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.
People who exercise have better mental fitness, and a new imaging study from UC Davis Health System shows why. Intense exercise increases levels of two common neurotransmitters — glutamate and gamma-aminobutyric acid, or GABA — that are responsible for chemical messaging within the brain.
Published in this week’s issue of The Journal of Neuroscience, the finding offers new insights into brain metabolism and why exercise could become an important part of treating depression and other neuropsychiatric disorders linked with deficiencies in neurotransmitters, which drive communications between the brain cells that regulate physical and emotional health.
“Major depressive disorder is often characterized by depleted glutamate and GABA, which return to normal when mental health is restored,” said study lead author Richard Maddock, professor in the Department of Psychiatry and Behavioral Sciences. “Our study shows that exercise activates the metabolic pathway that replenishes these neurotransmitters.”
The research also helps solve a persistent question about the brain, an energy-intensive organ that consumes a lot of fuel in the form of glucose and other carbohydrates during exercise. What does it do with that extra fuel?
“From a metabolic standpoint, vigorous exercise is the most demanding activity the brain encounters, much more intense than calculus or chess, but nobody knows what happens with all that energy,” Maddock said. “Apparently, one of the things it’s doing is making more neurotransmitters.”
The striking change in how the brain uses fuel during exercise has largely been overlooked in brain health research. While the new findings account for a small part of the brain’s energy consumption during exercise, they are an important step toward understanding the complexity of brain metabolism. The research also hints at the negative impact sedentary lifestyles might have on brain function, along with the role the brain might play in athletic endurance.
“It is not clear what causes people to ‘hit the wall’ or get suddenly fatigued when exercising,” Maddock said. “We often think of this point in terms of muscles being depleted of oxygen and energy molecules. But part of it may be that the brain has reached its limit.”
To understand how exercise affects the brain, the team studied 38 healthy volunteers. Participants exercised on a stationary bicycle, reaching around 85 percent of their predicted maximum heart rate. To measure glutamate and GABA, the researchers conducted a series of imaging studies using a powerful 3-tesla MRI to detect nuclear magnetic resonance spectra, which can identify several compounds based on the magnetic behavior of hydrogen atoms in molecules.
The researchers measured GABA and glutamate levels in two different parts of the brain immediately before and after three vigorous exercise sessions lasting between eight and 20 minutes, and made similar measurements for a control group that did not exercise. Glutamate or GABA levels increased in the participants who exercised, but not among the non-exercisers. Significant increases were found in the visual cortex, which processes visual information, and the anterior cingulate cortex, which helps regulate heart rate, some cognitive functions and emotion. While these gains trailed off over time, there was some evidence of longer-lasting effects.
“There was a correlation between the resting levels of glutamate in the brain and how much people exercised during the preceding week,” Maddock said. “It’s preliminary information, but it’s very encouraging.”
These findings point to the possibility that exercise could be used as an alternative therapy for depression. This could be especially important for patients under age 25, who sometimes have more side effects from selective serotonin reuptake inhibitors (SSRIs), anti-depressant medications that adjust neurotransmitter levels.
For follow-up studies, Maddock and the team hope to test whether a less-intense activity, such as walking, offers similar brain benefits. They would also like to use their exercise-plus-imaging method on a study of patients with depression to determine the types of exercise that offer the greatest benefit.
“We are offering another view on why regular physical activity may be important to prevent or treat depression,” Maddock said. “Not every depressed person who exercises will improve, but many will. It’s possible that we can help identify the patients who would most benefit from an exercise prescription.”
So we all know that feeling that we get after exercise – we feel generally happier, less stressed, less anxious and also sleep better. Exercise produces a rush of happy hormones we also know as endorphins. So what are these endorphins and why do they make us feel happy?
Endorphins are chemicals that are produced in our brains in response to stress or pain. Running, doing a hard workout, playing a sport or any exercise at all that increases our bodies stress response has the ability to make our brains release endorphins. The endorphins have the ability to travel through our neural networks as a neurotransmitter. One thing we do know about endorphins is that they make us feel really good. So how does this work then?
