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The Thinking Practitioner Episode 06: Tendons and Tendinopathies

Whitney Lowe:                 Welcome to the Thinking Practitioner podcast.

Til Luchau:                         A podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today.

Whitney Lowe:                 I’m Whitney Lowe.

Til Luchau:                         And, I’m Til Luchau.

Whitney Lowe:                 Welcome to the Thinking Practitioner.

Til Luchau:                         Welcome to the Thinking Practitioner. This episode is sponsored by ABMP, Associated Bodywork and Massage Professionals. ABMP membership combines the insurance you need, a free CE you want, and the personalized service you deserve. They are featuring their new dynamic, five minute muscle review app with muscle specific palpation and technique videos in the award winning Massage & Bodywork Magazine, where both Whitney and myself, Til Luchau, are frequent contributors.

Whitney Lowe:                 Yes, it’s certainly easy to see why people love ABMP. I, myself, have been a member for years, and it’s clear the organization is driven to offer loads of key benefits to their members, and their primary focus on delivering exceptional opportunities and services. So, for our listeners who join ABMP as new members, you can save $24 on your membership at ABMP.com/thinking. With ABMP, you can expect more.

Til Luchau:                         Cool, that’s a good offer. Thanks for joining me today, Whitney. We’re going to talk about an interesting topic. We’re going to talk about tendinopathy and tendon issues.

Whitney Lowe:                 That sounds great. Tendon tissue issues, today. So, how are things out in the Rocky Mountains this morning?

Til Luchau:                         It’s winter. It’s awesome. It’s time to get out, and get in the snow, and ski, and do that kind of stuff.

Whitney Lowe:                 Yeah, absolutely. I went skijoring with my dogs yesterday, which is always an adventure. It’s like, hang on for dear life, and get ready to have an anterior cruciate ligament sprain associated with it.

Til Luchau:                         That’s where you tie your dog to your waist and they pull you around on skis?

Whitney Lowe:                 Yeah.

Til Luchau:                         Is that what it is?

Whitney Lowe:                 Yeah, and I’ve got two of them, and they’re both young and strong. I run them every day on my bike, so they’re used to pulling very hard every day. So, when I get out there on the skis, usually once or twice a year we get to do it, because we’re not getting that much snow these days. But, a couple times a year I get to do it. I went out and did it yesterday. It was perfect conditions for them. So, I survived. That’s the mark of a successful skijoring operation.

Til Luchau:                         That’s awesome.

Whitney Lowe:                 I’m so blessed with no injuries.

Til Luchau:                         It’s definitely on my wishlist. Not the injury, but getting pulled by the dog kind of thing.

Whitney Lowe:                 That’s right, yeah. It’s fun. Yeah, so I didn’t develop any tendon injuries, but that’s what we’re going to be talking about here today.

Til Luchau:                         Okay, shall we jump right in?

Whitney Lowe:                 Yeah.

Til Luchau:                         I’ve got a question for you.

Whitney Lowe:                 Let’s do it.

Til Luchau:                         Can you tell us what is tendinopathy, or some examples? That kind of thing. Get us oriented to the territory here.

Whitney Lowe:                 Yeah, so there’s been quite a bit of sort of convoluted perspectives around terminology, especially with this condition, for a while, the last couple of decades. The most common term that people hear about and talk about when we think tendon pathology is the term tendonitis. Of course, by its name, it does indicate, by the suffix -itis, it does indicate an inflammatory condition.

Whitney Lowe:                 For many years, that of course was the primary thought process around what was going on with tendonitis, that it was an inflammatory problem. I know back when I was in school, we were taught that tendonitis was a problem which was caused by micro tearing of tendon fibers and the subsequent inflammatory reaction that comes as a result of that. So, we treated it as an inflammatory problem.

Whitney Lowe:                 Some time back around roughly mid 80s or so, I think this was, mid to late 80s, with the development of some other imaging capabilities, we were really learning a lot more about chronic overuse tendon disorders, and finding that in many instances there was an absence of inflammatory cells. And, this really was not in fact tendon fiber tearing in most of these disorders, but was in fact more of a collagen degeneration, collagen breakdown on the construction matrix of the tendon itself.

Whitney Lowe:                 So, the term tendinosis began to be used a bit more frequently. That basically means pathology of the tendon. Or, more commonly nowadays, too, we see the term tendinopathy, which simply just means tendon pathology. So, those are the two most common terms, and it does become important. We’ll get into this a little bit later in our discussion, too, about making that distinction between inflammatory versus non-inflammatory variations of those chronic overuse tendon pathologies.

Til Luchau:                         I look forward to chiming in there because I, as you know, am an inflammation fanatic. There’s actually… I don’t know if you’re familiar with Jill Cook’s 2016 paper where she came back and said, “Well, maybe I was wrong about that inflammation stuff.”

Whitney Lowe:                 Yes, right.

Til Luchau:                         Okay, cool.

Whitney Lowe:                 That sounds interesting. It was like, okay. So, I started changing all this stuff in things that I was writing, and then you’re like, okay, now we go back in the other direction.

Til Luchau:                         Yeah, we’ll get to that.

