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.
Okay. So you’ve decided to embark on a fitness regime in order to shed some kilo’s, get fit or just for fun. New gym membership. Check. New sparkling runners. Check. Gym gear (a bit tight at the moment). Check. Alright, let me at that treadmill/rower/crosstrainer/zumba class!
“Hold on a second – what about your warm-up!”
“Warm-up” you scoff, “you’ve got to be kidding. No time to waste on that”.
Sorry folks, but the warm-up is an important part of your exercise routine and plays a crucial role in preparing your body for exercise. Skimp on the warm-up and you run the risk of injury during exercise or sport, as well as reduced performance levels.
“But what’s so important about doing a few stretches?” I hear you ask.
A proper warm-up involves more than just standing around stretching and talking. It prepares your body for the exercise/sport it is about to undertake and should simulate the actions involved.
The benefits of a warm-up are:
1) Increase in core body temperature
2) Preparation of muscles, tendons and joints for the stresses/strains of activity
3) Increase in nerve impulse conduction to muscles
4) Increase in blood flow to muscles
5) Increase in respiratory (breathing) rate
Let’s have a closer look at each of these benefits.
1. Increased core body temperature – this is important as it prepares the body for the change in activity level from being sedentary to exercising and gets the body into a ‘ready’ state. This also results in an increase in muscle temperature which makes them more pliable, supple and loose.
2. Prepares muscles, tendons and joints for activity – each sporting activity stresses the body in different ways so it is vital to prepare in a way that simulates these activities. For example, if you are a basketballer you need to include in your warm-up the jumping, running and change of direction that occurs during the game. If you pump weights at the gym, it is vital to perform a warm-up set of each exercise at a lower weight to allow your body to adjust to each specific movement.
3. Increased nerve conduction – muscles that are in a ready or aroused state react quicker and more efficiently than muscles that aren’t prepared for activity.
4. Increased blood flow to muscles – through increased blood flow there is an increase in oxygen flow to muscles as well as nutrient flow. This increased flow allows for improved performance
5. Increased respiratory rate – prepares the lungs for an increase in activity level and improves oxygenation of the blood flowing to the muscles.
Okay, so now that we know why we are performing a warm-up, what should it involve?
One common misconception out there these days is the importance of stretching as part of a warm-up. Note I said part of a warm-up.
Stretching on its own does not constitute a warm-up – rather it forms a critical part of one.
An effective warm-up has a number of very important key elements, which work together to minimize the likelihood of sports injury and prepare the individual for physical activity.
These key elements are:
1) The general warm-up
2) Static stretching
3) Sport specific warm-up
4) Dynamic stretching
1. The general warm-up
This consists of light physical activity such as walking, jogging, easy swimming, stationary bike, skipping or easy aerobics. The intensity and duration of the general warm-up is dictated by the fitness level of the participating athlete. For the average person, this part of the warm-up should last between 5 and 10 minutes and result in a light sweat.
2. Static stretching
Yes! Static stretching. This is a very safe and effective form of basic stretching. There is a limited threat of injury and is beneficial for overall flexibility. All the major muscle groups should be included for a period of 5 to 10 minutes.
Debate has raged about whether static stretching should be part of a warm-up and some studies have shown that static stretching can have an adverse effect on muscle contraction speed and therefore performance. It is for this reason that static stretching is performed early in the warm-up and always followed by sports specific drills and dynamic stretching. It is important these first two elements are completed properly as it allows the more vigorous and specific activities of elements three and four to then be performed.
3. Sport specific warm-up
In this part, you are specifically preparing the body for the demands of your particular sport or activity. During this part of the warm-up, more vigorous activities should be employed. Activities should reflect the type of movements and actions which will be required during the activity.
4. Dynamic stretching
Finally the warm-up should finish with a series of dynamic stretches. Caution should be taken with this form of stretching as it involves controlled, soft bouncing or swinging motions to take a particular body part past it’s normal range of motion. The force or the bounce of the swing is gradually increased but should never become radical or uncontrolled. These exercises should also be specific to the sport or activity.
