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PT and tendons: where are we at?

“Complicating matters further is the mismatch between reported pain (and disability) and imaging (and pathology), as well as evidence of widespread sensory nervous system sensitization in some tendonopathies.”

A little background. Pain is not always viewable. This is a large debate even among the highest level of pain organizations. The IASP (Thanks to Colin Windhu for catching a mistake) is looking to change the definition of pain to include tissue based problems, or at least perceived problems.

Not all pain has a tissue based component, as some have a cognitive and emotional based component. For instance, I treated a person that was so afraid of performing activities that this person developed a pain from the thought of movement. After establishing that movement was safe, this person more than 10X increased the ability on a functional test…in less than 6 weeks.

This person, and others that I’ve worked with, have a “stinking thinking” type of pain. This may not be the fault of the patient, but instead it may be the fault of the faulty medical system. One that drives fear.

How many people have heard a physician say

“This is the worst spine I have seen”

“You shouldn’t squat/run because it’s bad for your knees”

“You shouldn’t work with heavy weights because it’s bad for your back”

“Your knees/hips are bone on bone and you will need a new knee/hip in the future”

Your pain is because you have a rotator cuff tear/disc herniation/arthritis etc”

These types of interactions do more to hurt the patient than help the patient and can start the cycle of inactivity out of fear of breaking oneself.

Don’t buy into the hype. A little stat, when a physician diagnoses your back pain as a herniated disc, arthritis, muscle strain, stenosis, etc do you know that the diagnosis is only right about 10% of the time?!

People are hanging their health habits in a guess that has a worse chance of being right than flipping a coin. You would have better odds of getting 4 of a kind in Texas Holdem.

Let’s start by not placing too much weight into the diagnosis because it’s a best guess at best.

Here’s what we think may happen. Some pain can cause more pain. Nerves can communicate with each other.

It’s similar to an infection. Any nerve that comes in contact with the nerve that is irritated can then become infected (irritated). Hmm?

I’ve seen many patients that experience widespread pain even though “everything is healthy”.

Yet another reason not to hang your hat on one specific tissue problem.

“… A diagnosis of tendinopathy is reasonably easy to make clinically, on the basis localized pain over the tendon that is associated with loading of the tendon.”

If you hurt your biceps and you ask your biceps to work, it makes sense that it may not like that.

If you hurt/injured your biceps and it hurts when you make your ankle muscles work, we wouldn’t expect that to create a problem in the biceps if the problem is localized to the biceps.

Make sense?

In other words, when a tendon is injured, we expect specific behaviors like

1. Pain with contraction under load that may increase with increasing loads

2. Pain with compression of that area

3. Pain with stretching that specific area

4. No issues when that area is not moving.

If the symptoms operate outside of this narrow set of parameters, it may not be only a tendon issue. This is not to say there isn’t a tendon issue, but instead is meant to say that the tendon may only be a part of the problem and we have no idea how much of a part it is until more assessment is done.

“…management of tendinopathy should optimally involve addressing loading of the tendon”

A tendon connects a muscle to a bone. It doesn’t have a ton of blood flow and can be slow to heal.

It needs to work in order to get back to its normal function.

This is what it means to load the tendon. Make it work, but don’t irritate/create harm. As long as the tendon/pain is not worse following an activity…awesomesauce…no harm done.

“Management of load…usually commenced with complete removal of offending activities and the introduction of appropriate and graduated loading activities”

If you break your leg, you will expect to be on crutches. This is to allow the bone time to heal. This stage lasts anywhere from 4-6 weeks. Loading before then one is ready to accept load can result in worsening the injury. You would know this because the pain worsened or you would break it further.

Loading a tendon before it is ready to be loaded OR more than it is ready to accept will lead to increased pain in that area, pain that is lasting and worsening function over time.

These are the clues a patient needs to give their attention towards.

Sometimes you need to remove all load from a tendon to allow it to rest and others you can perform your normals daily activities, but any more would result in increased pain that lingers.

When the pain no longer lingers after an activity, it is time to do more activities and create a new norm.

It doesn’t have to be any more complicated than this. Some research shows that 1200 repetitions of calf raises should be performed weekly, but it doesn’t have to be this structured.

“…requires patient buy-in…involves the clinician educating the patient about the nature of the tendinopathy, its relationship to loading, and a likely recovery trajectory.”

