Is it REALLY tendinitis? Or tendinosis?

All physical therapy is NOT created equal. As a physical therapist with almost 2 decades of hands-on care, I have tried many approaches in treating soft tissue dysfunction. Tissue stress can be identified objectively through a comprehensive biomechanical evaluation and well as subjectively through a thorough interview with the patient. Patient compliance and therapist experience is paramount in achieving maximum results in minimum time. I strongly feel that the “missing link” in achieving permanent, maximum results is inadequate treatment of soft tissue fibrosis i.e. scar tissue throughout the kinetic chain. Let me explain!

One of the most contentious debates that I have had with physicians as well as physical therapists is the inflammation versus fibrosis debate. Many health care practitioners feel that inflammation is the main source of pain in chronic conditions (greater than 3 weeks). This is evidenced through their long-term use of anti-inflammatory meds, cortisone shots, and the over-use of anti-inflammatory modalities in physical therapy such as iontophoresis and phonophoresis. My main adage as a physical therapist is “there better be a good reason for everything you do!” Evidence-based or research-based treatment is fundamental to our professional growth. I feel that using anti-inflammatory procedures is a very effective strategy in the short-term. It is true that we are our own worst enemies during our hectic lives. Intermittent, acute inflammation can certainly occur. However, what underlying dysfunction is present that predisposes us to this chronic, intermittent pain? What does the research tell us?

Karim Khan,MD in “Time to abandon the “tendonitis” myth”, BMJ, 2002, 324(7338):626-7 reports that “animal studies conclusively demonstrate that, within 2-3 weeks of insult to tendon tissue, inflammatory cells are not present.”

Karim Khan,MD in “Histopathology of common tendinopathies”, SportsMed 1999;27(6):393-408 states that “We conclude that effective treatment of athletes with tendinopathies must target the most common underlying histopathology, TENDINOSIS, a non-inflammatory condition.”

Harvey Lemont,DPM in “Plantar fasciitis”, JAPMA 2003;93(3):234-237 states that, after analyzing tissue samples from 50 plantar fascia surgeries, “Histologic findings are presented to support the thesis that “plantar fasciitis” is a degenerative fasciosis WITHOUT inflammation, not a fasciitis.”

Although the literature states that inflammation is not present in chronic soft tissue lesions, many practitioners continue to get positive results with anti-inflammatory procedures. Why? Steroids have been shown to inhibit the early stages as well as the later manifestations of the inflammatory process. (Fredberg 96) Ultrasound guided peritendinous injections of achilles and patella tendonitis have shown a significant reduction in the average diameter of the affected tendons (Fredberg 04) as well as a disappearance of neovascularization. (Koenig 04) What this last statement means is that steroids have the ability to “shrink” pathological tissue. This “shrinking” has been associated with a decrease in pain, but it does not stimulate tissue regeneration and strengthening of the pathological tissue. As a result, the patient is susceptible to chronic reinjury. So how does the therapist stimulate tissue regeneration?

The first step in the process is to identify tissue texture abnormalities. Microscopically, healthy tissue is smooth, longitudinal, and symmetrical in presentation. Scar tissue i.e. fibrosis is laid down by our bodies in a very haphazard and erratic fashion. During palpation, both the clinician and the patient can detect areas of grittiness, nodules, and “knots”. A partial tear in the Achilles tendon is thicker, harder, and gritty compared to the healthy side. Fibrosis in the plantar fascia can be felt and heard as you stroke the edge of a coffee mug along the central band of the fascia. Once a lesion is detected, I utilize patented and proven techniques such as instrument assisted soft tissue mobilization(IASTM) and Active Release Technique to “break up” cross-links, adhesions, and/or restrictions in the tissue. Please read my links for Graston Technique and Active Release Technique for more information.