A part of the brain called the hypothalamus sends a signal to increase endorphin uptake through our bodies neural network when we subject ourselves to certain activities like exercise, sex, eat certain foods or experience pain. The endorphins then attach themselves to specific receptor sites within our neural network – these are called opioid receptors. These special receptors have the ability to block out pain signals and also to increase that euphoric happy feeling we get after we exercise. It is the same receptors that are locked onto when we take pain relief in the form of opiates.
Once we achieve a positive result in something we do, either though through exercise or simple activities like sticking to a plan you’ve made, your brain will also release another happy hormone called dopamine. Dopamine is responsible for us feeling addicted to pleasure seeking behaviors. By setting regular and achievable exercise goals that you reach it is highly possible to make exercise the trigger for your brain to release dopamine.
Serotonin is another one of our brains happy hormones that act as a natural anti-depressant. When we exercise serotonin levels in our brain increase and so does your level of happiness.
I know all these terms may seem confusing but there is another very important happy hormone called oxytocin. Oxytocin is released when we feel loved, cared for and connected to others. Your brain will also release oxytocin when you are kind to others.
So no matter how hard it may seem to get yourself moving on some days, putting one foot in front of the other and pushing yourself to move and exercise is not only good for your muscles and joints but also stimulates your brain. You’ll produce your very own happy hormones, reduces your stress levels and have you wanting to repeat it all over again next time. Give your fellow team mates, friends and family an encouraging kind words regularly as well- it will not only help them feel happy but will increase your happiness as well.
Ok so your shoulder has been hurting for a while and your Physio has diagnosed you with a Rotator Cuff injury. What the hell is a rotator cuff? How do I get rid of this pain!?!
Firstly, the rotator cuff is a group of four muscles which help to stabilise the shoulder. The shoulder is a ball and socket joint, similar to the hip, however the shoulder has a shallow socket in comparison. What the shoulder lacks in stability it makes up for in mobility, generally speaking, a healthy shoulder has almost 360 degrees of movement so it needs help from the surrounding muscles to maintain stability through movement. There is also another structure inside the shoulder joint called the labrum, which helps to deepen the joint and provide stability.
How does my Rotator Cuff get injured?
Rotator cuff injuries usually occur either acutely (immediate sharp pain) or over time (gradual increasing dull ache). Acute rotator cuff injuries can often involve a tearing of the rotator cuff tendons and leads to pain and weakness of the shoulder. Gradual onset of shoulder pain can be associated with repetitive overhead movements, which can lead to smaller tears in the tendon and inflammation around this area.
One of the main factors which can influence shoulder pain is the position of the shoulder. The further forward the humeral head (the ball) sits in the socket, the more compression of the tendon occurs and leads to injury.
How can I fix it?
Having your shoulder properly assessed by a qualified Physiotherapist is the first step in diagnosing a Rotator Cuff injury. Investigations such as Ultrasound or MRI may be relevant if the Physiotherapist feels there is significant injury. For acute rotator cuff tears, a small period of immobilisation in a sling or in some cases, just with some tape, will help settle the pain. Once pain and inflammation are under control then you need to get the shoulder moving and gradually strengthen the rotator cuff tendons and surrounding muscles.
For the gradual onset type shoulder pain there is usually a biomechanical cause for the loading of the tendons. Thorough assessment by a qualified Physiotherapist is a must to get to the bottom of your shoulder pain. Initially settling down the pain and inflammation around the tendons and encouraging gentle pain free movement is the first step. Then gradually increasing the load in the shoulder until the strength is back to normal
How can I prevent this from happening in the future?
Continuation of the strength and flexibility exercises prescribed by your Physiotherapist will help decrease the likelihood of re-occurrence. Identifying aggravating positions i.e. overhead movements or reaching in awkward positions will also decrease the likelihood of re-injury. If your job is a relatively sedentary and requires hours of sitting at a time, trying to break up your day with standing/walking will help, also an ergonomic assessment to ensure your workspace is properly set up to suit you will help ease the stress on your shoulders/neck.