This is by far and away the most important detail.

If the patient is not educated on how the body should respond AFTER performing the activity, then the patient may be reluctant to continue anything that creates transient (short-lived) pain.

This is one of those issues that only gets better with direct loading. It doesn’t “fix” with time because it needs to be strong enough to handle the loads that you would throw at it on a daily basis.

“This exercise program should be adequately supervised, reviewed, and progressed to ensure adherence and resolution of the tendinopathy.”

SOAPBOX: ADEQUATELY SUPERVISED DOES NOT MEAN THREE TIMES PER WEEK FOR SIX TO EIGHT WEEKS. THE PATIENT SHOULD BE PERFORMING THE HOME PROGRAM AND THE THERAPIST IS IDEALLY ONLY A PHONE CALL AWAY. THE PATIENT SHOULD RETURN IF SOMETHING U EXPECTED HAS OCCURRED OR THE PATIENT NO LONGER IS ABLE TO REPRODUCE THE SYMPTOMS WITH THE LOAD THEY ARE USING AT HOME.

“(a) symptom-guides management, (b) symptom-modification management (c) compressive versus tensile load (d) stages of loading through the rehabilitation process (isometric and isotonic strengthening, energy storage and release, return to play), and (e) what I will refer to as movement competency…in a way that does not provoke pain.”

This doesn’t need to be summarized and is great advice for most soft tissue disorders.

“In the lower limb (Achilles tendon, patellar tendon), it appears that pain up to 5/10 on a numeric pain rating scale during and after training is not harmful and may be desirable”

This is a little more aggressive than I go initially, but the patient’s response gets to dictate how hard we push.

If there is a 3 point change and the patient is no worse after repeatedly creating a 3-point change, the. They have earned the right to go to a 4-point change. At some point, we would predict that too much of an increase would lead to an inflammatory effect, but we just don’t know what that number is for that specific patient.

The only way we will ever know is to test it.

“The fad of giving all patients with tendinopathy an eccentric exercise program from the onset has largely abated; however, after adequate strength of the muscle has been achieved, it is necessary to use eccentric exercises to reinstitute the energy storage/return capacity of the musculotendinous complex”

Not sure if this is any different than just load the tissue. The tissue needs to be able to contract under load and stretch under load. That’s normal mechanics for a muscle.

“Movement competency…is mainly about the form and shape (posture and alignment) with which physical activity is performed.”

This is consistent with what Dr. Kelly Starrett has been preaching for years through his books, videos and interviews.

A squat should look like a certain shape and many things look similar, such as a lunge (squat with one leg), clean start position, deadlift start position, standing up from the toilet etc.

Of course I know there are nuances between the squat and deadlift regarding hip height and back angle, the clean and lunge regarding shin angle etc, but in the end the basic shape still applies (knee bent and hip bent with shoulders forward and back fairly flat with head looking straight ahead). The similarities are where most people need to function and the nuances are what make the exceptional athletes different.

Link to article

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Hip impingement? Is there a place for PT?

“surgical rates for correction of FAI have escalated, despite limited evidence to support a cause – and – affect relationship between FAI and hip pain.”

It is said that there is an 18X increase in procedures over the decade Studied.

The fact that this surgery has increased at such a dramatic rate may be a result of who the patient sees for the problem.

Physical Therapists do physical therapy.

Surgeons do surgery.

Pain management do management of pain through chemical means.

Chiropractors do chiropractic medicine.

Acupuncturists do acupuncture.

It’s a very easy equation to figure out. Who you see to manage your symptoms will dictate what is done for your symptoms.

“… The evidence from these studies is mostly level four (low level), the reported results are short term, and at least one studies suggest a notably lower level of sport activity at three years surgery. Currently, there are no high – quality randomized studies examining the effectiveness of surgery for FAI”

This makes it difficult to make a broad statement due to the lack of controlled research. For instance, a sham surgery (a surgery in which the patient is cut, but nothing else is done) compared to an actual surgery would start to give us information on the value of the surgery.

Looks like the study is in the process of being Completed.

I personally like case studies and case reports because sometimes a “classic study”, such as a randomized controlled study, may not capture the characteristics of the patient in front of the health care professional.

“75% of surgeons believe that FAI surgery prevent future osteoarthritis, although 62% of the surgeons were either unsure of or did not believe there was an optimal debridement of SAI lesions to prevent future osteoarthritis”

A belief plus 5 dollars will buy a coffee at Starbucks.

