion.6 This adds substantial load and should be avoided, even slowly, early in rehabilitation.
3. Don’t rely on passive treatments.
Passive treatments are not helpful in the long term as they promote the patient as a passive recipient of care and do not increase the load tolerance of tendon.Treatments like electrotherapy and ice temporarily ameliorate pain only for it to return when the tendon is loaded.7
4. Avoid injection therapies.
Injections of substances into a tendon have been shown to be no more effective than placebo in good clinical trials.8 Clinicians who support injection therapies incorrectly suggest they will return a pathological tendon to normal. There is little need to intervene in the pathology as
there is evidence that the tendonadapts to the pathology and has plenty of tendon tissue capable of tolerating high load.9 Injections may change pain in the short term as they may affect the nerves, but should only be considered if the tendon has not responded to a good exercise-based programme.
5. Don’t ignore tendon pain. Pain usually increases 24 hours afterexcess tendon load. An increase in pain of 2 or more (out of 10) on a daily loading test should initiate a reduction in the aspects of training that are overloading the tendon (point 2). The overload is likely to be due to excessive spring-like movements such as jumping, running and changing direction.
6. Don’t stretch the tendon.
Aside from the load on a tendon in sport, there are compressive loads on the bone-tendon junction when it is at its longest length. Stretching only serves to add compressive loads that are detrimental to the tendon.10
7. Don’t use friction massage.
A painful tendon is overloaded and irritated (reactive tendon pathology). Massaging or frictioning the tendon can increase pain and will not help pathology.7 An effect on local nerves may reduce pain in the short term only for it to return with high tendon loads.
8. Don’t use tendon images for diagnosis, prognosis or as an outcome measure.
Abnormal tendon images (ultrasound and MRI) in isolation do not support a diagnosis of tendon pain as asymptom- atic pathology is prevalent. There are also no aspects of imaging, such as vascu- larity and ‘tears’, that allow a clinician to determine outcome.11 Pathology on imaging is usually very stable and does not change with treatment and reductionin pain, so images are not a good outcome measure.12
9. Don’t be worried about rupture.
Pain is protective as it causes unloading of a tendon. In fact most people who rupture a tendon have never had pain and do not present clinically, despite the tendon having substantial pathology.13
10. Don’t rush rehabilitation.
Tendon needs time to build its strength and capacity. So does the muscle, the kinetic chain and the brain. Although this can be a substantial time (3 months or more), the long-term outcomes are good if the correct rehabilitation is completed.14
The above 10 treatment approaches take valuable resources and focus away from the best treatment for tendon pain—exer- cise-based rehabilitation. A progressive programme that starts with a muscle strength programme and then progresses through to more spring-like exercises and including endurance aspects will load the tendon correctly and give the best long- term results.
At first it was just a niggle in your knee when you climbed stairs or were squatting. Then the pain and stiffness became more than a niggle and you began to feel it when walking, sitting and resting.
You may be hearing popping or cracking sounds in your knee, and notice that your knee “gives out” every now and again.
The knee is an amazing but complicated joint and knee pain is one of the most common reasons that people visit a physiotherapist.
Pain behind the kneecap is commonly called runner’s knee because it is often seen in athletes and people with an active lifestyle, although it can also be seen in everyone from the young adolescents during growth spurts to elderly people.
The medical term is patellofemoral pain syndrome. It is pain behind the kneecap where your patella (kneecap) slides along the groove in your femur (thighbone) beneath.
Pain and stiffness occurs when the kneecap does not slide smoothly and misaligns causing it to rub against your femur. Repeated mis-tracking causes pain, stiffness, and ultimately can cause damage to your kneecap joint surface.
Knee pain is most commonly noticed during activities that involve knee bending, jarring or weight bearing.
People most at risk are those whose sport or activity includes running, jumping or the need to land in a squatting position. Sports most commonly associated with knee pain include running, netball, volleyball, basketball, tennis, skiing and cycling. Many tradies such as tilers and carpet layers also have problems.
Causes of Runner’s Knee
Overuse – increased activity or increased duration and intensity of the activity
Changes in footwear or playing surfaces
Tight outer thigh muscles and weaker inner thigh muscles causing the kneecap to be pulled to one side
A twisting injury
Flat feet and lack of arch support
Weak hip control muscles
First aid for Runner’s Knee
Generally, knee pain is gradual onset, which means it gradually increases in severity over time.
