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January 29, 2018


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In the Trenches

louis chabrier pulls his work set deadlift
Louis Chabrier pulls his work set deadlift at the Starting Strength Seminar held at Horn Strength and Conditioning last weekend. [photo courtesy of Nick Delgadillo]


Best of the Week

The SS approach to tendinopathy management
JHG

A popular topic of discussion among rehab professionals is the management of tendinopathy, with a heavy emphasis on understanding the pathogenesis of these injuries and attempting to devise loading parameters for the various stages of recovery.

At this time, we still do not know exactly how tendinopathy develops. There are a few theories of etiology, including; inflammation, collagen tearing, and the cell-mediated continuum model, which is thought to be the primary driver of pathology.

Given our patients’ motivations and goals to seek treatment for the purpose of pain reduction and return to activity, our goals in managing tendinopathy revolve around affecting pathology, reducing pain and restoring function.

This is where we see conflicting views. If we consider inflammation and collagen tearing as the cause of pathology, our primary intervention is rest in order to allow the inflammation to settle and for the collagen to heal. But we know that rest is bad for tendons and that tendons require loading to maintain structure and function.

We know that resistance training affects structural and physiologic change of skeletal muscle, but this does not seem to be the case for pathological tendons, as we know that pathological tendons are thicker than normal tendons, but there are no effective interventions that can rectify this structural change. Leading to the question whether it is important to effect structural change on pathological tendons anyway. We have also learned that pathological tendons have more good structure than normal tendons, which is encouraging in that we can safely assure our patients that we can and should load their tendons without fear of harm or chance of rupture.

Often times, tendon rehabilitation protocols may look something like this with varying loading parameters, set and rep schemes:

  • Stage 1 – Isometric exercises for pain reduction
  • Stage 2 – Strength training
  • Stage 3 – Sport specific loading (in cases of return to sport)

Given the simple and effective, yet informed, nature of the Starting Strength model, I am interested to learn how SSCs adapt the model for this purpose, and whether a physical rehabilitation text by SSCs who are also clinicians may be in the works?

Austin Baraki

This is all correct. It does not appear to be necessary (or possible) to restore "normal" structure in the course of tendinopathy rehab. Fortunately, as in numerous other contexts, structural issues correlate rather poorly with pain, so we can still reduce/eliminate pain and facilitate return to normal activities without reversing the structural "issues."

There is good evidence for this approach (though I don't always find the isometrics to be necessary), and I've used the same concepts in my own rehab as well as with trainees before. We treated Tom Campitelli's quad tendinopathy this way, in fact.

I am not aware of a physical rehab text in the works, though I've put out a lot of content on pain and injury management, and would be interested in doing something like this in the future together, perhaps with some of our DPT/SSC colleagues.

Nick D’Agostino

What you have above is a solid skeleton for tendinopathy management. Especially because the capacity to change a tendon’s structure is very limited, I think patient education about pain is very important here. Things like setting expectations about how long it will take to have significantly less pain, using pain experienced the next day as a marker for progress, explaining how much pain is ok to work into, what pain actually is and that it doesn't necessarily mean tissue damage. You need to figure out what your patient’s beliefs are about their experience and try to morph them into something that helps them and doesn't hold them back. I guess the above statement is kind of obvious but it always seems to be on the periphery of rehab protocols and I feel like it needs to start moving towards becoming a centerpiece.

JHG

It sounds like we are all in agreement with this. It is crucial that providers acknowledge and employ principles of CBT in physical medicine practice.

My initial inquiry was to learn whether SSCs approach tendinopathy management differently. It seems that the established program structure is the same, save the application of isometric exercises, for injury management. Following resolution, I presume a short linear progression will be programmed, regardless of training history. Then continued LP for novices, and intermediate/advanced programming for more experienced trainees.

John Petrizzo

I think it is important for people to note that true tendinopathy often times will have to be managed over the long term and is not something that there are any relatively quick fixes for. I also think that D'Agostino brings up a few excellent points in his post in regards to how we manage pain when dealing with clients with this particular condition. This is turning into a very informative thread for people who are dealing with this very common issue.

Will Morris

I treat willing/able tendinopathy patients slightly different than most. I prescribe the barbell lift most likely to engage the pathological tissue, and I have the patient perform tempo lifts where they perform a 3–5 second descent, a brief pause while maintaining position, and then a 1–2 second concentric. Our available literature suggests eccentrics are the treatment of choice, however, the evidence seems to point only towards eccentrics lowering pain compared to concentric exercise. They also routinely report eccentrics increase strength better than concentrics in tendinopathy patients, however, I have some issues with this. The ability of research teams to properly prescribe a concentric exercise program to actually induce strength improvements has not been reliably demonstrated to my liking. As is the case with so many other things, I have combined eccentric loading and concentric exercises that will certainly increase strength. As the pain and pain-induced weakness improves with the training, we start to pull back on the eccentric loading and begin having them perform the lift in a more natural tempo for that lifter.

With respect to the change in histology to the pathological tendons, I have seen nothing at all that shows an ability to change the conformation of the tendon structure itself. But, as Dr. Baraki stated, the structural changes are largely unimportant with regards to the patient's symptoms. If you look into the neuroinflammatory model of tendinopathy, I think we end up with a better overall picture of why these structural changes hurt in some, but are completely asymptomatic in others.

Neuroinflammatory model would be the general term to describe the changes in the nervous tissues around the area of the tendinopathy. I think there is some decent histological data that has shown a substantial increase in nonvascular nerve fibers in some samples of patellar/Achilles tendinopathy. Also, I want to say these fibers were found to be especially sensitive to substance-P. This model is likely a big component of the differences in pain reports with individuals with known tendinopathy. Increased nociceptive receptor density and a decreased anti-nociceptive ability with the supposed reduction in sympathetic vascular nerve fibers in the area would be expected to make things worse for that individual.


Best of the Forum

Whoa, impressive philosophical specificity in PPST Rip
Mitch Rivers
"Empiricism is a view of epistemology that holds the knowledge of the subject comes from direct sensory experience with it - empirical evidence." "...these people are typically those involved in generating this type of data, and they may regard the absence of an experimentally generated data set as an absence of knowledge"
"Rationalism is a competing epistemology that holds reason and logical analysis as sufficient test of knowledge and truth."
Impressive and particularly effect way of clearing up the gap in the peer reviewed literature regarding the novice effect and the differences between exercising and training.

Are you responsible for this particular piece of prose? I am a proponent of the benefits that logic and critical thinking provide and this is a great example of where/how it is seldom used effectively in every day modern life.

Mark Rippetoe

My prose. I'm rather impressed with it myself.

Tim K

I guess this would be cleared up by finding this passage in the book, but it's late so I'll just ask. Do you see your approach as being somewhere between these two extremes? On the one hand your approach is logical and reasoned, based on sound physical and biological theory, but on the other hand it rose out of direct experience coaching people so it is empirical in that sense, even though it hasn't (yet) been researched in a full-on scientific study.

Mark Rippetoe

I rely primarily on logic and reasoned analysis, and my experience. The peer-reviewed literature is usually useless. But our approach has been verified quite a few times by the reasoned analysis and the experiences of the people who have replicated my little experiments. We publish here. You are the peers.


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