Tendons: Lovers (or haters?) of Load

Hey everyone! This article is a quick information session on tendon rehabilitation – specifically, what tendons require vs. what is detrimental in their recovery. There are a lot of misconceptions out there about how to best manage tendon pathology, so I encourage you to read along if you have any tendon pain.

When we develop a tendinopathy, whether it is our Achilles, patellar tendon, or rotator cuff, it often occurs after a period of doing an activity at a level we are not accustomed to. For example, you might decide to sign up for a half marathon in a few months, so you start training – even though you haven’t gone for much of a run in a long time. Or, volleyball season just started up, and you jump right into the season opener weekend tournament. Or, you start a new job that involves a lot of repetitive motions of the wrist or arm over the course of your day. What all of these examples have in common is that they are a new level of load on your tendon that it is not currently accustomed to. 

You see, tendons are very particular about what they want. In order to have a healthy, non-pathological tendon, it needs a certain level of load on a relatively regular basis. Without load, tendons become weaker and less tolerant of activity (1). On the other hand, however, with too much load that it is not accustomed to, the tendon can sometimes react negatively and can cause you nagging pain that sticks around for much longer than you would like it to. You can think of a tendon’s tolerance as a threshold at a specific level of exercise/load/repetitive movement. This threshold is different for everyone, based on many factors such as usual activity level, genetics, nutrition, stress, etc., and can be surpassed when one of these factors or a combination of them is simply too much for the tendon to handle (2). 

With gradual exposure and appropriate load management, with the help of your physiotherapist, you can build up the tolerance threshold of your tendon. This takes time and patience, but it is ultimately what tendons need to heal when they are aggravated. Many people will choose to rest their tendon when it hurts and avoid activities or exercise as they believe this will fix the problem. Unfortunately, all this does is make the tendon more sensitive and less capable of handling load! (4) With this approach, a tendon can never properly heal. 

This is a difficult concept for some people to grasp – but exercise/activity is what caused my tendinopathy; how on earth is it going to help it?! The devil is in the details here - even though load is what got your tendon into this issue in the first place, it is also what will be its saving grace. Tendons are meant to withstand loads and absorb different forces; it is arguably their most important function in our bodies. Because of this, the tendon cells actually need to be mechanically loaded at the appropriate intensity in order to adapt and recover (4). 

But what about injections for my tendon pain? It is important that you make an informed decision about utilizing passive treatments for tendinopathy management. While a corticosteroid injection has the potential to relieve your pain for a month or two, there is little evidence to show any benefit beyond these initial months (5). Recent research done on rotator cuff tendinopathies has shown that the doctor would have to inject 5 different people for 1 person to get a good result (5). Furthermore, the results are short-lived, and there is no evidence to show that an individual can get continued relief from injections (if they work, they only seem to work the first time) (6). Additionally, there is evidence to show that injections can actually cause a tendon to become more pathological at the cellular level; in other words, it promotes deterioration of tendon cells as opposed to formation of new ones (6). At the end of the day, by choosing passive treatments for your tendon, it will not make the tendon more tolerant to load which is not only what it needs to truly recover at an anatomical level, but also what it needs to avoid future episodes of the same tendon pain. 

Key messages I want you to take away:

  1. Tendons need an appropriate and gradual loading program in order to recover
  2. Rest is the most detrimental thing for a tendon
  3. Passive treatments may temporarily help your pain, but they can be worse for your tendon in the long term 
  4. PHYSIO CAN HELP! Walking the line between too much and too little load for your tendon can be difficult to navigate – this is what we are here for ☺ 

