The Truth about Tendinopathy

Tendinopathy refers to the breakdown of collagen in a tendon. This causes burning pain in addition to reduced flexibility and range of motion. Although there are some inflammatory biochemical and cells involved in tendinopathy, it is not considered to be a classic inflammatory response. Anti-inflammatories may help if you have very high pain levels but it is unclear what effect they have on the actual cells and pathology. Tendinopathy is a very common injury due to vulnerability of tendons to repetitive and wear and tear injury.  The most common types are Tendinopathy of the lateral epicondyle of the elbow, Rotator cuff tendinopathy, Achilles Tendinopathy and Quadriceps Tendinopathy.  The wrist extensors and the Rotator Cuff are the most overuse tendon of the upper extremity while the Achilles and Quadriceps tendon are in the lower extremity.

Tendinopathy can be caused by many different risk factors. The main factor is a sudden change in certain activities – these activities include 1) those that require the tendon to store energy (i.e. walking, running, jumping), and 2) loads that compress the tendon. Some people are predisposed because of biomechanics (e.g. poor muscle capacity or endurance) or systemic factors (e.g. age, menopause, elevated cholesterol, increased susceptibility to pain, etc). Predisposed people may develop tendon pain with even subtle changes in their activity.

Tendinopathy does not improve with rest – the pain may settle but returning to activity is often painful again because rest does nothing to increase the tolerance of the tendon to load but Modifying load is important in settling tendon pain. This often involves reducing (at least in the short-term) abusive tendon load that involves energy storage and compression.

Exercise is the most evidence-based treatment for tendinopathy – tendons need to be loaded progressively so that they can develop greater tolerance to the loads that an individual needs to endure in their day-to-day life. In a vast majority of cases (but not all) tendinopathy will not improve without this vital load stimulus whereas it rarely improves long term with only passive treatments such as massage, therapeutic ultrasound, injections, shock-wave therapy etc. Exercise is often the vital ingredient and passive treatments are adjuncts. Multiple injections in particular should be avoided, as this is often associated with a poorer outcome.

Exercise needs to be individualised. This is based on the individual’s pain and function presentation. There should be progressive increase in load to enable restoration of goal function whilst respecting pain. Lastly, Tendinopathy responds very slowly to exercise. You need to have patience, ensure that exercise is correct and progressed appropriately, and try and resist the common temptation to accept ‘short cuts’ like injections and surgery. There are often no short cuts.

Why Do Muscles Feel Tight?

Why do muscles feel tight? Does that mean they are short? That they can’t relax? And what can you do about it?

Here are some of my thoughts about why muscles feel tight and what to do about it.

When I was in Physiotherapy school, my textbook will describe Tightness as a condition in which there is Limitation of movement in a particular joint due to a shortened muscle.  It is the right definition for sure but as I saw a lot of my patients with complaints of muscle tightness and stiffness with no definite objective finding I started to think that muscle tightness or stiffness could be a feeling of not being relaxed.

This ambiguity means that the feeling of tightness is just that – a feeling – which is not the same thing as the physical or mechanical property of excess tension, or stiffness, or shortness. You can have one without the other.

For example, I have many patients tell me their neck or shoulder feel tight, but they can easily lift their arms all the way up or bend their neck fully. I also have patients whose hamstrings don’t feel tight at all, and they can barely get their hands past their knees. So the feeling of tightness is not an accurate measurement of range of motion nor is it an accurate reflection of the actual tension or hardness of a muscle or existence of knots.

So why would a muscle feel tight even if it physically loose?

I think we can use pain as an analogy.  Pain can exist even in the absence of tissue damage, because pain results from perception of threat and perception does not always match reality. Pain is essentially an alarm, and alarms sometimes go off even when there is no real danger. Perhaps it is the same in the feeling of tightness. The feeling happens when we unconsciously perceive that there is threatening condition in the muscles that needs a movement correction. So what is the threatening condition that a feeling of tightness is trying to warn us about. It could be the absence of adequate rest or inadequate blood flow to the muscle. It can also be staying in a position for prolonged period of time. With this in mind, I think of the feeling of tightness is perhaps a pain too mild to deserve being called pain. But it is definitely bothersome and it push us to change our resting posture, or move around or stretch.

