The SS approach to tendinopathy management

[Fiddler]

I will happily pay you for said resource upon its creation. I've been battling a case of supraspinatus tendinosis for almost a year now, and it's been the bane of my existence.

FWIW, I had biceps tendinitis for over two years, subsequent to a bad fall. I trained through it, tried dumbbells, eventually went to a PT and did band exercises, but still couldn't comb my hair or put my gym bag in the car with that hand. Finally, the PT gave me a TENS unit, and that cleared the problem up in a couple of weeks.

[Mark Rippetoe]

If a TENS unit healed this up, it will be the first time such a thing has happened.

[Tom Campitelli]

We treated Tom Campitelli's quad tendinopathy this way, in fact.

While my tendinopathy is not healed, my knees feel WAY better than they used to. I did a number of things, but one of the most effective was to put a light weight on my back and descend until it the point that it hurt. This would often be in the area of a 1/4 to 1/2 squat. Then I would hang out there for 30 to 40 seconds. Much shaking ensued. I would do that 4 times a session. I also did some very slow eccentric squats (5 to 8 second descents), with a brief pause and a semi-slow ascent. Also quite light for sets of five. Both helped, but the isometric work seemed to give me more of a chance to work on the areas that were bothering me. Now I am in the process of figuring out how to train the squat again without irritating my quad tendons too badly again. I imagine I will have isometrics as part of my weekly program for a while.

For those wondering, I have had quad tendinopathy to a greater or lesser degree for at least 13 to 15 years. It started back when I was a runner. Squatting, especially the concentric portion, seemed to irritate it, although sometimes more than others. Tendinopathy is a tricky beast.

[John Petrizzo]

As Tom's post indicates, I think it is important for people to note that true tendinopathy is something that often times will have to managed over the long term and 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.

[GammaFlat]

I was doing some whacky workout program I found on the internet several years ago that had a "setup set" where there was a seated cable low row which was 60 seconds of pull followed immediately by 60 seconds of return at 75% of 1 rep max. It was 2 minutes of hell.. Seemingly not moving.. Voila! my golfers elbow was gone 2 weeks into the program (2 days per week). I was flabbergasted by my happy accident. I was in so much pain for so long (2 plus years) and then suddenly gone. This is admittedly anecdotal but I will never be convinced it was a coincidence.
It's suspiciously similar to the tendinopathy/isometric scenario discussed here.

[Will Morris]

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 LP will be programmed, regardless of training history. Then continued LP for novices, and intermediate/advanced programming for more experienced trainees.

I treat willing / able tendinopathy patients slightly different than most. My standard prescription for tendinopathy is pretty similar to what was done with Tom. 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.

[JHG]

I treat willing / able tendinopathy patients slightly different than most. My standard prescription for tendinopathy is pretty similar to what was done with Tom. 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.

Thanks for your insight, Will. This indeed has become an interesting and informative thread.

I wonder if you may expand on the neuroinflammatory model? A recent paper on inflammation in tendinopathy nicely outlines the inflammatory process with respect to pathogenesis, but no mention is made of a neuroinflammatory model, at least not in the paper: Inflammation in tendinopathy (PDF Download Available)

[Will Morris]

Thanks for your insight, Will. This indeed has become an interesting and informative thread.

I wonder if you may expand on the neuroinflammatory model? A recent paper on inflammation in tendinopathy nicely outlines the inflammatory process with respect to pathogenesis, but no mention is made of a neuroinflammatory model, at least not in the paper: Inflammation in tendinopathy (PDF Download Available)

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.

[JHG]

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.

This is correct. If I am not mistaken, some passive therapies have been shown to be efficacious in this respect, solely from a pain management perspective. But for more durable relief and functional restoration, tissue loading appears to be the single best option available to us.

I think the take home message, as a result of the input provided from the clinicians on this thread, along with Tom's case study, is that stock programs will not address the various presentations from patient to patient, and that Nick's emphasis on pain education to manage patient expectations and interpretations of symptom fluctuations throughout the course of care is especially important, if not simply to help ensure compliance throughout a rehab protocol.

[Will Morris]

This is correct. If I am not mistaken, some passive therapies have been shown to be efficacious in this respect, solely from a pain management perspective. But for more durable relief and functional restoration, tissue loading appears to be the single best option available to us.

I think the take home message, as a result of the input provided from the clinicians on this thread, along with Tom's case study, is that stock programs will not address the various presentations from patient to patient, and that Nick's emphasis on pain education to manage patient expectations and interpretations of symptom fluctuations throughout the course of care is especially important, if not simply to help ensure compliance throughout a rehab protocol.

I think our literature is fairly conclusive that manual therapy, soft tissue massage, instrument assisted soft tissue mobilization, etc is virtually useless for tendinopathy.