Whitney Lowe:                 Right. So, speaking of inflammatory things, now there is another inflammatory issue associated with tendon pathologies, that does not get spoken about quite as frequently, but it’s certainly something I think we need to be aware of. That’s something called tenosynovitis. The important thing about tenosynovitis is that not every tendon is susceptible to this. This only affects tendons that are surrounded by a synovial sheath. This is going to be, for the vast majority, tendons in the distal extremities that have to take a sharp angular turn around a joint, and then are bound closely to that joint by a fibrous retinaculum.

Whitney Lowe:                 Then, the tendon sheath is designed to reduce friction between the tendon and the synovial sheath, and then compression or chronic irritation of that tendon during movement will cause an inflammatory reaction, or sometime adhesions, to develop between the tendon and surrounding synovial sheath. That is tenosynovitis. So, those are the main types of tendinopathy or tendon pathologies that we tend to be looking at.

Til Luchau:                         That’s a great distinction. That’s interesting. I look forward to hearing what you have to say about that. So, what are… You got typical signs for us, or examples of conditions in the body that will give people a sense of what we’re talking about?

Whitney Lowe:                 Yes. So, interestingly, the signs and symptoms with all three of these are virtually identical and very difficult to distinguish. Even in inflammatory versions of tendonitis and tenosynovitis, it’s rare that you see really significant visible inflammation in those problems, even though where there may be some inflammatory aspects present. To me, that’s why I think it is so important to zero in on other aspects of the physical examination process, because there are some clear patterns that show up during physical examination with, in particular, pain with resisted movements. Pain of the tendon with resisted movements. Pain with direct compression of those tendons.

Whitney Lowe:                 So, knowing their location, knowing how to put a load on them, those are important factors that will help indicate the likelihood of them. So, they tend to be most painful from chronic overuse, and then they are less painful with rest. So, there’s a group of sort of key indicators that we see when we look at what seems to be the symptom pattern that shows up with that.

Whitney Lowe:                 Then, of course, really important, I think, is looking at information that comes out of the history from an individual about what kind of things might come from this. So, if we were to talk about history a little bit, what would be some of the things that you would think of to look at as possibile causes that you’d try to pick up in discussions with somebody about them?

Til Luchau:                         Well, I’ve got some thoughts about that, but I want to make sure that we get some actual examples of the kinds of complaints clients will have. I wrote down something key that you said. You said pain on resisted movement.

Whitney Lowe:                 Yeah.

Til Luchau:                         Before I jump into the causes, what are some of the conditions? I’m thinking like, hamstring tendon sensitivity. I don’t have the list up here, but let me look it up, because I want to know-

Whitney Lowe:                 Yeah, so just is we were to think about some of the very most common tendon pathologies places, where they seem to occur really frequently. Like, patellar tendon is far more common for a tendon pathology than hamstring tendons are. A lot of this has to do with the biomechanics of how load is focused on those particular tendons.

Whitney Lowe:                 So, during your physical examination, if you were to find tenderness to palpation in the patellar tendon itself, and pain with resisted knee extension, which is a movement that would put a load on that tendon, at the same time that we’re testing and evaluating it. So, knowing your muscle actions and being able to determine how to put a load on that particular tendon.

Whitney Lowe:                 Let’s say you’re looking at the wrist. The common wrist extensors, with a condition like a lateral epicondylitis, which is a chronic overuse tendon disorder. Performing a wrist extension movement, and then even sometimes when you palpate the tendon at the same time, that really even ramps up the pain response of, again, even higher. So that’s, another good indication that we’re looking at tendon pathology, versus something like ligament disorders, or muscle problems, or something like that.

Til Luchau:                         Okay, so you mentioned a few things commonly known as tennis elbow, golfer’s elbow. There’s also things like plantar fasciosis, or fasciitis, in the foot. You mentioned patellar tendinopathy, or patellar pain. Hamstring tendinopathy.

Whitney Lowe:                 Yeah, and certainly rotator cuff tendon disorders-

Til Luchau:                         Rotator cuff.

Whitney Lowe:                 Are really common, especially with the posterior rotator cuff muscles, the infraspinatus, and teres minor, and throwing athletes and people who are doing upper extremity throwing activities, those are certainly real common ones as well.

Til Luchau:                         Yup. So, you’ve made some real interesting distinctions about different types of mechanical factors in those different conditions, but there’s also some universal things there that we can think about, and look at, and talk about. Some of those actually apply to other inflammatory tissue conditions, too. Or, potentially inflammatory, because I know that’s a debate. Such as, bursitis or things like that, we can use some of these same principles for those things.

Whitney Lowe:                 Yeah, absolutely. So, what about the causes we were going to dive into? Tell me a little bit what your thoughts are on causes and things.

Til Luchau:                         Well, I did a little of my homework, reviewed some of this for myself before our conversation today and basically it’s as I remembered it, there’s no consensus about causes. There’s lots of different people with their theories and lots of different methodologies that assume a particular cause and they include, this is just right off of Wikipedia, they’re saying theories that involve strain, tenosite related collagen synthesis disruption, that’s back to the potential degeneration thing that you mentioned before. Load induced ischemia, neural sprouting, which is an interesting one I’ll mention later too. Thermal damage-

Whitney Lowe:                 Yeah. And let’s back up just a little bit and talk about those two and just sort of explain a little bit about what that might mean.