So how can we cure tightness? Here are some ways to do:

1.    Stretching- We stretch muscles that have remained in a short position for a while, and this usually makes us feel immediately better. But, as noted above, most people who suffer from chronic tightness have already tried and failed at this strategy, which suggests the issue is less about bad mechanics and more about increased sensitivity. This would of course make sense if the root of the problem was short or adhered tissues. But if the root problem is in fact increased sensitivity, then aggressive stretching might just make the problem worse. On the other hand, stretching can often have an analgesic and relaxing effect.

2.    Soft Tissue work- There are various soft tissue treatments like deep tissue massage, Foam rolling, Graston and ART intended to lengthen short tissues, break adhesions, or melt fascia. These techniques will not lengthen tissues but it could decrease the sensitivity and make some feel less tight as well as increase blood circulation to the area.

3.    Motor Control for Muscle Tightness- Motor control pertains to change of habits or posture.  Improvement of posture, change position every few minutes and always be conscious of muscle tension.

4.    Exercise and Strength Training-   Full range of motion strength train increase flexibility, perhaps more than stretching. It creates local adaptations in muscle that may improve endurance and make them less likely to suffer metabolic distress and exercise also has an analgesic effect and can lower levels of inflammation that cause nervous system sensitivity.

Conclusion:

When you feel stiff, remember it is a feeling, and not necessarily a physical condition of shortness that needs an aggressive structural solution. Like other feelings, you feel it more when you are sensitive. And like other forms of sensitivity, it will go down if you improve your overall fitness, strength, awareness, motor control and health.

To ice or not to ice after an injury?

Ice is an extremely hot (or rather, cool) topic in sports medicine and acute injury rehab, and for good reason. The way we treat injuries is continually changing based on the most up to date research. Due to this, it’s no wonder there is confusion around whether ice is good, bad or indifferent for injuries.

When someone rolls their ankle, most of us instinctively grab an ice pack. When we see professional athletes get injured, they’re wrapped in ice before they’ve even made it off the field. Ice appears to be an ingrained part of the acute injury management process, but does this align with the latest research?

The earliest documentation of ice as part of the acute injury management protocol dates back to 1978 when the term RICE (Rest, Ice, Compression, Elevation) was coined by Dr Gabe Mirkin (1). His intention behind using ice was to minimise the inflammatory response in an attempt to accelerate healing. This initial protocol became deeply rooted in our culture and for 20 years we were ‘RICE-ing’ injuries before P was included for protection (PRICE). 14 years later, POLICE (Protection, Optimal Loading, Ice, Compression, Elevation) replaced PRICE (2).

The reason for the changes?

Research has since identified that ‘Optimal Loading’ (OL) aids recovery through cell regeneration induced by light mechanical loading in the early stages. Subsequently, Rest (R) or a lack of movement is detrimental to recovery (3).

But what about ice?

There is certainly a consensus throughout the literature that ice acts as a great analgesic (pain numbing agent) by cooling the skin’s temperature. However, the impact on underlying muscles is non-existent, as muscle temperature remains unchanged from topical ice application. What we are much less certain of now then we were in 1978, is it’s healing properties. Anecdotally (and likely due to the analgesic effect) most people report ice makes injuries “feel better”, at least in the short-term. But what impact does immediately icing an injury have in the mid to long-term?

In 2014, Dr Mirkin acknowledged changes in the research and, as any evidence-based scientist would, retracted ice from his initial protocol. He stated that coaches had been using his “’RICE‘ guideline for decades, but now it appeared that both ice and complete rest may in fact delay healing, instead of helping” (3).

What Dr Mirkin is referring to is the necessary benefits of the inflammation process. When we injure ourselves, our body sends signals out to our inflammatory cells (macrophages) which release the hormone Insulin-like Growth Factor (IGF-1). These cells initiate healing by killing off damaged tissue. Although when ice is applied, we may actually be preventing the body’s natural release of IGF-1 and therefore delaying the initiation of the healing process (3).