Another important factor to keep in mind when undertaking any new exercise regime, is the time it takes for the body to adapt to training. If you have had a period of time away from sport or activity, then your body won’t be used to the stresses and strains put on it from exercise. It can take up to 4 to 6 weeks for your muscles, tendons and joints to become adjusted to the movements involved in your sport or activity.
During this period it is advisable to start with low to moderate intensity exercise which gradually builds over time. Heading straight up the red or blue arrow as your first exercise session in 3 or 4 months isn’t a great idea. Starting out with flat walks or jogging and gradually increasing time and intensity is a better way to start. After 4 to 6 weeks you will be at the stage where you can tackle more intense sessions.
The same goes for weight training. Starting with lighter weights and more repetitions will allow your tendons and joints in particular, to adapt to lifting load. Going too heavy too soon can lead to tendon injuries or severe muscle and joint soreness.
A very common running injury is a calf strain or a tear. We have two main calf muscles, Gastrocnemius and Soleus, which are under repetitive load when we run. There are two reasons for this, the first one is to absorb the shock of our body weight during landing, and the second is to help move us forward into our next stride.
When we run, we take on average 937 strides per km. Obviously any weakness in the calf complex, or elsewhere in your lower limb or pelvis, will affect your running technique. Any muscle imbalance in your kinetic chain (above and below the calf) will lead to an increased load on the calf and predispose you to injury, strain or tear.
Just as your calf is designed to absorb shock and propel us forwards, the muscles above and below the calf are stabilising muscles. These are responsible for keeping the ankle, knee and hip joints stable during movement, so that your calf can carry out its main function. However, if your muscles aren’t up to the job they were designed for, particularly at the foot and ankle complex, the calf will begin to try and take on a stabilizing role. It isn’t designed to do this so it gets overworked or injured. A common example is over pronation of your foot (rolling inwards) or weak gluteal muscles causing excessive inward rotation of the knee.
A lack of a warm-up session is often a reason why many of us sustain calf injuries. The warmer the muscle, the more elastic it becomes. As we get older, there becomes a decrease in elasticity towards our tendons and muscles, causing an increase risk in calf strains for those more senior to running. Warming down after a run with calf stretches helps maintain the elasticity in your calf muscles.
Don’t forget that dehydration affects your muscle function by reducing blood flow to your muscles and decreasing muscle elasticity, flexibility and endurance. So stay hydrated.
Properly fitted footwear that isn’t worn out and provides adequate cushioning is also an important factor to consider when avoiding calf strain. Calf compression socks or long skins can also assist with keeping muscles warm and increasing circulation.
What to do if you have calf strain or tear?
Initially, the Rest, Ice, Compression, Elevation (R.I.C.E) principal should be followed. Book an appointment with a Physiotherapist for assessment and treatment of your injury so we can start your individual rehabilitation programme. We may refer you to have a scan of your injured calf muscle if we suspect a grade 2 or 3 strain.
Approximate timescales for rest are;
3 weeks for a Grade 1 strain
4-6 weeks for a Grade 2 strain
Grade 3 tears will most likely require surgery followed by a 12-week rehabilitation programme.
As with any injury, it is very important to avoid secondary injuries that occur through compensatory movement patterns. These may have become a habit during the injured period. All the more reason to get self assessed early to avoid this from occurring.
The rehabilitation period is also a good opportunity to target those areas that often get ignored in our weekly training routines. Core stability and gluteal muscles are a great place to focus on when running activity is restricted. At Saanichton Physiotherapy and Sports clinic our Physiotherapists will design a programme to suit your individual needs.
Research conducted has found that the stronger these muscles are, the more likely you will gain a successful outcome in not only injury recovery, injury prevention, but also importantly your performance.
Foot Pain OUCH!
You leap out of bed in the morning and you get stabbing pains in your heels or the arches of your feet. You hobble a few steps, and then hobble a few more until the pain reduces. Most of the day your feet feel OK …except when you tackle stairs or when you have been sitting for a while when the pain makes a reappearance.
