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 Post subject: Chronic Tendon Injuries
PostPosted: Wed Jun 12, 2013 1:49 pm 
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I've been spending quite a bit of time while I'm in the US doing on-line educational activities, playing catch-up on my required continuing medical education while I have some spare time and good internet access. I have to say that a lot of the activities available are of minimal real-life value to me, but this one is a major exception--in fact, I thought it would be of interest to many members of the forum.

"Chronic tendon injuries" are those lasting more than a few weeks. The four most common of these injuries are:

Achilles tendinopathy
Patellar tendinopathy
Lateral epicondylitis ("tennis elbow")
Rotator cuff tendinopathy

(By the way, pain in the main part of the Achilles tendon is different from pain where it attaches to the heel, but details.)

The biggest single piece of take-away knowledge from the article I read is that CHRONIC tendon injuries are NOT mediated by INFLAMMATION! (That is why these are now referred to as "tendinopathy" rather than "tendinitis". This single bit of knowledge changes radically the approach to treatment. The biggest change in the approach for most doctors is that anti-inflammatory medications are NOT effective in these conditions.

Now, the thing that is most relevant to this forum, is that the best-proven therapy for Achilles and patellar tendinopathies is eccentric strengthening exercise. Note that this is not merely stretching the affected tendon (which has been recommended in the past), but eccentric strengthening. Intuitively, I'd tend to assume that that would make either condition worse, but I'd be wrong! For Achilles tendinopathy, the recommended exercise is a sort of calf rise done with both feet on the edge of a step, then eccentrically lowering using only the injured side, then again using both feet on the concentric. The authors recommend doing 3 sets of 15 reps twice a day for 12 weeks, adding weight after 2 weeks. Seems like a lot of volume to me! There is also mention of repeating the exercise with the knees slightly bent, but they don't make clear if they want you to do that for the same volume as the straight-leg version every day.

For patellar tendinopathy, they recommend a sort of 1/4 squat done with both legs with heels elevated. The illustration provided shows a subject doing this while standing on a foam wedge. I'd think doing it on a solid surface with a small heel lift would be more stable. They recommend the same rep-set scheme as for Achilles tendinopathy.

A whole host of other possible therapies are discussed, but they are all either significantly less effective, or significantly more invasive and risky than eccentric strengthening.

They also discuss tennis elbow and rotator cuff injury, but there is no discussion of eccentric strengthening for those injuries. By the way, rotator cuff injury is the injury for which steroid injections has the best track record. This is risky for Achilles and patellar, and not very effective for tennis elbow.

I'm not sure if people who are not members of the American Academy of Family Physicians, or a paid subscriber can access the full article or just the abstract, but here's a link you can try:
http://www.aafp.org/afp/2013/0401/p486.html

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PostPosted: Wed Jun 26, 2013 7:29 am 
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Jungledoc wrote:
I've been spending quite a bit of time while I'm in the US doing on-line educational activities, playing catch-up on my required continuing medical education while I have some spare time and good internet access. I have to say that a lot of the activities available are of minimal real-life value to me, but this one is a major exception--in fact, I thought it would be of interest to many members of the forum.

"Chronic tendon injuries" are those lasting more than a few weeks. The four most common of these injuries are:

Achilles tendinopathy
Patellar tendinopathy
Lateral epicondylitis ("tennis elbow")
Rotator cuff tendinopathy

(By the way, pain in the main part of the Achilles tendon is different from pain where it attaches to the heel, but details.)

The biggest single piece of take-away knowledge from the article I read is that CHRONIC tendon injuries are NOT mediated by INFLAMMATION! (That is why these are now referred to as "tendinopathy" rather than "tendinitis". This single bit of knowledge changes radically the approach to treatment. The biggest change in the approach for most doctors is that anti-inflammatory medications are NOT effective in these conditions.

Now, the thing that is most relevant to this forum, is that the best-proven therapy for Achilles and patellar tendinopathies is eccentric strengthening exercise. Note that this is not merely stretching the affected tendon (which has been recommended in the past), but eccentric strengthening. Intuitively, I'd tend to assume that that would make either condition worse, but I'd be wrong! For Achilles tendinopathy, the recommended exercise is a sort of calf rise done with both feet on the edge of a step, then eccentrically lowering using only the injured side, then again using both feet on the concentric. The authors recommend doing 3 sets of 15 reps twice a day for 12 weeks, adding weight after 2 weeks. Seems like a lot of volume to me! There is also mention of repeating the exercise with the knees slightly bent, but they don't make clear if they want you to do that for the same volume as the straight-leg version every day.

For patellar tendinopathy, they recommend a sort of 1/4 squat done with both legs with heels elevated. The illustration provided shows a subject doing this while standing on a foam wedge. I'd think doing it on a solid surface with a small heel lift would be more stable. They recommend the same rep-set scheme as for Achilles tendinopathy.