References

  1. Lipman, K., Wang, C., Ting, K., Soo, C., & Zheng, Z. (2018). Tendinopathy: injury, repair, and current exploration. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5865563/.
  2. Rio, E., Kidgell, D., Moseley, G. L., Gaida, J., Docking, S., Purdam, C., & Cook, J. (2015). Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. British Journal of Sports Medicine50(4), 209–215. doi: 10.1136/bjsports-2015-095215
  3. Cook, J. L., Rio, E., Purdam, C. R., & Docking, S. I. (2016). Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British Journal of Sports Medicine50(19), 1187–1191. doi: 10.1136/bjsports-2015-095422
  4. Cook, J. L., Docking, S.I. Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ‘tissue capacity’: a core concept for clinicians, (2015). Retrieved from https://research.monash.edu/en/publications/rehabilitation-will-increase-the-capacity-of-your-insert-musculos.
  5. Gelber, J. D. (2016). CORR Insights®: Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clinical Orthopaedics and Related Research®475(1), 244–246. doi: 10.1007/s11999-016-5044-4
  6. Dean, B. J. F., Lostis, E., Oakley, T., Rombach, I., Morrey, M. E., & Carr, A. J. (2014, February). The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24074644.

Ankle Ligament Sprain Injuries: Reverse Lunge Wood Chops

Hold onto a ten pound dumbbell with your hands on both ends and engage your inner core stability muscles below your belly button. Then lunge backwards with your right leg performing a wood chopping motion with the upper body and arms turning only your torso. Push back up with the right foot to the start position.

Repeat this for 10 repetitions doing 3 sets for each side.

This exercise is excellent for strengthening your ankle and developing better balance and proprioception and more optimal neuromuscular activation patterns after an ankle injury.

If you have any problems doing this exercise, please contact one of our Physiotherapists at either our North Burnaby location on Hastings Street or in Vancouver on Cambie street just across the street form the King Edward Sky Train Station. 

Preventing Cycling Injuries and Hip Injuries – Core & Hip Strengthening with Leg Weight

Hi this Simon Kelly here at the Insync Cambie Village clinic just showing you a slight progression from the last exercise I showed.

What you need to get is like a sweeping brush, this is the end of a sweeping brush obviously holding it out in front of you like that. A good idea again to keep the elbows slightly bent.

Instead of having a thera-band around my foot this time I am after attaching a weight and then we are going to be a little straighter up like that, arms bent and you're going to lift your knee right up and slowly on the way down and again for me, right up and slowly on the way down.

This is actually quite good for balance as well, something that we call proprioception. So again we are just re-enacting what we are doing on the bike again its working the hip flexors even more here. If you go down slowly you're working the hip flexors eccentrically which is lengthening so its better to go slow on the way down. Thank you

Hurling – Injury Prevention and Strengthening the Hamstrings

Hi folks, my name is Simon Kelly. I am an Irish physiotherapist practicing out of the Cambie Village Insync Physiotherapy clinic located on Cambie and King Edward.

Today is just a short blog on injury prevention and strengthening of the hamstring in Gaelic games.

The hamstring is by far the most injured area of the lower limb in Gaelic sports. The hamstring and quadriceps are an antagonistic muscle pair, meaning they work together in harmony to perform controlled smooth movement for locomotion. 

The reason the hamstring is injured so frequently is because these muscles: 

1.  Cross both the hip and knee joints (biarticular joint). They extend the hip and bend the knee. They are made up of three muscles----semitendinosus, semimembranosus and biceps femoris.

 2. There is a work rate ratio of 3:2---the former being the quadriceps and the latter being the hamstring.

3. The hamstrings fire at the start of swing phase to bend the knee and they fire again at the end of swing phase to control the leg as it moves into knee straightening --- this controls the leg before heel strike. The later being the most reported hamstring injury phase during sprinting and directional changes.

Risk factors --Muscle tightness, muscle imbalances, poor conditioning, muscle fatigue:

Some injury prevention tips for the hamstring muscles:

  1. Muscle tightness:---Dynamic stretching ---far more important than static stretching. Drills must always be dynamic pre game.---the more you simulate play the better
  1. Muscle imbalances: Hamstring strengthening should be a major part of every Gaelic teams strength and conditioning program with particular emphasis on the eccentric phase of training  (lengthening of a muscle under tension)

Nordic hamstring curls---slow on the way down (eccentric) and quick on the way up (concentric contraction)

Nordic hamstring curls with a ballistic/ more dynamic type alteration --fall forward let you hands touch the floor and push up  

  1. Poor conditioning. If your muscles are weak (core/lumbar/hamstrings), they are less able to cope with the stress of exercise and they are much more prone to be injured.