Til Luchau:                         Yeah.

Whitney Lowe:                 What would be load induced ischemia? What is neural sprouting? For people who might not be familiar with those concepts or terms.

Til Luchau:                         Yeah. I am just reading the list here. Load induced ischemia is not something that I’m typically thinking of when I’m working, although it’s, again, it’s a theory of what might induce that tendinopathy situation. Just guessing from the words there, you tell me if you know more than me about this, but it’s talking about disruptions to the kind of circulatory perfusion that’s needed to keep it healthy based by load.

Whitney Lowe:                 Yeah.

Til Luchau:                         Based on load. So neural sprouting, overgrowth of neural branches, nerve arborization into injured tissues often are into the areas around injured tissues that, this is a theory, that increases their sensitivity or increases the pain. More nerve endings equals more signal in this theory.

Whitney Lowe:                 Yeah, no, this is one that I found really interesting when you were mentioning this in our discussion beforehand about the neural sprouting because it’s not ever been real clear in a lot of instances why tendinosis is painful. If it’s not fiber tearing, what is it that produces that pain and this, the idea of the neural sprouting seems to me like a viable or plausible discussion or explanation for what might be the cause of pain in a lot of those tendon disorders.

Til Luchau:                         Sure. There’s the whole discussion about do nerve endings equal pain? Which is not clear. It’s not always a linear relationship.

Whitney Lowe:                 Yeah.

Til Luchau:                         And then there’s also the inflammation debate that inflammatory situations in tissues, when they get inflamed, they release cytokines and things that irritate nerve endings and cause pain.

Whitney Lowe:                 Yeah.

Til Luchau:                         So and then degeneration too, that might be a pain signal generator, a nociceptive generator. And then there’s a whole central nervous system phenomenon there where the degradation or degeneration does set up the nervous system to be more sensitive in the future to painful stimulus. So if you’ve been through it, pain in a particular tendon, you’re more likely perhaps to feel pain there later.

Whitney Lowe:                 That’s an important one I think because especially when you look at chronic overuse movement patterns, and that certainly is a key thing that seems to lead to a lot of these overused tendon disorders, the history of a prior pain in that area, again, we’re talking about maybe it’s not so much just that there is weakened or damaged tissue in that area as much as maybe we have sort of a sensitized neural pattern that we need to change the patterning around somehow or other.

Til Luchau:                         That’s right. That is right. And the good news is that manual therapy can play a great role as can movement and different things like that, which we’ll mention those as we go through, I’m sure. I wanted to mention too a [inaudible 00:13:19] paper that just came out this year on Achilles tendinopathy causes. It was a systematic review. We looked at I think nine studies. Unfortunately, he and his team said they were all pretty highly biased, but they still extracted the most significant features out of those for causes, at least in terms of Achilles tendinopathies. And the most significant factors he found were medications, especially a couple of classes of antimicrobials and transplants, if you’ve had an organ transplant or taking these kind of super antibiotics, you’re more likely to have tendon issues.

Whitney Lowe:                 Yeah.

Til Luchau:                         The second-

Whitney Lowe:                 And there’s a particular family of antibiotics they mentioned in there, the fluoroquinolones.

Til Luchau:                         Yeah, let me write that down. That’s it. That’s it.

Whitney Lowe:                 Yeah.

Til Luchau:                         That’s it.

Whitney Lowe:                 That are of particular concern and a lot of people are taking those just for basic bronchial infections and things like that and make no connection whatsoever between, “Hey, I suddenly started having some Achilles tendon problems and I can’t figure out why because I’m not running or jumping or anything like that.”

Til Luchau:                         Yeah.

Whitney Lowe:                 And that’s a really good indicator of why to look at medications and things like that in the history.

Til Luchau:                         That’s right. Interesting also, [inaudible 00:14:22] found alcohol consumption as the second most significant factor. And this was-

Whitney Lowe:                 That was interesting.

Til Luchau:                         Yeah, this is moderate alcohol consumption.

Whitney Lowe:                 Yeah.

Til Luchau:                         Cold weather training, reduced plantar flexor strength. So plantar flexors are anything that helps you point your toes, including the [inaudible 00:14:38] complex and muscles probably within the foot. And then there’s other, what he called putative causes, things that people say cause it, but they couldn’t find evidence for included obesity, static foot posture and physical activity level, either too much or too little. Couldn’t find a clear evidence-based correlation between that and tendinopathy, at least for Achilles tendon.

Whitney Lowe:                 Yeah. So I mean, I can see even with a lack of a, and again, there’s some interesting things in this paper, we will put notes about this paper in the show notes as well. Some interesting things that I think you could draw correlations about this when you think about something like obesity or what was the last couple of things that you said in addition to obesity and…

Til Luchau:                         No good evidence for obesity, static foot posture like overpronation and physical activity level, either too much or too little.