A whole host of other possible therapies are discussed, but they are all either significantly less effective, or significantly more invasive and risky than eccentric strengthening.

They also discuss tennis elbow and rotator cuff injury, but there is no discussion of eccentric strengthening for those injuries. By the way, rotator cuff injury is the injury for which steroid injections has the best track record. This is risky for Achilles and patellar, and not very effective for tennis elbow.

I'm not sure if people who are not members of the American Academy of Family Physicians, or a paid subscriber can access the full article or just the abstract, but here's a link you can try:
http://www.aafp.org/afp/2013/0401/p486.html


Eccentric Connective Tissue Stretching

As you noted, this is an effective rehab method for connective tissue.

Personal Experience

A few years ago, I had "Golfer's Elbow" it is the same as "Tennis Elbow" but on the other side of the arm, tendonitis.

I was at a powerlifting meet lifting, Dr David Foster (Chiropractor/powerlifter) was at the meet. I ask Foster about my problem.

Foster them performed the...

Graston Technique
https://www.youtube.com/watch?v=lMfWyena_j4

Basically, this technique "Eccentrically stretches" the tendon.

Foster advised me prior to performing the Graston Technique that it would hurt. I have a high pain tolerance and said, "No problem."

Wow, was I wrong! I was literally crying.

However, after the treatment, it felt better.

Foster then showed my girl friend how to perform it. Over the next month, we did the Graston Technique just about every day.

Cured

After a month of almost daily Graston Technique treatments, my tendon problem disappeared.

Accentuated Eccentric Stretching

As you stated in your post in regard to eccentrically stretching the calf, I utilized Accentuated Eccentrics as a rehab method for a different tendon problem. It works.

Kenny Croxdale

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PostPosted: Wed Jun 26, 2013 4:13 pm 
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Actually, the article refers to "eccentric strengthening" rather than "eccentric stretching".

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PostPosted: Tue Sep 10, 2013 6:43 pm 
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I am searching for Rotator Cuff relief, and came across this.
Wish it had more discussion.

fwiw, I think its rotator cuff (still prefer to avoid the Docs!) because it hurts when
1. I try to scratch my back
2. More at night as it gets tighter
3. OH Pressing
4. More so if I flare my elbows
5. Putting hands on hips like a girl who's mad at you (palms in, fingerd pointing down)
6. Doing wall slides, which I have limited movement for now

I think it was developed over several weeks from
1. Getting back into pressing too much too soon (? maybe)
2. Trying a few too many strained reps with dumbell bench pressing
3. Aggravatnig it by not seeing/heeding signs earlier
4. Not considering the need to make sure the tendons were ready (thinking now I should have done some RC work, like I did when I first started lifting, since I've had a history of dislocations)


So now, I emphsis more legs work and keep more pulling. Floor DB press with palms facing inward seems to be the least uncomfortable. Lateral Raises are out.


I dont get sick or injured, so I keep telling myself I'm fine.

cheers.


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PostPosted: Wed Sep 11, 2013 8:27 am 
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I though you abandoned us. Tell us about how things are going in your journal.

I just saw this blog post and thought about you. http://www.ericcressey.com/exercise-of- ... bell-carry

When I had my rotator cuff thing, I had a few months of physio but what really helped was the right exercises. Rows, face pulls, etc, but especially unstable overhead work like in the video. Turkish Getups, waiters walks and the thing that brought it together for me was the arm bar. http://robertsontrainingsystems.com/blo ... ll-armbar/

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Let thy food be thy medicine, and thy medicine be thy food.~Hippocrates
Strength is the adaptation that leads to all other adaptations that you really care about - Charles Staley
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Thanks TimD


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PostPosted: Thu Sep 12, 2013 5:35 pm 
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Joined: Tue Oct 19, 2010 1:12 pm
Posts: 2406
Nah, just my usefulness had run its course
But mostly, I'm busy with work and trying to be more discisplined about stuff I put off


I wanted to say thanks for the response and once I can view the video at home, I will certainly consider it and the remaining advice, like TGUs - I'll have to start really light, for confidence if nothing else.


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PostPosted: Sun Sep 22, 2013 7:45 am 
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Oscar, Jason has me doing TGUs for balance, not weight. I do them with my sneaker balanced on my fist. Kind fun. Forces you to concentrate on keeping everything lined up.

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Our greatest fear should not be of failure, but of succeeding at things in life that don't really matter.--Francis Chan


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PostPosted: Tue Sep 24, 2013 8:50 pm 
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Joined: Tue May 10, 2011 8:09 am
Posts: 337
Location: Buckhannon, WV
I have tendonitis around my elbow joint. The trainer at my gym has had me do 50 reps of Hammer Curls for one set of increasing weight with deliberate movement in both directions for the pain. It actually does help lots.


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