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!