Whitney Lowe:                 Yeah. So some of those factors could be related to how those tissues are getting loaded under certain conditions and it’s just difficult to identify that accurately with research. So those are certainly things that we could look at and think about them as pertinent and relevant factors maybe, but not the kinds of things that you have to… you don’t ever want to say, “Oh, this is a no brainer just because this person is large, they’re going to have tendon disorders.” There certainly isn’t that kind of thing in there. I did want to also make one quick comment too back to what we had mentioned a couple moments ago about medications, because there’s another very important category of medications they had mentioned in that paper that’s also been identified with tendon disorders and that’s corticosteroids.

Whitney Lowe:                 And I had read this paper a number of years back, I’m not sure if this has been validated multiple times since then, but I thought it was quite interesting that it was indicating that they were looking at Achilles tendon ruptures and looking at the various factors that had led to a likelihood or predisposition to Achilles tendon ruptures, be it chronic overuse or what are all the different factors that we had mentioned a moment ago. And one of the most common causes or reasons for a person developing Achilles tendon ruptures had turned out to be a history of corticosteroid treatments for Achilles tendinosis. So when they had been treated with corticosteroids, that has a detrimental effect on the connective tissue strength and can cause more tendon degeneration over time.

Til Luchau:                         Which is interesting because the steroids, the corticosteroids, turn off inflammation, so they make it feel better, but they also turn off the healing and repair processes.

Whitney Lowe:                 Yeah.

Til Luchau:                         And there’s been a bunch of studies into that, including [inaudible 00:17:13] or the Coombes and Bisset, that’s the one I’d noted down in my homework here, where they saw steroid injections, people that had steroid injections had worse outcomes, more recurrences and decreased effectiveness of their physical therapy compared to doing nothing. So it hurt less when they got the injection, but then their longterm effects were not.

Whitney Lowe:                 Yeah. And when you think about this idea of these problems being less of an inflammatory problem and more one of chronic tendon or collagen degeneration in there, and then you see why a treatment like corticosteroid injections, which tends to weaken collagen synthesis and the development of good healthy collagen rebuilding, that really is a good indicator of why those treatments are highly problematic in many instances.

Til Luchau:                         I’m not sure I’m on board with the less inflammatory thing, by the way. Just a little extras there.

Whitney Lowe:                 Okay. No, right, yeah.

Til Luchau:                         It’s a, yeah, well, let’s get to that when we get there, but-

Whitney Lowe:                 And going back, just let me sort of clarify a little bit when I say that too, because my understanding from some a Jill Cook’s thing was saying that the inflammatory thing may be occurring at, for example, earlier stages and not so much at later stages or something like that. So that may be more of a staged process of when that’s happening as opposed to just not being there at all. So-

Til Luchau:                         Yeah, and she does, even though she came back and says, “Well, I was really against inflammation in the 90s and now I’m back in 2016 saying, well, actually there is signs of inflammation.” Even at that point she’s saying it mean, I don’t… she says, “I don’t think, my opinion, it’s not causing the pain,” is what she’s saying.

Whitney Lowe:                 Yeah.

Til Luchau:                         She’s still treating it as degeneration, degradation, but the, I don’t know, it’s a useful thing to keep, for me to keep in mind as a practitioner that maybe the things that cause inflammation are causing someone’s distress. She’s got an interesting test. Actually, I’m not sure it’s her or somebody else I heard talking about this, but the ice cube test where you actually, if you ice a tendinopathy or a place you suspect might have one of these conditions we’re talking about for 10 seconds and it gets better, then she’s suspecting an inflammatory component. If it gets worse, she suspecting a central sensitization component.

Whitney Lowe:                 Interesting.

Til Luchau:                         So that’s triggering some thermal sensitivity in that case if it gets worse and then it’s a sign that it’s actually probably more nervous system than inflammatory.

Whitney Lowe:                 Yeah. I remember how, man, I cannot remember this exactly right and I’d have to go back and look it up again, maybe you might know this too. This was in one of Lorimer Moseley’s discussions about making distinctions between central versus peripheral sensitivity, and one of them has heightened sensitivity to thermal applications distally peripherally and the other does not, if I remember correctly, it’s peripheral sensitization that has heightened sensitivity to thermal stuff. Is that correct?

Til Luchau:                         I remember it the other way around, but I wouldn’t [crosstalk 00:20:10].

Whitney Lowe:                 Yeah, you might be right on there. I may be getting it backwards, so we’ll have to look that up and see what that is. We’ll address that in another episode at some point when we talk about central and peripheral sensitization, but the point being one of them causes more reaction to thermal sensitivity, locally in the periphery, less so for the other one.

Til Luchau:                         Okay. I’m going to try to bring myself and you out of the weeds here. It’s so easy to get into these little cool details about stuff. There’s one more point that I wanted to make about causes. Tendons don’t like compression. This seems to be the, again, the consensus amongst a lot of researchers these days. They don’t like compression.They don’t like angular pressing on them. They do like load. They do like tension. They do like to be tightened or loaded up with either a stretch or especially an effort. So a longitudinal load seems to, tendons respond well in their healing and their sensitivity normalization. They don’t like to be squeezed, compressed or angularly poked on.

Whitney Lowe:                 So, can you give me some anatomy examples maybe of something where tendons would be under compression? Because that’s not something that we think about a lot. Maybe other than the obvious, like supraspinatus tendons getting compressed underneath the chromium process but there’s other things that seem to be pertinent as well.