Lumbar/core & pelvis stability are high on my list of gym exercise programs for GAA players: A stable base allows the extremities to work much more efficiently without compensatory patterns occurring. Think of a sailing ship mast or a tree trunk, everything stems from the strong core or middle section-simple.

  1. Muscle fatigue. Fatigue reduces the energy-absorbing capabilities of muscle, making them more susceptible to injury.
  2. Nutrition and hydration 

Tune in soon for wrist strengthening and torso rotation strengthening exercises which are all vital components in the hurling grip and swing.


Preventing Cycling Injuries – Hip Flexor Strengthening

Hi, this is Simon Kelly, physiotherapist in the Cambie Village clinic here, Insync. And today I’m just going to show you a simple exercise to really focus on your hip flexors while you're biking.

So I am just going to bring my right leg forward, nice straight back if you can. It’s good to keep your elbows a little bit bent as well when you're biking as well. So obviously the bumps in the road aren't going through straight arm, so I usually keep my arms a little bit bent in this as well just to get kind of re-enact exactly what you're doing on a bike.

So I usually do this maybe 12 sets and that's a nice burn on the right iliospasoas, your hip flexors here. Try to be as steady as possible, bringing the knee up, good! A little bend in the elbows and you would be doing that as I said 12 times, three times a day. Cheers!

Preventing Cycling Injuries & Low Back Pain – The Dead Bug Core Strengthening

Hi everybody, just Simon here again. Just going to give you a simple core exercise to do just to strengthen the core. Core is very important like I said before because it creates a stable base just to power into the lower limbs.

So the start position for this is if you just lie on your back, sort of hips and knees at ninety degrees, and arms up like I am here now, and then you're going to extend out your bottom left leg and extend out your right arm, nice nice straight and steady. Then you're going to come back to the start position. Then you're going to do the same on your right leg, extend out right leg and extend back your left arm. Perfect!

Then you’re going to do 10 reps of each for three sets if you can.

Preventing Cycling Injuries – Wall Squats

Hi everyone just another exercise to help with cyclists here. A pretty common one actually. I’m just squatting, here I have 10 lbs in each hand. So I'm going to go slowly down. I use a ball at the back actually for proprioception, I like feedback.

Knees are shoulder width apart, you're just slowly lower down. This is quite good for the quads here at the front. It lengthens under tension, which means its an eccentric contraction and then we are slowly going to come up.

We are going to do the same again. The main things that are going on here is really working the quads slowly on the way down even hold is for two or three seconds at the end then pump it up as well. Really really good for the gluts as well, all powerful muscles when you're trying to drive the bike forward. I would usually do this maybe 12 times, 3 times a day if I could.

It's also what we called a closed kinetic chain exercise so our feet are fixed to the ground just like you're doing in cycling. So that’s another good one just to add to the core exercises. Cheers everybody!

Vancouver Physiotherapist Christina Wan – Sport & Spinal Injury Rehabilitation

What do you like most about being a Physiotherapist?
I like that I am able to do an assessment and pin point what might be causing someone's discomfort or pain and then from there, being able to decide with the client what solutions might be beneficial for them to make a long-lasting impact for their life.

Why did you become a Physiotherapist?
I became a physical therapist when I realized that most people, live with some sort of pain in their life. Whether that means they have some of neck pain from studying or pain from day to day activities, or just knee pain from running. I think that most people are aware of the traditional medical approach with dealing with pain but not everyone's aware of the benefits that physiotherapy has. I want to be a part of that change.

Why did you choose to work at INSYNC PHYSIO?
Well, first of all I really like that INSYNC wants to build this bond with the community and the commitment they have with their clients. One of the things that stood out to me was that INSYNC offers focused one on one treatments, which to me emphasizes that they really do care about their clients and they want them to get better. I also like that they are onsite and available at a lot of sports and community events. Aside from helping people who get injured during these events, they bring awareness to the community as to how physiotherapy can help.

What are your outside interests/ hobbies?
I love trying new things, I love eating, I love finding new places to eat, I love travelling… that’s kind of what I like to do.