As a result of almost 2 decades of asking questions and critically appraising my successes and failures, I have become convinced that the “missing link” in the treatment of chronic pain is the release of scar tissue adhesions. In conjunction with IASTM and Active Release Technique, rehabilitation is accomplished through the functional integration of strengthening, stretching, joint mobilization, cardiovascular exercise, and compliance with a home exercise program. Correcting biomechanical deficiencies with foot orthotics is also a consideration. Most physical therapists do an adequate job of treating pain. Acute pain usually resolves with the most innocuous of therapy interventions. However, the only way to prevent reoccurrence of symptoms is to ensure that every aspect of the dysfunction is being treated in the most comprehensive manner. At WalkWell, we do just that!

Shoulder Impingement Syndrome

Shoulder pain is the third most common musculoskeletal disorder, following low back and neck pain (Donatelli).   Because of the mechanical demands placed on the shoulder, it is susceptible to numerous soft-tissue injuries.   One of these injuries is called shoulder impingement syndrome.  It is the result of compression of the soft tissues i.e. most typically, the rotator cuff tendon, within the sub-acromial space.  Impingement results from the cumulative stresses of repetitive shoulder motion such as pitching or sustained overhead activity such as painting.  This repetitive stress can lead to tendonitis, rotator cuff tears, bone spurs, or bursitis.

Impingement syndrome can be classified in two ways – external vs. internal and primary vs. secondary.  An external impingement affects the superior surface of the humeral soft tissues in the sub-acromial or coraco-acromial region.  Applicable clinical tests include the Neer and Hawkin’s/Kennedy tests.   An internal impingement may affect the undersurface of the rotator cuff, the posterior labrum, and is, more specifically, a post/sup impingement.  Clinical exam may produce post/sup shoulder pain with passive ER which can be alleviated with a passive posterior humeral glide.  A primary impingement is caused by the structural anatomy of the sub-acromial region.  X-Rays can determine an abnormal variation in the shape of the acromion process.  A type 3 “hooked” acromion may require surgical intervention to correct.  On the other hand, a secondary impingement is the result of dysfunctional biomechanics of the shoulder joint.  It may be due to weakness of the rotator cuff muscles, poor posture, gleno-humeral joint stiffness, thoracic hypomobility, and/or in-coordination/weakness of the scapular stabilizing muscles. And that is what WE treat at OrthoWell?

“I play tennis and developed pain in my shoulder so strong that I could not even sleep, let alone play!  After the very first treatment (ART combined with joint mobilization) 80% of my pain was gone!  I am practically pain free now after 4 visits.  Thank-you Chris!  Great job!” – DK

What is the best exercise for patellar tendinosis?

Patellar tendon pathology or tendinosis can be a resistant and recurrent condition in running and jumping sports.  An important part of your  physical therapy program should include eccentric exercise.  What are eccentrics?  Eccentric contractions occur when the muscle-tendon unit LENGTHENS during exercise, producing so-called “negative work”.  Squatting down slowly or going down stairs are examples of  quad eccentrics.  Eccentric force production may exceed concentric (shortening contraction) and isometric (tensing without motion) forces 2-3 times. (Stanish et al)  Eccentric training drills stimulate the production of new collagen tissue-the main tissue in your achilles. (Khan et al)   This effect helps to reverse the tendinosis cycle.

The eccentric exercise commonly recommended for the patellar tendon is the squat.  What kind of squat is best?  A mechanism that may decrease the eccentric load on the quad is active or passive calf tension.  This tension may limit the forward movement of the tibia over the ankle while performing a squat.  This effect can be minimized, and load on the patellar tendon maximized, by performing a squat on a 25 degree decline. (Purdam et al)  In a small group of patients with patellar tendinosis, eccentric squats on a decline board produced good clinical results in terms of pain reduction and return to function. (Purdam et al)  In the flat-footed squat group, the results were poor.

The eccentric training protocol for chronic patellar tendinosis should include 3 sets of 15 reps, 2 times per day, for up to 12 weeks.

“I started therapy at a rehab close to home but was not getting results after 12 visits.  I then came to Chris and within 2 weeks (4 visits) the results have been substantial.  What a difference!”  — Kristin M.

Do you really NEED that cortisone shot?

