The SS approach to tendinopathy management The SS approach to tendinopathy management

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Thread: The SS approach to tendinopathy management

  1. #1
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    Default The SS approach to tendinopathy management

    Rip,

    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 effecting 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 effects 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. Lending 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, a 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?

    Thank you

  2. #2
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    Perhaps Will Morris will respond.

  3. #3
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    We know that resistance training effects 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. Lending 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.
    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".

    Often times, a 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)
    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.

  4. #4
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    Quote Originally Posted by Austin Baraki View Post
    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.
    Thanks for your response, Austin. I'd be happy to assist in this initiative, if such a project materializes.

  5. #5
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    Quote Originally Posted by JHG View Post
    whether a physical rehabilitation text by SSCs who are also clinicians may be in the works?
    Yes. There is. Slowly coming along.

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    Quote Originally Posted by Will Morris View Post
    Yes. There is. Slowly coming along.
    Will, if I can be of assistance, you know how to reach me.

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    There are some cool things in the works.

  8. #8
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    Quote Originally Posted by Will Morris View Post
    Yes. There is. Slowly coming along.
    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.

  9. #9
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    Quote Originally Posted by JHG View Post
    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 effecting pathology, reducing pain and restoring function.
    What you have above is a solid skeleton for tendinopathy management. Especially because the capacity to change a tendons 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 patients 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 center piece.

  10. #10
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    Quote Originally Posted by Nick D'Agostino View Post
    You need to figure out what your patients 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 center piece.
    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.

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