As with most injuries, the best initial first aid is rest, ice packs (15 minutes at a time every 2-3 hours), and taking anti-inflammatory painkillers such as ibuprofen.
You do not need a referral from a doctor to see a physiotherapist. If the pain is moderate, then you can seek treatment with your Physiotherapist immediately.
Physiotherapy is a proven treatment for runner’s knee. Your physiotherapist may initially tape or strap your kneecap to help pull it back into alignment and reduce pain.
Massage and joint mobilisation techniques are also commonly used to reduce swelling and restore movement.
You will be prescribed exercises to stretch and strengthen muscles that may be contributing to the problem. These exercises will change as you heal and will gradually increase in intensity to match your recovery.
If you wish to continue exercising to maintain your fitness during your treatment, then explore swimming, deep-water running and low-impact gym equipment such as elliptical trainers.
Depending on your knee pain cause, you may also be advised to explore arch supports, orthotics or different footwear. You may also require postural or technique correction in your chosen sport to stop problems from recurring, as well as a strength and conditioning plan to get you back to full competitive fitness.
In our experience, over 90% of runner’s knee physiotherapy clients will be pain free within six weeks of starting treatment. However, for severely damaged joints or arthritic joints, surgery may be required.
Things to Remember
Runner’s knee or patellofemoral pain syndrome is a common cause of knee pain.
It is a gradual onset injury and is most commonly noticed during activities that involve knee bending, jarring or weight bearing.
Physiotherapy is a proven method to speed healing, and prevent recurrence of knee pain.
Future management may also involve assessment of your gait and posture during exercise, and prescription of arch support or custom made orthotics.
As your cold-weather footwear makes the seasonal migration from the back of your closet to replace summer’s flip flops and bare feet, don’t underestimate the benefits of padding around naked from the ankles down.
Barefoot activities can greatly improve balance and posture and prevent common injuries like shin splints, plantar fasciitis, stress fractures, bursitis, and tendonitis in the Achilles tendon, according to Patrick McKeon, a professor in Ithaca College’s School of Health Sciences and Human Performance.
The small, often overlooked muscles in the feet that play a vital but underappreciated role in movement and stability. Their role is similar to that of the core muscles in the abdomen.
“If you say ‘core stability,’ everyone sucks in their bellybutton,” he said. Part of the reason why is about appearance, but it’s also because a strong core is associated with good fitness. The comparison between feet and abs is intentional on McKeon’s part; he wants people to take the health of their “foot core” just as seriously.
The foot core feedback loop
McKeon describes a feedback cycle between the larger “extrinsic” muscles of the foot and leg, the smaller “intrinsic” muscles of the foot, and the neural connections that send information from those muscle sets to the brain.
“Those interactions become a very powerful tool for us,” he said. When that feedback loop is broken, though, it can lead to the overuse injuries that plague many an athlete and weekend warrior alike.
Shoes are the chief culprit of that breakdown, according to McKeon. “When you put a big sole underneath, you put a big dampening effect on that information. There’s a missing link that connects the body with the environment,” he said.
Muscles serve as the primary absorbers of force for the body. Without the nuanced information provided by the small muscles of the foot, the larger muscles over-compensate and over-exert past the point of exhaustion and the natural ability to repair. When the extrinsic muscles are no longer able to absorb the forces of activity, those forces are instead transferred to the bones, tendons, and ligaments, which leads to overuse injuries.
It’s not that McKeon is opposed to footwear. “Some shoes are very good, from the standpoint of providing support. But the consequence of that support, about losing information from the foot, is what we see the effects of [in overuse injuries].”
Strengthening the foot core
The simplest way to reintroduce the feedback provided by the small muscles of the foot is to shed footwear when possible. McKeon says activities like Pilates, yoga, martial arts, some types of dance, etc. are especially beneficial.
“Anything that has to deal with changing postures and using the forces that derive from the interaction with the body and the ground [is great for developing foot core strength],” he said.
McKeon also described the short-foot exercise, which targets the small muscles by squeezing the ball of the foot back toward the heel. It’s a subtle motion, and the toes shouldn’t curl when performing it. The exercise can be done anywhere while seated or standing, though he recommends first working with an athletic trainer or physical therapist to get familiar with the movement.
He notes the exercise seems to have especially positive results for patients suffering from ankle sprain, shin splints, and plantar fasciitis. It’s even been shown to improve the strain suffered by individuals with flat feet.