Til Luchau:                         Hamstring tendinopathy is where you’re sitting on your hamstring attachments, you’re sitting in your hamstring tendons and just that sitting is a compression load on those, sorry, compressive force on those tendons that they don’t like apparently. If they do it too much then that keeps them irritated. That’s one reason that hamstring tendinopathies are so hard to recover from because you’re always irritating them with the sitting on them.

Whitney Lowe:                 Yeah. I think, and I had been looking at one of the, we probably were looking at the same paper that was talking about the compression factors in tendinopathies and I thought this was really interesting. They were giving some anatomical examples of places where tendons are kind of bow strung across a bony prominence during a particular movement and that causes both compression and tension forces on those tendons.

Til Luchau:                         That makes sense to me. I’ve heard that concept but I didn’t remember reading it. I was looking at [inaudible 00:22:19] 2016 for this. He says it’s the biggest single factor, compression is for tendinopathies.

Whitney Lowe:                 Really?

Til Luchau:                         Yeah.

Whitney Lowe:                 Huh. So I’ll tell you what, I’ll go, let me see if I can find that particular paper so we can make note of it and we will make sure it put that in the show notes and in the meantime it is time for our halftime, sponsor’s message.

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Whitney Lowe:                 All right, great. Back from our halftime sponsor message there and thank you to Books of Discovery for that message and right before our break, I was mentioning something about compressive forces on the tendons and I did look that up during the break and that actually was also one of Jill Cook’s papers and we will put that in the show notes.

Whitney Lowe:                 That paper was called, Is Compressive Load a Factor in the Development of Tendinopathy. So there’s some really good anatomical discussions in there about things that are likely to cause those tendon disorders. Now of course when we talk about how these tendon disorders have come up, our big concern, what most of us want to hear about is, well what can we do about it? So tell me a little bit about what you think is the role of manual therapy in addressing tendon disorders.

Til Luchau:                         Oh geez. Okay. Put me on the spot because there is a lot of controversy about that too. It’s an interesting topic because a lot of people [inaudible 00:24:09] massage therapies. I know structural integration people too in the early training are often taught don’t work on it if it’s inflamed, if it has some of these signs we’ve been talking about, especially the swelling, redness, that kind of sensitivity that gets worse with use, instead of overuse, then-

Whitney Lowe:                 Which poses a challenge for us, I think because so many of these tendinopathies even when there is an inflammatory process present, it’s a really low level inflammatory process and not often easily identifiable through our usual methods of identifying that.

Til Luchau:                         Well, even if we were the kind of person that follows the rules, which I have to confess I’m not always then yeah-

Whitney Lowe:                 You’re rule breaker.

Til Luchau:                         Then finding, does it fit the classical inflammation science is challenging but being a rule breaker, turns out that sometimes when you work inflamed things they get better, although it’s a really high risk maneuver. I’m not recommending that here because there’s a lot of considerations. So even direct work like fairly deep work can help inflammatory conditions or degenerative conditions under the right circumstances, but it’s not the first line of approach at all.

Til Luchau:                         There’s, like I said, a lot of considerations about your skill, your training, the client’s overall health and resilience, all those kinds of things. Still, there are a lot of approaches that treat tendinopathies pretty directly like the Cyriax model, like Gua sha, like different things that get in there, or Graston to get in there and just really aggressively work inflamed areas to try to make them better.

Til Luchau:                         The strange thing is, in spite of some of the horror stories and scary things that you’ll see on the internet, if you Google any of those to look for pictures, they do seem to help some people. People will get better sometimes after skilled, careful direct work.

Til Luchau:                         Now the theory there is that maybe we’re rebooting an inflammatory process, that’s one of the theories. Each of those methods I mentioned has their own theories and mechanisms they propose but the one that makes the most sense to me is that direct work can sometimes reboot or restart an inflammatory cycle that’s been stalled out. Because inflammation is good, it’s when it doesn’t resolve that it’s bad.

Whitney Lowe:                 Yeah. I know when I was originally taught ideas about treating tendinitis problems, and this was back in the ’80s, our model that we were going by was this idea that you’re getting in there and realigning scar tissue on torn tendon fibers when you do deep friction applications. We do know now there’s all kinds of problems with that idea that really don’t make it as plausible, but people get-

Til Luchau:                         We’re not sure this, I’m going to jump in. We’re not sure that we can break it up and we’re not sure that it reorganizes as it heals. But no, we were taught the same thing as Rolfers. Let’s get in there and reorganize it.

Whitney Lowe:                 Exactly, yeah. Then the question comes up, well maybe if there’s not as many torn tendon fibers in there and again, there’s still other questions about how much could we really reorganize microfibers that small with what we’re doing with manual pressure on some of those tendons.

Whitney Lowe:                 What we do know is that people, like you said, lots of people get better when we do that. So what’s really happening? There has been, I don’t think, by all means, the jury’s not out or the jury is still out on this in terms of what the real answer is but there has been some indication that pressure and movement on a tendon stimulate fibroblast activity that help in the collagen rebuilding process. Maybe that’s what a lot of this is really about is about the stimulation of the collagen rebuilding process.