What is your special interest / focus in treatment if any?
I really like treating necks and backs. The reason why is because I think that everyone at some point in their life will have some sort of neck and back pain. I think those are the two areas that piqued my interest and are things that I am passionate about.

Preventing Cycling Injuries – Bike Fit and Bike Hacks with Simon Kelly

Hi everybody, my name is Simon Kelly, physiotherapist here at Insync Physio and at Cambie Village here. Today is just a session on sort of bike hacks and bike fit. I personally rode the Gran Fondo from Whistler to Vancouver. It was 122 km. So I obviously trained locally. Did the local mountains, you know the Grouse Grind it's called obviously for that, Seymour Mountain and Cypress, that was really good training I felt. Up a hard mountain, 1km up is pretty tough going but that kind of prepared me well for the 122km.

Anywho, I'll discuss what happened on that in a moment.

First of all I just want to say how important the bike fit is. If the handle bar is down too low, you know a cyclist holds like this, especially in a downward position, there is a little nerve that runs through our hand here on the inside. It's called cyclist palsy. But the nerve is called ulnar. So it's very important to change your grip more so to the thumb side of the hand, or else wear a pair of gloves and make it wider so you're not compressing that nerve.

The other nerve that passes through the wrist, far more common people know a lot more of it, is the median nerve or carpel tunnel syndrome. You might of heard it before. That's from keeping your hands in this position. Now this would usually happen with riders that are riding for hours on end. Didn't happen me thank god on the Fondo.

When the bar is too low, as well it can also create pain in the back of your neck. I'll kind of show you here briefly if I can, sort of. So it it's too low, you're leaning down and your head is craning up, so a lot of cyclists looking up like this get a lot of pain in the back of the neck. So you want to make sure this is the proper height.

Same on the saddle. Saddle height it very very important. If it's too high, you're going to get pain in the back of your knee. If it's too low, a lot of cyclists can have pain in the front of the knee, anterior knee pain or patellar femoral knee pain is what we call it. Lots of different fancy names for that but we talk about that again.

The other thing I wanted to talk about is cleat position as well, also affects pain in the knees. Some cleat position--obviously cleats are what you have under your shoe that clip in here. I don't have them on right now, so I might have to show you in another video. But that can sort of have pain in the outside of the knee that's known as ITB band syndrome where you get a lot of friction from constant bending of the knee here on the outside. Where the ITB band comes down, you can kind of see my ITB joining onto the outside here. So cleat position can be very important for that. They are just a couple of hacks I just wanted to discuss here today.

Tune in sorry - Just before I go when I was personally doing the Gran Fondo, I had a bit of numbness in my left foot actually at about maybe 90km, wasn't too sure why. I had to research it afterwards actually. Sometimes it's due to very tight footwear which I kind of like things very very tight, because I don't want anything falling or moving when I'm cycling that kind of distance. So that's one little fix if you're getting numbness into the left foot. If it's numbness though and it's kind of continuing too long, it could be something more serious. You might have to go to your doctor. It's something called compartment syndrome but that's something else.

Final thing I wanted to talk about was numbness and I was getting a lot of pain sort of in my lower abs. So I believe my core was actually quiet weak. So it think it's very very important to have a strong core, strong stability that drives into your lower legs and that will get you up doing long races like that as well.

Cheers thank you!

Vancouver Physiotherapist Simon Kelly – Sport and Spinal Injury Rehab

The thing I like most about being a physiotherapist is just helping people walk through their goals and their rehab, their rehab stages, I really enjoy the fact that I get to talk to people on a daily basis.

I always knew from a young age when I was eighteen picking my profession that I didn't want to sit in front of a computer nine to five, just couldn't do it. I do have to use a computer still with this job but  I don't have to do it full time so that's great.  I also get to like, its like problem solving, I like to come in and be a bit of a detective and kind of figure out what's the root cause of somebody's problem.

I don't believe in like relying on analgesics for short term fixes so I believe in conservative management for many many different injuries is much more important, than just a quick fix in a doctors office.

And why did you become a physiotherapist?