The payoff could be more than just physical, as there could be financial savings. With strong feet, McKeon suggests that — depending on the activity — consumers may not need to invest hundreds of dollars in slick, well-marketed athletic sneakers (though he doesn’t recommend going for the cheapest of cheap sneakers, either). People with a strong foot core can actively rely on the foot to provide proper support, rather than passively relying on the shoes alone.
“You might be able to get a $50 pair of basketball shoes that don’t have the typical support that you’d expect. Because you have strong feet, you’re just using the shoes to protect the feet and grip the ground,” he said.
The easiest way to get started on strengthening the small muscles of the foot, though, is to kick off your shoes in indoor environments.
“The more people can go barefoot, such as at home or the office, is a really good thing,” McKeon said.
Ithaca College. “Going barefoot: Strong ‘foot core’ could prevent plantar fasciitis, shin splints, and other common injuries.” ScienceDaily. ScienceDaily, 17 November 2015. <www.sciencedaily.com/releases/2015/11/151117181929
The Instituto de Biomecánica (Biomechanics Institute-IBV) has developed SUNfeet, insoles which are customized to the anatomy of the user’s foot, which increase the comfort of footwear and reduce pain and fatigue in the feet. This product is now available in Europe.
These insoles display an innovative technology used in their development: a combination of a system for capturing and digitizing the shape of the foot which is easy and intuitive for the user via smartphone and a 3-D printing system which allows insoles to be manufactured in a totally personalized manner.
SUNfeet arose from the idea of combining the latest trends in health, technology and fashion to develop exclusive insoles which make footwear more comfortable and care for the feet, thus promoting an active lifestyle.
The SUNfeet smartphone app was designed for the 3Dcapture system, making it possible to obtain the shape of the foot extremely accurately and conveniently from any location.
The process is very simple: while seated, the user places the bare foot on one side of a sheet of paper. The app itself will guide him/her until three images of each foot are obtained. The files are then sent to a server which reconstructs the foot in 3-D, using pattern recognition and shape analysis algorithms. The 3-D image of the foot can be displayed on screen in less than one minute. Finally, the system assigns a unique identification code to each image, which will subsequently be used to design the customized insole.
At the same time, this technology is also present in the manufacturing process through 3-D printing, opening the way for more creative designs and the customization of the functional properties of resistance and flexibility, adapting them to the specific needs of each user and activity.
The power and precision of SUNfeet technology allow for optimal customization: not only are the insoles adapted to the anatomy of the foot, but also to the characteristics and lifestyle of each user. With this in mind, three different models of insole have been created (Sports, Casual and Elegant), taking into account the type of activity and the characteristics of the footwear in order to select the most suitable materials and thicknesses. Thus, the impact cushioning, energy return and pressure distribution requirements are adapted to each use and to the characteristics of each individual.
The Instituto de Biomecánica (Biomechanics Institute — IBV) has introduced, as part of the Science Museum “Príncipe Felipe” of Valencia, this SUNfeet technology, incorporated as a new module of the exhibition “We Take Care About Your Quality of Life.”
IBV director, Javier Sánchez Lacuesta, reminded those present that “this exhibition -promoted by CVIDA association- was developed by IBV in collaboration with the Science Museum and opened in October 2007 in order to make available to the citizen technologies, products and services that take care of their health and wellbeing. This is an interactive show in which the visitor can check their skills in different environments and attractions.”
The foot care is essential to reduce hassles that come to limit the way of life. Using comfort insoles helps keep feet healthy during daily activity. SUNfeet combines a precise system of capturing and digitizing the foot and a 3D printing system that allows develop fully customized insoles.
The user can select the insole that best suits his lifestyle: Casual insoles for continued use shoes that achieve comfort and reduce foot fatigue; Elegant insoles that fit with most elegant and formal shoes; and Sports insoles that improve performance and help to prevent injuries.
Juan Carlos Gonzalez, IBV Clothing Director, showed attendees the performance of this system, highlighting the ease of use, accuracy when carrying out the capture of the foot and versatility of the system that allows getting perfectly tailored insoles to the needs and characteristics of the user and the function to which they are intended.
Asociación RUVID. “SUNfeet technology for the customization of comfort insoles using a smartphone.” ScienceDaily. ScienceDaily, 19 October 2015. <www.sciencedaily.com/releases/2015/10/151019072208.htm>.