Til Luchau:                         Or that fibroblasts, from an inflammatory point of view, that in fibroblasts help regulate inflammation. Maybe they’re building fibers, they are, but maybe their activity actually modulates the inflammation. That’s the other possible component in there. Anyway, there’s some more about manual therapies role that I wanted to mention, that a lot of this stuff normalizes sensation.

Til Luchau:                         The jury’s out as you said, on the actual tissue effect but what we know and agree on is that when you get good touch, whether it’s light touch or deep touch, it’s helping you refine your proprioception and it’s helping your brain and central nervous system calm down a little bit around what you’ve been experiencing as pain. So a lot of the manual therapies role is probably in that sense. We’re probably getting the brain used to sensation there in a way that it doesn’t have to protect against so much.

Whitney Lowe:                 That’s also still a really important factor in the rehabilitation process because there’s several other things that I had been reading about changes in sort of our perception about tendon treatments have indicated that, well some of the stuff that we’re doing may not necessarily be changing a lot of tissue construction properties per se, but the pain management process really helps the body be able to get to a place where the rebuilding can really recur.

Whitney Lowe:                 So like in the tendon regeneration process, a lot of what’s really important is that in these chronic overuse tendon disorders, a lot of collagen rebuilding builds around the damaged tissue and doesn’t necessarily repair what’s there, but it sort of strengthens and builds stuff around that. Have you run across that discussion as well?

Til Luchau:                         Well, Jill Cook, again, my biggest source on that, she says no, it’s, once you’ve got that degradation or degeneration, there’s not really good evidence that it does thoroughly get back to how it was before. You do get repairs. The repairs are typically with type three collagen, which is stretchier and not as structural as the type one collagen it was originally, and that that structural propensity, she says in her structural view, leaves it vulnerable to feeling pain again later. Now she sees movement and exercise and loading as being the way to prevent that. If you keep moving, you keep loading it, then it keeps it, even if it has undergone an injury keeps it less sensitive over time. And so there is hope there.

Whitney Lowe:                 Yeah, and there’s certainly been a lot of emphasis on eccentric loading of those tendons as an important part of the rehabilitation process. And I think there’s still some debate about why is that particularly beneficial. But there is a fair amount of evidence that does point to that being helpful and beneficial. And I think the important thing really, the big takeaway that I see from this is, Greg Layman has a great quote that he said a number of years ago and he’s put that out in some of his article and reference material about dealing with… And this really is true for soft tissue problems all over the body in all kinds of instances. And he says basically, “Most of our rehab work can be boiled down to a really simple statement, which is calm shit down and then build shit back up.” And that’s really what we’re all trying to do here.

Til Luchau:                         Greg Layman, he’s really using the tendinopathy research as a model for a lot of his work with pain throughout the body. He’s really saying that, “Yeah, when we calm it down and build it up, that we’re actually helping people get back to function and we can do that in simple ways. We don’t have to get so complicated about it.” He’s got some interesting things to say. I got a couple more things about manual therapies roll. Should I get back to that?

Whitney Lowe:                 Yeah, sure.

Til Luchau:                         So one of them is gliding. If we get back to, again, physical possible mechanisms, there isn’t really good evidence that we’re rearranging fibers. There’s decent evidence that we change gliding with manual therapy or with other kinds of movement, retain movement between structures. And so that is relevant to say the bursitis situations or the paratenons, the wrappings around the tendons that exist everywhere whether or not there’s a synovial sheath, that those are gliding surfaces.

Til Luchau:                         And that even within the tendon there’s a kind of gliding within the fascicles that they extend kind of like a car radio antenna that they kind of have a internal intratendon gliding that is increased by a manual therapy where you can suppose, or we can at least imagine, and that seems to help people’s tendons feel better. There’s also ways that we’re probably increasing perfusion and all the good things that brings in. When you get more goodies in there, in your blood or lymph flows or interstitial flows, healing can happen more. There may be a role for manual therapy in changing golgi tendon organ regulation of that muscle’s tone as well.

Til Luchau:                         There may be a way that just helping that muscle have a lower set rate could give the tenant a break, teaches you how to relax deeper. And then in our approach, in our advanced mal facial techniques approach, we have a whole CALMS protocol. CALMS is the acronym that gives like five different ways to work with different kinds of inflammatory conditions and they probably are all useful.

Whitney Lowe:                 What’s that? Can you elaborate on what that acronym stands for?

Til Luchau:                         Oh, it’s a secret, actually. No, I’m kidding. I’m kidding. It’s not a secret, but it is, let’s put it this way, it is more of a punchline to a joke, but it, I’ll just-

Whitney Lowe:                 Okay. All right.

Til Luchau:                         It’s just real briefly, it’s client engagement, autonomic nervous system changes, liquids and hydration, movement safety, and stimulating responses. So those are the four kind of established and well-accepted ways that manual therapy can help different kinds of conditions like these.