Our patients are our best advertisement. Word of mouth travels fast! But what happens when the doctor becomes the patient? Please read the testimonial below from one of your colleagues on the North Shore who was treated at WalkWell Rehabilitation.

As a family practitioner I thought I knew a fair bit about musculoskeletal problems and their treatments. But after a few treatments I had learned a tremendous amount of new things about physical medicine and I have not felt better in years. I now recommend Chris to all my patients who need physical therapy for treatment of conditions of the lower extremities.” – PhillipBurrer,MD of Family Medicine Associates

-ITIS VS -OSIS…
WHAT YOU NEED TO KNOW!!

One of the most controversial topics in orthopedic medicine is the –ITIS versus -OSIS debate. Many health care practitioners feel that inflammation is the main source of pain in chronic conditions. This is apparent through the use of NSAIDS, steroid injections, and modalities such as iontophoresis. As a physical therapist with almost 2 decades of hands-on care, I have tried many approaches in treating chronic pain. Evidence-based treatment is the MAIN FOCUS in my clinic. Can we prevent the reoccurrence of pain by ONLY treating the inflammation?? What does the research tell us?

Karim Khan, MD in “Time to abandon the “tendonitis” myth”, BMJ, 2002, 324(7338):626-7 reports that animal studies conclusively demonstrate that, “within 2-3 weeks of insult to tendon tissue, inflammatory cells are not present.”

Karim Khan, MD in “Histopathology of common tendinopathies”, SportsMed 1999;27(6):393-408 states that “We conclude that effective treatment of athletes with tendinopathies must target the most common underlying histopathology, TENDINOSIS, a non-inflammatory condition.”

Harvey Lemont, DPM in “Plantar fasciitis”, JAPMA 2003;93(3):234-237
states that, after analyzing tissue samples from 50 plantar fasciotomies, “Histologic findings are presented to support the thesis that “plantar fasciitis” is a degenerative fasciosis WITHOUT inflammation, not a fasciitis.”

Almekinders, Temple, et al in “Etiology, Diagnosis, & Treatment of tendonitis: an analysis of the literature”, Med Sci Sports Exer 1998;30(8):1183-1190 state that they “found little evidence that NSAIDS and corticosteroids were helpful in treating tendinopathy.”

Because no inflammatory cells have been demonstrated in biopsies from chronic tendinopathy, some authors have abandoned the tendonitis “myth” as well as the use of steroids. Recent studies, however, have begun to question this new opinion. Recent placebo controlled, randomized studies of ultrasound-guided peritendinous steroid injections have been shown to be very effective in reducing the pain and thickness of Achilles and patellar tendons in athletes with chronic tendinopathy.

Fredberg et al in “Ultrasonography as a tool for diagnosis, guidance of local steroid injection..”, Scand J Rheumatol 2004; 33: 94-101 state that steroid injections “significantly reduced the average diameter of the affected tendons” and “in several cases the thickening of the tendon regresses completely.”

Koenig, et al in “Preliminary results of colour Doppler-guided intratendinous glucocorticoid injections..”, Scand J Med Sci Sports 2004: 14: 100-106 found that “neovascularization disappears” after ultrasound-guided, intratendinous injections.

Injection technique appears to play a pivotal role in the effect of the steroid on pathologic tissue. Should the practitioner continue to inject “blindly” or use ultrasonography to guide the precise placement of steroid? The next unanswered question is how to maximize the therapeutic benefit AFTER injection. Fredberg also states that steroids “cannot repair degenerative changes” and attempted to explain “the high frequency of relapse” 6 mo after the first injection. He now recommends 3-6 months of rehabilitation after injection. At WalkWell Rehabilitation, the functional regeneration of tissue is our goal.

GRASTON versus Scar Tissue!! Any bets??

The first step in treatment is to identify scar tissue. Microscopically, healthy tissue is smooth, longitudinal, and symmetrical in presentation. Scar tissue i.e. fibrosis is laid down by our bodies in a very haphazard and erratic fashion. Picture below.