I was involved in lots of sports from a young age. I played hurling which is an Irish sport.  One of the fastest field sports in the world actually.  Played rugby as well, played soccer, tennis every sport you could think of. Probably too much actually because I got injured on numerous occasions.  But the injury I remember the most is that dislocating and breaking my left elbow, my ulnar nerve which is the nerve that passes back here. Got impacted and I had a bit of tingling into my baby finger which I found out later on what that was all about. But I enjoyed going to the physiotherapist and I kind of thought to myself this would be a really nice way to actually make a living out of.

Biology was always my favourite subject in school. I went to the west of Ireland a place called Galway to do physiology. That's kind of what I majored in, that's kind of looking at the body at sort of a molecular level, ions in and out of cells. Kind of complex stuff but a little too micro. So I decided to do a masters in physiotherapy in Edinburgh in Scotland.  I brought it up to a macro level.  I enjoyed the whole anatomy and the fact that most of the language comes from latin which I kind of enjoy actually.

And why did you choose to work at Insync Physio?

I choose to work at Insync Physio because it's a small clinic which I quiet like, it's kind of personable, you can become much more friendly as opposed to being lost in a nationwide company. I worked in a nationwide company back in England and I felt like I was just a number. So here its a lot more personable there's Physios that get together. We get together once a month. We sort of bounce ideas off one another and we can sort of come up with the latest research, techniques, sort of investigate each others techniques. And that way we can become better practitioners actually. The other thing I like about here, is it's kind of patient centred it's one on one. You build a lot of rapport. It's not just like a factory setting where your getting clients, rush them through the door in and out, thanks for coming, it's more just like one on one, 30 minutes or 45 minutes. I like that the most to be honest, and I can build good rapport with my clients due to that.

What other outside hobbies and interests do you have?

My latest hobby is actually cycling. I picked up cycling at the start of the summer and I love it actually. I cycled the Gran Fondo, it's a race from Vancouver to Whistler, its 122 km, and didn't take too long. I was kind of happy with my progress. Trained a little bit, but could of trained a little bit harder. But I found a few little things that I might incorporate into my sessions with cyclists in the future, you know a lot of core. My core was kind of grumbling early on in the race, and a little bit of tingling into my left shoe as well. So have to address that but maybe that will be in another video.

And in the winter I like to ski in the mountains and there is not too many mountains in Ireland to be honest, so I only picked that up four years ago when I came over here. Started to do a few little jumps which is, I'm pretty impressed with after three years. A bit of an adrenaline junkie. I like the speed even though I know the injuries involved with that as well. So that's kind of a kind of funny as well.

I play hurling as well but I kind of gave that up two years ago, that's that fast sport I was telling you about earlier, kind of like a cross between lacrosse and field hockey. But lots of injuries in that too but I hope to get back into that in the Irish community as well so.

What’s your special interest or focus in treatment?

My special focus in treatment is mainly just educating the patients on the diagnosis, time lines, never keeping them in the dark but also mainly got to do with like pain modulation. You know people use medication like I spoke about earlier, I just don't think that, that's just a quick fix and the doctor is just getting you out of the office in a two minute consult. We deal a lot more with hands on. Mobility, nerve flossing, other techniques that kind of desensitize pain and different methods of pain modalities.

I heard a lot of bad stories about people just being put in a room and put on electrical machines and forgotten about. That's not how I work. I kind of do a bit of a combined method. Maybe some machine work, maybe some hands on, mobility and lots of strength and conditioning as well. Most of the research basically goes for strength and conditioning once the acute and sub acute stages have settled, that kind of where I'd be going, education on pain modulation is by far the most important thing and not relying on analgesics and surgeries if we can - avoid them.

Are there certain types of injuries that you’re more drawn to treating?

Yeah, particularly interested in the shoulder and the knee they are more so my specialty. I enjoy that. And there is lots of shoulder injuries in many many sports more because you're sacrificing mobility for stability, so that pretty enjoyable to me. And sometimes the neck as well we get a lot of sensation down into the fingers for different reasons. Anywhere sort of in the upper quadrant I kind of like.

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