PTAaron
07-22-05, 07:34 AM
This is an old article I typed up about a year ago for another board, but I like to spread it around when I end up someplace new, because I think it has some useful info in it... Enjoy!
This past week we had a local Sports Medicine doctor come in and do a presentation to our clinic on Tenodon Injuries - apparently the medical community is changing its view on treatment of these common injuries - and I wanted to share some of the insight I gained.
The following information is from a lecture by Dr. Sami Rifat MD, FACSM and is paraphrased by me:
What is a tendon? A tendon is a structure that attaches a muscle to the bone. It gains its primary strength from collagen fibers that run through it. Think of collagen as the little strings that run through packing tape - that is what they should look like when the tendon is healthy.
The common view of tendon injuries was once that the majority of the time a patient comes in with a tendon problem, it must be a tendonitis. Tendonitis implies that there is an inflammation of the tendon which needs to be decreased, and then the problem will go away. A typical true tendonitis will resolve in 2-4 weeks if it is a new onset, and if it is a longer standing tendonitis it should be better in 4-6 weeks - recovery rate from a "true" tendonitis is 99%. The common tendonitis treatment is anti-inflammatories, rest, and ice. Typically people who have had long term probelm and go in for treatment with this protocol will not respond very well and will become quite frustrated.
Anti-inflammatory treatments have a few problems with them anyway:
-Cortisone injections cause breakdown of collagen fibers and can lead to tendon rupture if performed on a high stress tendon.
-Most over the counter anti-inflammatories take 4-8 weeks of continuous use before they have their anti-inflammatory effect. For example Ibuprofen takes about 6 weeks of taking 600-800 mg 3 times per day. Perscription anti-inflammatories vary a lot also Naprosyn (Naproxyn) takes 8 weeks before it begins to show an anti-inflammatory effect, whereas newer drugs like Celebrex and Bextra take about 8-10 days. This means that for the most part, by the time your meds are actually doing their anti-inflammatory job - your problem should already be gone if it was a true tendonitis. By the 8 week point if the problem is still present - there are generally no longer any inflammatory cells present anyway - which we will see in a minute.
New research has lead medical professionals to realize that in the majority of patients (about 90%)who come in with "tendonitis" the problem is no longer tendonitis, but tendonosis which is a degenerative condition of the tendon.
Tendonosis is characterized by degeneration of the collagen fibers in the tendon (the fibers that provide the tensile strength), tendon weakness, abnormal growth of unhealthy blood vessals through the tendon, and most importantly no inflammatory cells. Basically the nice straight strong fibers of collagen become a tangled mess of strings with little pockets of "jelly" and small weak blood vessals. If you look at pictures of a healthy tendon it will be white and glistening, tendons with tendonosis are dull and brownish. Keep in mind that this is not an inflammatory process, so there is no reason for anti-inflammatories or injections.
Tendonosis is a more difficult problem to heal with only an 80% chance of resolving. Typical tendonosis can take anywhere from 8 weeks to 9 months to resolve depending on how long you have had the problem. There are quite a few treatment options out there right now but the best protocol seems to be: Relative rest, ice, friction massage, and exercise. I will go over each of these steps for you...
-Relative Rest: What this means is do NOT stop using the injured tendon - disuse leads to the tendon losing more strength - tendons need load on them to maintain and gain strength. You should decrease your activity level though, and try to avoid activities that severely irritate the problem.
-ICE: This is one of the most important parts, you need to perform ice massage on the injured area several times per day. Ice massage has a few effects - first it inhibits the production of the chemicals that cause the abnormal blood vessal formation we mentioned earlier, second it slows the nerve conduction so you are less likely to feel the pain, and finally it promotes healing. The best way to do an ice massage is to take a paper or styrofoam cup, fill it with water, and freeze it - then you can peel off enough of the cup to expose the ice while leaving yourself something to hold onto. Rub the ice over the area that is sore with moderate pressure until you go through all of the stages: Cold, burning, aching, and numb. You want the area to be numb and red - this takes 3-5 minutes usually - but be careful not to go too long and give yourself frostbite.
-Friction Massage: This is the "other" most important one... Friction massage is deep tissue massage that is performed across the fibers of the tendon with a firm pressure - it does not feel good, if usually hurts a lot. The reason we do this is to break up the fibers and promote "proper alignment"... some people speculate that it also helps to break up the "jelly" pockets... others believe that it helps to cause some inflammation in the area which "reminds" your body that there is an injury there. Over time the body seems to "ignore" tendonosis and stop attempting to heal it. To perform friction massage - first numb the area with ice massage. Next using your thumb or index finger reinforced with your middle finger and push on the tendon with a firm pressure and move from side to side across the tendon. Do this for 3-5 minutes or until your finger/thumb gets too tired. You may find that it is more sore immediately afterwards, but it will feel better after a little while.