Ice was finally revoked in 2019 from the injury management process with the latest and most comprehensive acronym: PEACE & LOVE (Protection, Elevation, Avoid Anti-Inflammatory Drugs, Compression, Education & Load, Optimism, Vascularisation and Exercise) (4).

With all of this new-found evidence on the negatives of icing injuries, it begs the question:

‘If ice delays healing, even if it can temporarily numb pain, should we still be using it?’

Probably not.

I will however caveat this with one thing. While some inflammation may be warranted for recovery, too much or prolonged oedema (swelling) is bad news. Excessive oedema applies unwanted pressure on the tissues, restricts movement, can increase pain and decreases muscle function (5).

This is often seen in severe joint sprains (such as ankle sprains) where swelling is significant enough that range of movement is impeded. Another example is arthrogenic muscle inhibition of the quadriceps following ACL surgery.

In these circumstances ice may be a viable option, as the goal is not to necessarily prevent all swelling, but to limit the extent of it (6). In contrast, muscle tears often elicit less oedema and hence ice is likely not going to be of benefit in the early stages (or at all) during injury management.

So for now, based on the current research, I’d keep ice in the freezer for the most part. As we currently understand it, ice is less important than we once thought. The exception to this rule would be when injuries are severe and in circumstances where swelling will likely be the limiting factor for recovery. In these cases, ice may be beneficial in the early stages only.

What then should be our primary focus?

Encouraging people to return to movement safely again, as soon as it is practical.

The Role of Physiotherapist amidst Covid-19 Pandemic

Covid-19 Pandemic has created havoc in our lives. It has been more than a year now since this pandemic has started and we still has no idea when this will end. Small business like ours has been affected immensely and most people are still confused if Physiotherapy and other healthcare treatment is essential or not.

Physiotherapy care, whether delivered in the ICU, in clinics, in long-term care facilities, through virtual care, in homes, or in outpatient clinics is essential care. As autonomous self-regulated health care professionals bound by a code of ethics, physiotherapists, chiropractors, RMT’s and other regulated healthcare professionals exercise their judgement to act in the best interests of patients and the public to ensure that treatment that could be reasonably delayed is not pursued at the expense of public health precautions. During the pandemic, physiotherapy care has been safely provided across the health system in compliance with all required infection prevention and control measures. Physiotherapy care can and continues to be adapted using alternate delivery approaches, such as virtual care, to manage exposure risks during pandemic restrictions and ensure patients can safely continue treatment.

• Many Canadians have had to delay treatments due to the mandatory measures enacted to slow the spread of COVID-19. As a result, the health conditions of many have deteriorated, pain has persisted or increased, mental health has worsened, and preventive or maintenance treatments have not been delivered.

• A growing number of Canadians are living with pain and chronic conditions as a result of the surgical backlog created by the delay/postponement of elective surgeries1,2 during the initial phases of the COVID-19 pandemic response.

• Post-operative physiotherapy helps patients to recover and return home more quickly.3

• The care and treatment offered by physiotherapists is crucial in keeping Canadians healthy and in preventing the need to access urgent or emergency services in-hospital. In addition, research shows that physiotherapy can delay or prevent the need for elective procedures, such as hip and knee replacements, further decreasing the burden on our health care system during a second or third wave.

• Care provided by physiotherapists with appropriate safety precautions contributes to the health of Canada’s workforce by helping Canadians stay mobile, healthy, and active contributors to our economy and communities. Further, physiotherapy care has not been a source of community spread.

• Uninterrupted access to physiotherapy care in communities supports the wider health care system’s capacity by easing pressure on hospitals and improving recovery trajectory for patients.

• In order to keep Canadians safe, physiotherapists and other regulated health care professionals, are trained in, and adhere to, strict infection control practices.

• Canadians want to stay healthy and active during the pandemic and the last place Canadians want to be is in-hospital. The early months of 2020 saw a 25 percent decrease in ER visits compared to the same period in 2019