During palpation, fibrosis will feel gritty or knotted. At OrthoWell/WalkWell, we may use Graston’s instrument assisted soft tissue mobilization (IASTM)  to “break up” restrictions. This deep massage creates a reactive inflammation which “jump starts” healing. Keep in mind that inflammation can occur without healing, but healing cannot occur without inflammation. During the inflammatory stage, scar tissue can be reabsorbed by the body. During the fibroblastic or re-growth phase of healing, the damaged tissue is replaced by new collagen. This new collagen is reformatted through proper exercise. This “process” can take 3-6 months in chronic cases. So what does the research tell us about IASTM?


Instruments of Assisted Soft Tissue Mobilization

Craig Davidson et al in “Morphologic and functional changes in rat Achilles tendon following collagenase and GASTM”, J Am College Sports Med, 1995;27 showed increased fibroblast proliferation in the IASTM group and stated that “the study suggests that IASTM may promote healing via increased fibroblast recruitment.”

Gale Gehlsen et al in “Fibroblasts responses to variation in soft tissue mobilization pressure”, Med Sci Sports Exer, 1999;31:531-535 showed morphological evidence indicating that “the application of heavy pressure during IASTM promoted more fibroblastic proliferation compared to light or moderate pressure.”

Mary Loghmani et al in a 2006 research project at Indiana University (pending publication) revealed that “ligaments treated with IASTM were found to be 31% stronger and 34% stiffer than untreated ligaments” using Graston Technique instruments.


As a result of almost 2 decades of asking questions and critically appraising my successes and failures, I have become convinced that the “missing link” in the treatment of soft tissue lesions is the proper release of scar tissue. Rehabilitation is accomplished through the functional integration of deep massage, strengthening, stretching, joint mobilization, cardiovascular exercise, and compliance with a home exercise program. Correcting biomechanical deficiencies with foot orthotics is also a consideration.

Most physical therapists do an adequate job of treating pain. Acute pain usually resolves with the most innocuous of therapy interventions. However, the only way to prevent reoccurrence of symptoms is to ensure that every aspect of the dysfunction is being treated in the most comprehensive manner. At OrthoWell/WalkWell, we do just that!

Graston Technique:

Patellar Tendinopathy – The role of Eccentrics.

Patellar tendinopathy can be a resistant and recurrent condition in running and jumping sports. An important part of your patient’s physical therapy program should include eccentric exercise. What are eccentrics? Eccentric contractions occur when the muscle-tendon unit LENGTHENS during exercise, producing so-called “negative work”. Squatting down is an example of a quad eccentric. Eccentric force production may exceed concentric (shortening contraction) and isometric (tensing without motion) forces 2-3 times. (Stanish et al) Eccentric training drills stimulate mechanoreceptors in tenocytes to produce collagen. (Khan et al) This effect helps to reverse the tendinopathy cycle.

The eccentric exercise commonly recommended for the patellar tendon is the squat. What kind of squat is best? A mechanism that may decrease the eccentric load on the quad is active or passive calf tension. This tension may limit the forward movement of the tibia over the ankle while performing a squat. This effect can be minimized, and load on the patellar tendon maximized, by performing a squat on a 25 degree decline. (Purdam et al) In a small group of patients with patellar tendinopathy, eccentric squats on a decline board produced good clinical results in terms of pain reduction and return to function. (Purdam et al) In the flat-footed squat group, the results were poor.

The eccentric training protocol for patellar tendinopathy should include 3 sets of 15 reps, 2 times per day, for up to 12 weeks.

“I started therapy at a rehab close to home but was not getting results after 12 visits. I then came to Chris and within 2 weeks (4 visits) the results have been substantial. What a difference!” — Kristin M.

The Missing Link – SCAR TISSUE

 

Scar Tissue

All physical therapy is NOT created equal. As a physical therapist with 2 decades of hands-on care, I have tried many approaches in treating soft tissue dysfunction. Tissue stress can be identified objectively through a comprehensive biomechanical evaluation and well as subjectively through a thorough interview with the patient. Patient compliance and therapist experience is paramount in achieving maximum results in minimum time. I strongly feel that the “missing link” in achieving permanent, maximum results is inadequate treatment of soft tissue fibrosis i.e. scar tissue throughout the kinetic chain. Let me explain!