-Exercise: Like I mentioned with "relative rest" exercise is extremely important for proper healing becuase loading actually increases tendon strength. The best rule of thumb for exercising an injured area is this: If it hurts after you do it, but the "new pain" goes away in less than 1 day - you did enough. If it hurts more than 1 day from something you did, then you did too much.
There are also a few things that we do in Physical Therapy that can help speed up the healing process, but keep in mind the process takes a very long time - up to 9 months if you had a long standing problem to begin with - and also keep in mind that there is only an 80% full recovery rate.
There are surgical options out there - things like tendon stripping and debridement of the tendon - but these are much more risky with only 50% of people have the procedures returning to their previous 100% level of function (based on an average of all procedures). U of M is working on a procedure that involves using a 14 gauge needle guided by ultrasound to "scramble" (Dr. Rifat's words) the "Jelly pockets" in the unhealthy tendons - this has had fairly good results and is much less invasive than a surgical procedure, but it is still under investigation.
What do you do if you think you have tendonitis?
- Start icing the area right away - ice massage is the best - and do it several times per day.
- Start taking anti-inflammatories even though they won't have their true effect until after the problem should have resolved. This is because they DO help with the pain through their analgesic action before they help with the inflammation. Best bet would be to go to your doctor and get some Celebrex or Bextra right away.
- Stop doing the exercises that provoke the problem - take a 2 week break, your body could probably use it! The problem should resolve in 2-4 weeks if it is really tendonitis and it is new.
- Start doing friction massage once a day to the area.
What if it doesn't go away in a few weeks?
- Go to the doctor for sure this time - get some x-rays maybe you have a bone spur or maybe you have something more serious going on. Get some meds - Maybe it is still inflamed and the anti-inflammatories will help. Most of all ask your doctor if she/he knows what tendonosis is - chances are they will not - because it is a fairly new concept. If your doctor doesn't know, then ask to be referred to a sports medicine doctor (FACSM). Also ask for a referral to Physical Therapy. When you call the PT clinic be sure to ask how many patients the therapists treat per hour - if it is more than 2, consider a different clinic because you may get handed off to a PTA or an ATC - not that PTAs and ATCs don't provide good care - the ones I work with are great, but in too fast paced of a setting you are likely to not see the PT enough to assess your progress and modify your program.
- Keep doing your ice massage and friction massage.
- Consider taking more time off from working out following the "relative rest" guidelines...
This past week we had a local Sports Medicine doctor come in and do a presentation to our clinic on Tenodon Injuries - apparently the medical community is changing its view on treatment of these common injuries - and I wanted to share some of the insight I gained.
The following information is from a lecture by Dr. Sami Rifat MD, FACSM and is paraphrased by me:
What is a tendon? A tendon is a structure that attaches a muscle to the bone. It gains its primary strength from collagen fibers that run through it. Think of collagen as the little strings that run through packing tape - that is what they should look like when the tendon is healthy.
The common view of tendon injuries was once that the majority of the time a patient comes in with a tendon problem, it must be a tendonitis. Tendonitis implies that there is an inflammation of the tendon which needs to be decreased, and then the problem will go away. A typical true tendonitis will resolve in 2-4 weeks if it is a new onset, and if it is a longer standing tendonitis it should be better in 4-6 weeks - recovery rate from a "true" tendonitis is 99%. The common tendonitis treatment is anti-inflammatories, rest, and ice. Typically people who have had long term probelm and go in for treatment with this protocol will not respond very well and will become quite frustrated.
Anti-inflammatory treatments have a few problems with them anyway:
-Cortisone injections cause breakdown of collagen fibers and can lead to tendon rupture if performed on a high stress tendon.
-Most over the counter anti-inflammatories take 4-8 weeks of continuous use before they have their anti-inflammatory effect. For example Ibuprofen takes about 6 weeks of taking 600-800 mg 3 times per day. Perscription anti-inflammatories vary a lot also Naprosyn (Naproxyn) takes 8 weeks before it begins to show an anti-inflammatory effect, whereas newer drugs like Celebrex and Bextra take about 8-10 days. This means that for the most part, by the time your meds are actually doing their anti-inflammatory job - your problem should already be gone if it was a true tendonitis. By the 8 week point if the problem is still present - there are generally no longer any inflammatory cells present anyway - which we will see in a minute.
New research has lead medical professionals to realize that in the majority of patients (about 90%)who come in with "tendonitis" the problem is no longer tendonitis, but tendonosis which is a degenerative condition of the tendon.
