TENDINITIS…TENDONOSIS…TENDINOPATHY…O MY!

TENDINITIS…TENDINOSIS…TENDINOPATHY…O MY!

 

Many people have had Achilles tendinitis, or tendinosis depending on your doctor’s education level. The modalities for this are outdated and although I don’t go into detail, this paper does state that performing exercise (you doing something) is better than passive modalities (other people doing things to you). We are animals and need to move!

 

  1. “This isolated eccentric loading paradigm has since gained considerable popularity and is now widely regarded as the treatment of choice, although there is a lack of convincing evidence that it is the most effective exercise regime”

For tendinopathies, eccentric lowering based exercises are given very frequently in the clinic, although this may not be the only way to treat the tendon. As a quick review, tendons connect muscles to tendons and ligaments connect bone to bone. Picture eating a chicken leg… when you get towards the handle portion of the chicken leg, there is that hard ropy part that we all spit out or try to eat around. That is the tendon. Thick, ropy and attaching the delicious chicken meat to the bone. Tendinopathies are injuries to the tendon that haven’t seemed to heal correctly.

Eccentric contraction is the type of contraction performed when the muscle becomes longer. For the meatheads, this is considered the negative portion of the lift. I remember being in PT school and describing the exercise as the positive portion, static portion and negative portion. Meatheads will understand this terminology. My professor said “Vince, we don’t use those terms here. We use concentric, isometric, and eccentric” respectively. I was instantly smarter because of this. (Sense the sarcasm). Every profession has it’s own language and these languages is why healthcare is so expensive. We have come up with smarter ways of saying the same thing that gym rats say everyday.

 

  1. Paraphrasing: After exercising, there are physical changes that occur: increased blood flow, collagen formation, bigger muscles/tendons. This occurs from varying the intensity of exercise, which can be done as follows: force or weight of the load to be moved, range of motion through which the muscle is contracted, contraction type (see above)speed of contraction, number of repetitions, and rest between sets.

For anyone that has ever read FLEX or Muscle and Fitness, these are all basic tenets of exercise. We can all agree that to make an exercise harder, we can always add weight. This one is easy and all of my PT students say this answer first when asked how to make an exercise harder. That’s great, but PT students are now considered doctors and I can get the same advice from my Dad, who was a laborer. We as medical professionals have to be able to give better advice than our patients can get from their neighbors.

Range of motion is considered how far we are moving our joints while moving weight. If you have ever been to the gym and watched someone squat, you already understand range of motion. One guy almost always does the set and says “did I go deep enough?” If the question has to be asked, the answer is always no. Anyways, it is obvious that the person that just unlocks his knees and stands back up is doing much less overall work that someone that lowers their butt until it is just inches above the floor (aka A$$ to Gra$$). We all know that the first guy didn’t do the same amount of work as the second guy, even if he used heavier weight. For some reason though, no one ever tells him this…I don’t get it.

Speed of contraction is huge. Dr. Squat (Fred Hatfield PhD…if you are a lifter and don’t know this name…stop and google him right now! I won’t be offended if you don’t read the rest of this but come back asking for an explanation of compensatory acceleration) used to talk about the speed in which we transition from the eccentric to concentric phase. In many people, it looks like a smooth wave…NO GOOD! He wants it to look like a checkmark, with the least amount of time needed to transition from one type of contraction to another. Getting back to the point, speed is another way to change the intensity or power output of an exercise. The faster you move a certain weight or body part, the more power output you have compared to a slower movement. For instance, the snatch is one of the most powerful movements in sports, but most people in the US only think derogatorily with this word (shame on you…you know who you are.) MORAL: The faster you move, the more power you produce. The heavier you lift, the stronger your tissues. The smaller the range of motion in a squat…douche.

 

  1. “It is well known that the tendon cells (fibroblasts) respond to mechanical stimuli in the form of strain, and that depriving them of strain (relative tissue deformation) leads to degeneration and apoptosis (cell death).”

In other words, if you don’t want your cells to die, then you have to do something strainful to the tendon. In other words: Get up off the couch and move! Or your cells will die. What happens to the body when the cells start dying? That’s why I get paid the big bucks, I know the answer. DOH! I’m giving away the answers.

 

  1. “…the evidence suggests that increased time under load, increased number of load cycles, and increased loading rate result in a positive adaptive response”

Simply put, spending some time under the bar (time under load) with multiple repetitions (load cycles) frequently (loading rate) is good for you (positive adaptation). You don’t need me to say this, but I will anyway. The stronger person is always more functional than the weaker person…all other things being equal. As we age, we lose the ability to be powerful. Think of it…even Arnold doesn’t look like AHNOHLD anymore. Start today. Get bigger, stronger, faster. You may never beat Bolt, but you can always beat the you of yesterday.

 

  1. “slow loading may therefore produce particularly strong cell stimuli that can be beneficial to the tendon if the strain is sufficient”

Okay, we are much smarter today than our ancestors…or are we. There is a guy by the name of Arthur Jones (again…Google him. This guy may not be able to squat as much as Fred Hatfield, but my Lord this guy is way more interesting…Why are you still reading…GO GOOGLE!). That’s right, he carried a gun almost everywhere he went. Jones proposed last century the benefits of slow training. He knew inherently that it made the tissues stronger. We now know he was right.

 

  1. “…imply that given a sufficiently high force (and resulting strain on the fibroblast), the contraction mode is inconsequential”

WHO CARES WHAT TYPE OF EXERCISE YOU DO! PUT YOUR HAND ON THE SCREEN..GO FORTH AND EXERCISE AND YOU WILL BE HEALED! (I say this, all the while picturing the grey haired preacher, from the 90’s on tv) We have overcomplicated treatment of tendon injuries. We just need to make the tendon stronger. We can do this through negative or positive lifting, assuming that there is enough weight to actually make a difference. Now let me retract slightly because I typically follow MDT paradigms. In Mechanical Diagnosis and Therapy, a tendinopathy would be classified as a contractile dysfunction. Robin, in the 1980’s thought that we just have to get the tissue stronger (remodeled). In this method, the patient is told to lift the weight just enough to reproduce the symptoms (pain) and then perform this repeatedly multiple times per day. When this no longer produces pain…go heavier. I know! He was such as genius!

 

  1. “Therefore, collectively, there is no firm evidence to support the notion that eccentric loading is more efficient than concentric or other loading regimes”

Do I need to elaborate?

 

MORAL: The person that doesn’t move will die (apoptosis). Movement heals all (general overstatement) and the type of movement is not as important as simply moving.

Author: Dr. Vince Gutierrez, PT, cert. MDT

After having dedicated 8 years to growing my knowledge regarding the profession of physical therapy, it seems only fitting that I join the social media world in order to spread a little of the knowledge that I have gained over the years. This by no means is meant to act in place of a one-one medical consultation, but only to supplement your baseline knowledge in which to choose a practitioner for your problem. Having completed a Master of Physical Therapy degree, the MDT (Mechanical Diagnosis and Therapy) certification and currently finishing a post-graduate doctorate degree, I have spent the previous 12 years in some sort of post-baccalalaureate study. Hopefully the reader finds the information insightful and uses the information in order to make more informed healthcare decisions. MISSION STATEMENT: My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations. I choose to be a leader of example, and not words, all the while reducing negativity in my life. I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment. I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

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