Whitney Lowe:                 Yeah. So what I think we can really see here is there’s a plethora of ways in which manual therapy can be beneficial for addressing these types of problems. And we don’t necessarily yet know all the mechanisms of exactly why that’s happening, but we certainly do seem to have some good theoretical models and possibilities to explain why. And we do know that people get really good results from it. And then the big important takeaway here is that, this is a situation I think where it’s very unlikely that manual therapy approaches are contra-indicated for most of these chronic overuse tendon disorders. And they can really provide very good treatment approaches as long as you’re not overdoing it. So that whole-

Til Luchau:                         Did you say they’re not contra-indicated? I mean it’s okay to do manual therapy with these, is that what you’re saying?

Whitney Lowe:                 I’d say for the vast majority of them, they’re not contra-indicated if you stay within that Goldilocks zone, which is don’t do too much, but do enough to really get some of those physiological properties happening. Now, can you overdo it and over-treat somebody and cause further injury? Absolutely. I think a really badly irritated chronic overuse tendon disorder that you get down and then just crank on with manual pressure and compression and friction, whatever, you can certainly make that worse. So you’ve got to be in that Goldilocks zone of not too much, but just enough to help make a difference there. And that zone of course can differ from person to person based on history and all kinds of things.

Til Luchau:                         So important, yeah. So important and so variable. And then the other factor in there is, well, one’s pressure, the Goldilocks amount of pressure, but also the length of time you’re working on it, how frequently you’re working on it, all those kinds of things are such important things to tune and play with.

Whitney Lowe:                 Yeah. What are your thoughts on, certainly a lot of controversy these days there we’re hearing about ice applications… Is it good? Is it not so good anymore? Are we jumping off the ice bandwagon? Are we still doing it? What are your thoughts on that for these overuse tendon disorders?

Til Luchau:                         I usually claim to be an agnostic there because I don’t really use ice in my practice. I don’t have a lot of direct experience with it. And I know that there are ardent supporters and people that oppose ice’s use on both sides. The arguments against it being that if it slows down the inflammatory processes, it’s actually slowing down healing. And there does seem to be some evidence for that. There is good evidence that it’s analgesic, that it does a short term pain relief, which might be why it’s used quite a bit still in professional top level sports where they really are looking at bang for their buck. They really don’t want to use treatments that aren’t giving them a dollar return on their investments and ice is still used there. But their measure is usually return to play. They want to get people back in the game and ice seems to help people do that. Whether that’s good for longterm healing or not, that’s what the debate is about.

Whitney Lowe:                 Yeah, and I’m in full agreement with you there. I think the big things that I think personally are most beneficial with ice is really around it’s analgesic benefits right now for pain management more so than our former models or ideas about, “We need to stop the inflammation process cause it’s out of control,” sort of thing. So I think that does seem to be kind of where the trend in the rehab world is moving.

Til Luchau:                         The same thing applies then to NSAIDs like ibuprofen or pain killers that dampen inflammation. They do help short term, but maybe they don’t help with healing. In fact, there’s a window of a couple of days thereafter an injury where some people are saying, “Avoid them if you can because you’ll get that inflammatory cycle through its worst stages quicker if you’re not taking an antiinflammatory.”

Whitney Lowe:                 Yeah, that’s an interesting idea. Yeah. And then maybe think about them later on down the road if-

Til Luchau:                         If needed.

Whitney Lowe:                 When you’re in that building stuff back up process, that there is some discomfort. But again, not to the point that you’re masking beneficial pain. It’s telling you, “Hey, I’m overdoing it.”

Til Luchau:                         Yeah, or interrupting beneficial physiology that’s trying to fix you, to repair you.

Whitney Lowe:                 Yeah. Yeah. So it would be great if we came with a user manual that gave us all these explanations specifically for how to handle stuff.

Til Luchau:                         Oh man.

Whitney Lowe:                 Or could dial up technical support on our tendon pathologies.

Til Luchau:                         I think that’s what a lifetime is. It’s like the writing your users manuals and then you know at some point. Then you’re done.

Whitney Lowe:                 It is. Yeah. Yeah. Good. So, good, well I think we’ve-

Til Luchau:                         What else do you want to talk about? Other, I’ve got a couple of other effective treatments. You want to touch on about those?

Whitney Lowe:                 Yeah. Let’s hear it. Let’s hear those. Yeah.

Til Luchau:                         All right. Graded loading. You mentioned graded work like mental therapy, but it’s also important that people move and load them. It needs to be graded. People need to learn how to use their sensitive tendinopathy possibility part of their body, part that isn’t possibly has some of that going on, they need to learn how to use it in a way that’s graded and right. And that’s probably for most of the manual therapists that might not be in your scope of practice. That might be a strength and conditioning coach or physical therapist or somebody that really has that kind of background to help someone come up with routines that help them load it and move in it in a restorative way. Being the inflammation junkie that I am, resolving or addressing any systemic contributors to inflammation can help with these local tendinopathies as well. Those are the big ones. Sleep, stress, self care, movement, et cetera. Maybe, yeah.

Whitney Lowe:                 And one other thing I want to put a plug in here for too. There was some really good stuff that was written in Eyal Lederman’s book on, and I’ll have to put this in the show notes cause I cannot remember right off the top of my, his book on manual therapy, the exact title of it, but he-

Til Luchau:                         The brain, something about the brain.