Tendonosis is characterized by degeneration of the collagen fibers in the tendon (the fibers that provide the tensile strength), tendon weakness, abnormal growth of unhealthy blood vessals through the tendon, and most importantly no inflammatory cells. Basically the nice straight strong fibers of collagen become a tangled mess of strings with little pockets of "jelly" and small weak blood vessals. If you look at pictures of a healthy tendon it will be white and glistening, tendons with tendonosis are dull and brownish. Keep in mind that this is not an inflammatory process, so there is no reason for anti-inflammatories or injections.
Tendonosis is a more difficult problem to heal with only an 80% chance of resolving. Typical tendonosis can take anywhere from 8 weeks to 9 months to resolve depending on how long you have had the problem. There are quite a few treatment options out there right now but the best protocol seems to be: Relative rest, ice, friction massage, and exercise. I will go over each of these steps for you...
-Relative Rest: What this means is do NOT stop using the injured tendon - disuse leads to the tendon losing more strength - tendons need load on them to maintain and gain strength. You should decrease your activity level though, and try to avoid activities that severely irritate the problem.
-ICE: This is one of the most important parts, you need to perform ice massage on the injured area several times per day. Ice massage has a few effects - first it inhibits the production of the chemicals that cause the abnormal blood vessal formation we mentioned earlier, second it slows the nerve conduction so you are less likely to feel the pain, and finally it promotes healing. The best way to do an ice massage is to take a paper or styrofoam cup, fill it with water, and freeze it - then you can peel off enough of the cup to expose the ice while leaving yourself something to hold onto. Rub the ice over the area that is sore with moderate pressure until you go through all of the stages: Cold, burning, aching, and numb. You want the area to be numb and red - this takes 3-5 minutes usually - but be careful not to go too long and give yourself frostbite.
-Friction Massage: This is the "other" most important one... Friction massage is deep tissue massage that is performed across the fibers of the tendon with a firm pressure - it does not feel good, if usually hurts a lot. The reason we do this is to break up the fibers and promote "proper alignment"... some people speculate that it also helps to break up the "jelly" pockets... others believe that it helps to cause some inflammation in the area which "reminds" your body that there is an injury there. Over time the body seems to "ignore" tendonosis and stop attempting to heal it. To perform friction massage - first numb the area with ice massage. Next using your thumb or index finger reinforced with your middle finger and push on the tendon with a firm pressure and move from side to side across the tendon. Do this for 3-5 minutes or until your finger/thumb gets too tired. You may find that it is more sore immediately afterwards, but it will feel better after a little while.
-Exercise: Like I mentioned with "relative rest" exercise is extremely important for proper healing becuase loading actually increases tendon strength. The best rule of thumb for exercising an injured area is this: If it hurts after you do it, but the "new pain" goes away in less than 1 day - you did enough. If it hurts more than 1 day from something you did, then you did too much.
There are also a few things that we do in Physical Therapy that can help speed up the healing process, but keep in mind the process takes a very long time - up to 9 months if you had a long standing problem to begin with - and also keep in mind that there is only an 80% full recovery rate.
There are surgical options out there - things like tendon stripping and debridement of the tendon - but these are much more risky with only 50% of people have the procedures returning to their previous 100% level of function (based on an average of all procedures). U of M is working on a procedure that involves using a 14 gauge needle guided by ultrasound to "scramble" (Dr. Rifat's words) the "Jelly pockets" in the unhealthy tendons - this has had fairly good results and is much less invasive than a surgical procedure, but it is still under investigation.
What do you do if you think you have tendonitis?
- Start icing the area right away - ice massage is the best - and do it several times per day.
- Start taking anti-inflammatories even though they won't have their true effect until after the problem should have resolved. This is because they DO help with the pain through their analgesic action before they help with the inflammation. Best bet would be to go to your doctor and get some Celebrex or Bextra right away.
- Stop doing the exercises that provoke the problem - take a 2 week break, your body could probably use it! The problem should resolve in 2-4 weeks if it is really tendonitis and it is new.
- Start doing friction massage once a day to the area.
What if it doesn't go away in a few weeks?
- Go to the doctor for sure this time - get some x-rays maybe you have a bone spur or maybe you have something more serious going on. Get some meds - Maybe it is still inflamed and the anti-inflammatories will help. Most of all ask your doctor if she/he knows what tendonosis is - chances are they will not - because it is a fairly new concept. If your doctor doesn't know, then ask to be referred to a sports medicine doctor (FACSM). Also ask for a referral to Physical Therapy. When you call the PT clinic be sure to ask how many patients the therapists treat per hour - if it is more than 2, consider a different clinic because you may get handed off to a PTA or an ATC - not that PTAs and ATCs don't provide good care - the ones I work with are great, but in too fast paced of a setting you are likely to not see the PT enough to assess your progress and modify your program.
- Keep doing your ice massage and friction massage.
- Consider taking more time off from working out following the "relative rest" guidelines...