Not a fan of these types of studies because it demonstrates the bias of the profession. The shocking statistic is the reverse. The fact that 25% of surgeons don’t believe that surgery prevents future OA is cool. Unfortunately, we don’t know the education level, outside of the fact that the people polled were surgeons, of each person in the poll. For instance, if it’s the best of the bell curve that believe surgery has no effect on OA, then I may side with that opinion. We just have to think critically when reading these numbers.

“… The fact that 34% of both pediatric and adult patients diagnosed with FBI stated that they I knew they wanted FAI surgery (21% not willing to try conservative therapy for six months) suggest that orthopedic/sports patient has a propensity for overconfidence in surgery as the gold standard treatment.”

We are all salespeople for our profession.

Don’t believe me…just check out how many people are selling PTs education on Sales tactics and marketing.

It seems that surgeons are doing a great job of sales in that 1 in 3 believe that surgery is the answer.

As PTs, many of us are learning how our language affects the patient, both positive and negative.

It would be easy for me to convince a patient that they are weak and need us, but I don’t know if that is doing more of a service or disservice st that point.

“We think we could all benefit from learning from our past, when, despite similar increased endorsement of surgical intervention (746% increase in shoulder arthroscopy for impingement over a ten-year span), surgical patients fared no better than those treated conservatively.”

Yup.

Another way to say conservative = non surgical.

I’m going to leave this final quote from the article as the final statement. 👇

“Stop accepting morphology as pathology”

Link to the article

THAT JUST CHAPS MY ARSE!

THAT JUST CHAPS MY ARSE!

 

MORAL: We know a little more than we did 10 years ago, but we didn’t know much then either. We now know that we have been calling trochanteric bursitis by the wrong name. WHOOPEE! We think we know how to treat hip pain (isometrics progressing to loaded movement), but we aren’t completely sure yet. Don’t you love evidence-based medicine? I know I do. I feel smarter after reading this article (shaking my head no at the same time).

 

  1. “Gluteal tendinopathy is though to be the primary cause of lateral hip pain”

 

Gluteal, otherwise known as buttock, tendinopathy (a dysfunction of the tendon) is a major cause of lateral hip pain. Of course before we go here, the therapist or physician should rule out the spine as a cause of your symptoms. If he/she does not know how to do this, go to find a MDT therapist.

A long time ago (couple of years ago actually) there was this common diagnosis that we would get as a referral…trochanteric bursitis. It would make patients feel so smart that they remembered this term for their entire lives, because at some point a doctor may have told them that this is what is causing their pain. In 2 out of 10 patients with hip pain (outer border of the thigh), this diagnosis may be correct. If so…you are such a smarty pants. For the other 8 of 10, this article will apply to you (see below).

 

  1. “While this condition has traditionally been referred to as trochanteric bursitis, gluteus medius and/or minimus tendinopathy is now accepted as the most prevalent pathology in those with pain and tenderness over the greater trochanter…of 75 individuals…only 8 had bursal involvement”

 

This to me is awesome! Think about it…the medical profession has been around as long as prostitution and yet we still don’t know what we are selling. At least the other profession knows its product.

 

The research on this diagnosis is relatively new…the past 15 years, but I didn’t hear about this while going to PT school. I’ll tell you what I did learn about though…trochanteric bursitis. It’s a shame that the research is not making it into the school system. If your doctor/therapist/chiropractor/naturopath/neighbor calls it trochanteric bursitis it means one of two things, or both: 1. They don’t read current research 2. They graduated from a school that doesn’t teach current research. I know that it is semantics, a rose is but a rose and all, but a name is important. If we are treating trochanteric bursitis, we are assuming from the name that it is an inflammatory issue of the trochanteric bursa (fluid filled sack that hurts like heck when irritated). If we are treating gluteal tendinopathy, then we are treating a muscle tendon dysfunction. These are treated totally different based on tradition and current research; so the name matters.

 

  1. “While a number of risk factors for the development of gluteal tendinopathy have been proposed, few have been validated”

 

In other words, we think we know what places you at risk, but we can’t be sure. Modern science is awesome. Everyone wants information, but also needs to understand that we don’t have crystal balls. This whole evidence based practice thing is fairly new…considering the overall length of time that medicine has been practiced. It will take a long time in order to obtain answers. All we can give you at this point in time is our best guess.