Pain in your heel or the bottom of your foot is most commonly caused by Plantar Fasciitis. Your Plantar Fascia is the ligament that goes from the underneath of your heel to your toes. If you strain it, micro tears can form, which leads to swelling and sharp pain.
While most people experience the pain in their heel, some also get pain through to the arch of their foot. In about 70% of cases, the pain is in both feet, making walking a very painful experience.
You most commonly notice the pain first thing in the morning when you get out of bed and it reduces as your feet warm up with movement. It can reappear during the day after periods of rest or sitting, if you have been standing for a while, or when climbing stairs or ladders.
Plantar Fasciitis is more common in middle-aged people, although it can also affect younger people who use their feet a lot like joggers, dancers, or soldiers. That’s why it is also often called Joggers Heel.
Causes of Plantar Fasciitis
While the actual causes of plantar fasciitis are not known, there are risk factors that will increase the likelihood of you getting plantar fasciitis.
Overuse – excessive running, walking or dancing, or changing your training pattern so you dramatically increase hill running (for example).
Standing on hard surfaces
Flat feet or high foot arches (this is one time when average is better!)
Tight Achilles tendons or calf muscles
Your feet roll in when you walk or run
Ill-fitting shoes, worn out or unsupportive footwear such as thongs/slides
Walking barefoot on hard surfaces
First aid for Plantar Fasciitis
Generally, plantar fasciitis is gradual onset, which means it gradually increases in severity over time. If you ignore it and try to run through the pain, then the symptoms can get worse, ultimately leading to you changing your gait, limiting your activity or triggering the growth of heel spurs.
For initial symptoms, you need to rest, apply ice packs (15 minutes at a time every 2-3 hours), and take anti-inflammatory painkillers such as ibuprofen.
You don’t need a referral from a doctor to see a physiotherapist. If the pain is moderate then you can seek treatment with your Physiotherapist immediately as the sooner you begin treatment, the sooner you will experience relief.
Occasionally your plantar fascia can snap and you could hear a clicking or snapping sound, accompanied by swelling, intense pain and significant swelling. You need to see a doctor urgently if this occurs.
Physiotherapy & Treatment Options
Your physiotherapist will assess the extent of your injury, and will explore the causes of your injury.
Depending on your symptoms, you may have the soles of your feet taped or strapped to support your feet and reduce pain. You may also need to wear a plantar fasciitis brace or heel cups in the initial stages of healing.
Your physiotherapist will take you through a number of gentle stretching exercises for your feet, as well as exercises to address any tight Achilles tendons or calf muscles.
We will combine these with pain reduction techniques that you can do at home such as rolling your foot on a frozen water bottle or frozen golf ball to help ice your injury site.
Massage, joint mobilisation techniques, dry needling and ultrasound therapy will also be used to reduce swelling and restore movement.
For your footwear, we recommend you replace your joggers every 650km of use, and only wear shoes that support your feet while healing. Definitely no thongs or slides!
It also helps to put your shoes on first thing in the morning, before you take your first steps. Avoid barefoot walking on tiles or hard surfaces while you heal.
If the cause of your injury is your feet shape or foot pronation, you may need special orthotics. If this is indicated, we would conduct a walk/run assessment on you and have your technique analysed.
To maintain your fitness during your treatment, we recommend swimming and cycling. Don’t return to running until you have been pain free for at least one week, and then only run on soft surfaces until you rebuild your strength and stamina. If pain is felt at any time, then go back to swimming and cycling rather than running.
Unfortunately, Plantar Fasciitis is a long-term injury, and may take a number of months to fully heal even with the most aggressive treatments.
Things to Remember
Plantar Fasciitis is the most common cause of heel and arch pain, and is caused by micro tears to the plantar fascia.
It is a gradual onset injury and causes sharp pain when taking the first few steps in the morning or after rest.
Physiotherapy can treat plantar fasciitis, while reducing pain and increasing movement during healing.
Your physiotherapist may advise you of techniques for the improvement of your walk/running style, or provide you with solutions for arch support, to help prevent further reoccurrence.
Healing may take many months for full recovery.