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.
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.
Plantar fasciitis is inflammation of the plantar fascia and is the most common cause of heel pain. The plantar fascia is the thick band of connective tissue under the foot that runs from the heel bone at the back of your foot to the toes at the front. It essentially acts like a sling to support the arch of your foot.
What causes Plantar Fasciitis?
There are a number of causes including:
Age as it is more common in middle-aged people due to ‘sagging’ of the arch of the foot, but can occur in younger people who put a lot of load through their feet.Weaknesses can occur in the muscles that support the arch of the foot, which causes the plantar fascia to take an increased load which can irritate
Poor bio-mechanics can contribute to plantar fasciitis i.e. having flat feet or high archesWeight gain or excess weight can put extra load on the plantar fascia, irritating .
the tissues; this can also occur from the weight gain during pregnancy
Repetitive loading i.e. high level sports or working on your feet
Poor support from footwear i.e. worn or ill-fitting shoes
Arthritic foot joints can irritate the plantar fascia
Diabetic people have an increased chance of suffering from plantar fasciitis
Signs and Symptoms of Plantar Fasciitis
Pain at the base of the foot near the heel with weight-bearing
More pain after getting out of bed, or after prolonged sitting
Heel pain will be worse with the first few steps and will gradually improve as you move more
Generally your physiotherapist will be able to diagnose plantar fasciitis from your history, symptoms and a clinical examination.
Calf stretches often give relief to sufferers – it is important to stretch both calf muscles, so stretch with a straight leg and also a bent leg. Hold each stretch for 30 secs and repeat twice. Try to do this at least morning and night every day.
Freeze some water in an old water bottle and roll the bottom of your foot up and down on this.
Taping can offer you some relief while you are doing your exercises to off-load the plantar fascia.
Strengthening is an important component of treatment for plantar fasciitis as it improves the ability of the foot and ankle muscles to support the arch of your foot hence off-loading the plantar fascia.
Book an appointment with one of our physiotherapists who can help you with ideas for strengthening exercises to help ease the pain caused by plantar fasciitis.
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.