Whitney Lowe:                 See if I, I was trying to see if I had it on my bookshelf here, not right in front of me. He’s got a concept in there that he talks about called function size, which is don’t get too wrapped up in having to have specific exercise movements that a person needs to be doing. Talk about what they’re doing on a daily basis that’s going to help load that thing, like unloading the dishwasher, putting away the dishes, sweeping the steps off.

Whitney Lowe:                 All of those things that are good functional movements that will put appropriate loads on those tissues in the rehabilitation process without feeling like you have to go get a gym membership and do all this kind of organizational stuff. Because what tends to happen with so many people is they just don’t do it. They don’t don’t do the movement things that they often need to be doing, but if you can really meld it into something that’s part of their daily life, that’s part of the daily activities that they’re doing, it’s far more likely to get a good degree of compliance with that.

Til Luchau:                         Can I throw in a couple more fun facts?

Whitney Lowe:                 Yeah, let’s do it.

Til Luchau:                         Val Jones, who I respect, she says… You did a review of the evidence for different treatments for tendinopathy. She says there’s actually some evidence for laser treatments, which I didn’t know, and I tend to be a laser skeptic honestly, but there is some evidence, although there’s not good evidence around the dosing for lasers. She says there’s evidence for short-term acupuncture benefit for tendinopathy, but not longterm. There is no evidence of benefits for ultrasound or electrical stimulation she says. There’s evidence for beneficial effect of taping while the tape is on, for example, but unclear whether it’s lasting or longterm. What else? Oh, my own tip, just … We’re ready for that, closing tips?

Whitney Lowe:                 Yes, absolutely. Let’s do it.

Til Luchau:                         I’d say it’s like don’t be afraid of it, but don’t keep provoking flare-ups. Watch for flare-ups. Flare-up is a sign that you did enough to stir things up. Stirring it up can be helpful once or twice in the otherwise resilient okay client, but don’t keep doing it because that won’t help it heal over time.

Whitney Lowe:                 Yeah. So these are some important guidelines I think to sort of key takeaways here that we want to think about are looking at causative factors. Make sure you take a thorough history. Get information about what might be the cause of chronic tendon disorders. Do some good physical examination to note where particular tissues might be overly pain sensitive. And then, target some of your treatments on those types of things with the variety of methods that Til had mentioned here, and those are good strategies I think to kind of keep in mind for methods to address it.

Til Luchau:                         And remember Goldilocks.

Whitney Lowe:                 That’s right, remember Goldilocks, not too much, just enough so yeah. So all right, well, that sounds like a good bit of things that we can dive into today to look at tendon pathologies and please be sure to join us again in two weeks. We’re going to be talking about scoliosis I believe. Is that where we are [crosstalk 00:41:52]?

Til Luchau:                         That’s what we get on our list unless something else catches our interest. In the meantime, that’s what we’re going to shoot for.

Whitney Lowe:                 Yeah. Okay. That sounds good. Well, we’d like to send again a big thank you to our sponsors for sponsoring the show, helping us make this available to everyone. And you can stop by our show for show notes, information on CE credit updates and any of the extras over there at thethinkingpractitioner.com. And Til, where can people find you on the web?

Til Luchau:                         Advanced-trainings.com, show notes are also there as well as information about our trainings, advanced-trainings.com. How about you, Whitney?

Whitney Lowe:                 And they can find us, information on us and training programs and other things that we’ve got going on over at theacademyofclinicalmassage.com. And as always, if you’ve got questions, comments, or would like to give us some input about things that you’d like to hear us talking about, send us a note to [email protected] You can also drop notes on our pages over on social media as well.

Til Luchau:                         Or rate us on Apple Podcasts please and wherever else you listen and then please send your friends.

Whitney Lowe:                 All right, that sounds good. So take care everyone and we’ll see you again in a couple of weeks.

Til Luchau:                         Thanks, Whitney. See you later.

Whitney Lowe:                 Okay. Take care.

 

 

Show Notes:

  1. Chen PC, Wu KT, Chou WY, et al. Comparative Effectiveness of Different Nonsurgical Treatments for Patellar Tendinopathy: A Systematic Review and Network Meta-analysis. Arthrosc – J Arthrosc Relat Surg. 2019;35(11):3117-3131.e2. doi:10.1016/j.arthro.2019.06.017
  2. Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? Br J Sports Med. 2012;46(3):163-168. doi:10.1136/bjsports-2011-090414
  3. Lederman E. The Science and Practice of Manual Therapy. 2n3 ed. Edinburgh: Elsevier; 2005.
  4. Murtaugh B, Ihm JM. Eccentric training for the treatment of tendinopathies. Curr Sports Med Rep. 1987;12(3):175-182. doi:10.1249/JSR.0b013e3182933761
  5. Lipman K, Wang C, Ting K, Soo C, Zheng Z. Tendinopathy: Injury, repair, and current exploration. Drug Des Devel Ther. 2018;12:591-603. doi:10.2147/DDDT.S154660
  6. Witvrouw E, Mahieu N, Roosen P, McNair P. The role of stretching in tendon injuries. Br J Sport Med. 2007;41(4):224-226.

 

 

 

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