 

  1. “…the prevalence of lateral hip pain (likely gluteal tendinopathy) in people with low back pain has been reported to be as high as 35%…Importantly, treating the tendon-related pain has been shown to improve the function of those with low back pain, suggesting an interaction if not a causal relationship”

 

Okay…the authors of this journal article just made some big boy claims. First, to say that the lateral hip pain is likely tendinopathy is biased and absurd. We can not say this until the spine has been ruled out as a cause of lateral hip pain. Lateral hip pain is just that…pain in the outside portion of the hip. Until we rule out the spine as a cause of the pain, we can’t even say that the pain is coming from the hip. To make a claim this bold is arrogant. KNOW THIS: MULTIPLE JOINTS CAN REFER PAIN TO THE LATERAL HIP. If there is a problem in the back, it can show up at the lateral hip, which as the authors say is very common to have both back pain and hip pain simultaneously. If the SI joint is causing you problems, it could also show up at the lateral hip (not as common, but at least we can test for this). Finally, if the hip joint is causing problems, this can also show up as pain at the lateral hip. This is all before even talking about the gluteal tendons! The above statement is arrogant.

 

The second statement that is a stretch is to say that gluteal tendinopathy is the cause of low back pain. If you truly believe that, then you should buy this bridge I’m selling. It overlooks the bay in San Fran. Treating the hip tendons (also knows as core stabilization) is shown to be helpful in a small category of patients with back pain. To say that the hip caused the back pain is just as absurd as making a broad statement as the back caused the hip pain. Neither can be said until the patient is evaluated by someone unbiased.

 

  1. “Many orthopedic hip tests can be used for diagnostic purposes for more than 1 condition”

 

This is like saying there are many tests that can be used to measure water pressure, but none of the tests can tell you where exactly the problem is coming from. The tests only tell us that you hurt when we do these tests. There is a good article by Jeremy Lewis, PhD called something along the lines of “Special tests aren’t that special”. This means that as much as we would like to hinge our decision making process on special tests…they don’t tell us much.

 

  1. “…signs of local soft tissue pathology at the greater trochanter are common in imaging of those without lateral hip pain; thus, diagnosis should not rely solely on imaging studies”

 

Holy mouthful Batman! I think that the authors just said that imaging doesn’t tell the whole picture. Healthy people…without pain healthy people…can have the same exact picture as you, only they have no pain! IMAGINE THAT! We know so much more now than 10 years ago, but some of our new knowledge just works to muddy the picture of the pathoanatomical model (saying that we know which tissue is the problem).

 

  1. “In studies of patients with clinical symptoms of lateral hip pain…atrophic changes in the gluteus minims and medius in 40% of the hips”

 

If your hip hurts, you may not use it as well (otherwise known as limping), which may cause a further problem with the muscles. This is just speculation, but the authors already speculated that hip pain causes back pain…so I feel justified.

 

  1. “The authors of a recent article have demonstrated that five 45-second isometric quadriceps contractions held at 70% of a maximum contraction provided almost complete relief of patellar tendon pain, immediately and for at least 45 minutes”

 

I find this study fascinating because based on MDT principles, maybe it wasn’t the force or the prolonged hold, but simply straightening out a knee that is typically bent. I’ll have to find the study and see if the authors of that study actually tried to classify the patients before giving the treatment.

 

  1. “Increases in night pain may indicate that the load has been too high and needs to be adjusted. Once each level of tensile load is well tolerated, the load should be slowly increased and the response monitored to maximize structural change in the musculotendinous unit, while avoiding or minimizing pain exacerbation. “

 

DON’T BE A MEATHEAD! Hi…my name is Vince and I am a meathead. I say this with love. If you do too much, you will create a chemical response in your body called INFLAMMATION (read it with the menacing voice like in the commercial for heinous diseases…like erectile dysfunction). If you do too much, you will hurt. The funny thing is that you won’t know you’ve done too much until you’ve actually done it. It’s like a new graduate not getting a job because they need 3 years of experience. The only way to get there is to get there.

 

EXCERPTS TAKEN FROM:

 

Grimaldi A, Fearon A. Gluteal Tendinopathy: Integrating Pathomechanics and clinical Features in Its Management. J Orthop Sorts Phys Ther. 2015;45(11):910-922.