One of the most contentious debates that I have had with physicians as well as physical therapists is the inflammation versus fibrosis debate. Many health care practitioners feel that inflammation is the main source of pain in chronic conditions (greater than 3 weeks). This is evidenced through their long-term use of anti-inflammatory meds, cortisone shots, and the over-use of anti-inflammatory modalities in physical therapy such as iontophoresis and phonophoresis. My main adage as a physical therapist is “there better be a good reason for everything you do!” Evidence-based or research-based treatment is fundamental to our professional growth. I feel that using anti-inflammatory procedures is a very effective strategy in the short-term. It is true that we are our own worst enemies during our hectic lives. Intermittent, acute inflammation can certainly occur. However, what underlying dysfunction is present that predisposes us to this chronic, intermittent pain? What does the research tell us?

Karim Khan,MD in “Time to abandon the “tendonitis” myth”, BMJ, 2002, 324(7338):626-7 reports that “animal studies conclusively demonstrate that, within 2-3 weeks of insult to tendon tissue, inflammatory cells are not present.”

Karim Khan,MD in “Histopathology of common tendinopathies”, SportsMed 1999;27(6):393-408 states that “We conclude that effective treatment of athletes with tendinopathies must target the most common underlying histopathology, TENDINOSIS, a non-inflammatory condition.”

Harvey Lemont,DPM in “Plantar fasciitis”, JAPMA 2003;93(3):234-237 states that, after analyzing tissue samples from 50 plantar fascia surgeries, “Histologic findings are presented to support the thesis that “plantar fasciitis” is a degenerative fasciosis WITHOUT inflammation, not a fasciitis.”

Although the literature states that inflammation is not present in chronic soft tissue lesions, many practitioners continue to get positive results with anti-inflammatory procedures. Why? Steroids have been shown to inhibit the early stages as well as the later manifestations of the inflammatory process. (Fredberg 96) Ultrasound guided peritendinous injections of achilles and patella tendonitis have shown a significant reduction in the average diameter of the affected tendons (Fredberg 04) as well as a disappearance of neovascularization. (Koenig 04) What this last statement means is that steroids have the ability to “shrink” pathological tissue. This “shrinking” has been associated with a decrease in pain, but it does not stimulate tissue regeneration and strengthening of the pathological tissue. As a result, the patient is susceptible to chronic reinjury. So how does the therapist stimulate tissue regeneration?

The first step in the process is to identify tissue texture abnormalities. Microscopically, healthy tissue is smooth, longitudinal, and symmetrical in presentation. Scar tissue i.e. fibrosis is laid down by our bodies in a very haphazard and erratic fashion. During palpation, both the clinician and the patient can detect areas of grittiness, nodules, and “knots”. A partial tear in the Achilles tendon is thicker, harder, and gritty compared to the healthy side. Fibrosis in the plantar fascia can be felt and heard as you stroke the edge of a coffee mug along the central band of the fascia. Once a lesion is detected, I utilize patented and proven techniques such as instrument assisted soft tissue mobilization(IASTM) and Active Release Technique to “break up” cross-links, adhesions, and/or restrictions in the tissue. Please read my links for Graston’s New IASTM and Active Release Technique for more information.

As a result of 2 decades of asking questions and critically appraising my successes and failures, I have become convinced that the “missing link” in the treatment of chronic pain is the release of scar tissue adhesions. In conjunction with IASTM and Active Release Technique, rehabilitation is accomplished through the functional integration of strengthening, stretching, joint mobilization, cardiovascular exercise, and compliance with a home exercise program. Correcting biomechanical deficiencies with foot orthotics is also a consideration. Most physical therapists do an adequate job of treating pain. Acute pain usually resolves with the most innocuous of therapy interventions. However, the only way to prevent reoccurrence of symptoms is to ensure that every aspect of the dysfunction is being treated in the most comprehensive manner. At OrthoWell/WalkWell, we do just that!