Pain only tells us there is a problem.
It does not tell us what that problem is.
I often get asked "Why does my back hurt?"
Honestly? I don't know. I need to talk to you and see how you move (or how don't as is often the case!)
But it's a back? All backs are the same aren't they?
Sort of. But it's not really the anatomy that I'm interested in. It's YOU.
Treating back pain is about more than just your back!
Stop chasing pain!
"Deadlifts hurt your back".
Don't blame the movement.
Blame the way you're doing it.
If you don't lift from the hips but you bend from the back then yes you may have a few problems.
But we are designed to pick up heavy shit and carry it.
Our backs are strong. And believing that they are anything but can lead to even more problems.
Yes there are exceptions. As in everything.
But in actual fact, I see more problems with people who don't lift heavy than in those who do.
There is no bad movement guys.
Nobel Prize recipient Dr. Roger Sperry says that the spine is the motor that drives the brain.
According to his research “90% of the stimulation and nutrition to the brain is generated by the movement of the spine.”
Do we really need any more reasons to keep moving?
The human body is a self-regulating organism.
It does not just passively allow physiological crises to happen to it.
They are happening for a reason.
And more often than not it's doing it because of self protection.
It's simply saving itself. We just don't realise it.
One of the things I ask my clients when I first meet them is whether or not they suffer with any pelvic or Bowel dysfunctions. But what I'm really asking is do they have a history of recurrent UTIs (Urinary Tract Infections), Yeast Infections, IBS (Irritable Bowel Syndrome) or pain 'down below'.
This is important is you are coming to see me with any musculoskeletal issues.
Well even long after an infection has cleared or you no longer have issues with IBS because you've sorted your diet out, these issues can lead to the neuromuscular impairments that you are now having problems with.
Let me give you an example….
Nina is 29 and has a history or recurrent UTIs. This then causes her bladder and urethra to become inflamed. This results in urethral burning and pain in her lower abdomen.
This in turn causes the connective tissue around her urethra, the muscles in her lower abdomen and the muscles in her groin to become restricted. Hence more pain.
As it's a UTI it makes her feel like she needs to 'go' all the time. But she can't because she needs to work and so ends up 'holding' or clenching herself in order to ease the feeling of urgency.
This clenching causes so many of her muscles to become tight resulting in lack of blood flow and possible 'Trigger Points' (small, taut areas of painful, involuntary contracted muscle fibres).
Even after the infection has cleared, the resulting neuromuscular impairments can still exist. And strangely enough they can actually mimic the symptoms of the infection too!
Usually in cases like this it's not just one episode of infections but severe infections that last a long time or are recurring events over a number of years.
So again, when I ask you about your pelvic and bowel health there is a reason for it…I promise!
"Your neck is crumbling"
"You have degeneration in your spine"
"You have 10 years to live" (which was an incorrect diagnosis)
"You'll end up in a wheelchair"
"You need to be careful"
"You need to protect your back"
Holy shit, I swear not only do I cringe every time a client tells me what they have been told by other Health Care Professionals but I get SO angry!
Where the hell is the 'care' when making them absolutely petrified to move, to live.
So much evidence is coming out that pathologies do not indicate that there will be pain, dysfunction or a reduced quality of life.
And in fact, causing people to fear their body and how they move will have a more detrimental impact on their health, wellbeing and life than any pathology ever will.
At the end of the day, sticks and stones may break bones but words can hurt forever.
Think before you say something that may change the course of someone's life!
I always feel lucky for being able to spend as much time with my clients as I need to. And I believe that's important.
Because after all that I’ve learned about the body, biomechanics, and everything physical, there is one guiding principle that I appreciate more than anything else… if we feel safe, cared for and in control, we do better. That means in critical moments such as injury or disease, or generally throughout our lives, being treated as an individual is what matters. Being listened to. Being taken seriously. And having someone take the time to understand what is going on, is what matters.
And when we are treated this way, we feel less pain, less fatigue, less sickness. Our immune system works with us instead of against us. Our bodies ease off on emergency defences and can focus on repair and growth.
Being given confidence and hope can mean more to someone's future and healing than the physical treatments. It might sound 'new age'. But our mind is more responsible for our health than we still give it credit for.
Do you know what percentage of the average adult population has degeneration on their neck on their x ray?
98% of people have arthritic changes in their neck and have no pain.
So how can we possibly know that the pain in someone's neck is due to arthritis?
Watch the full video here…
Fibromyalgia (FM) is a musculoskeletal pain condition that is characterised by chronic widespread pain and increased pain sensitivity. It's also often accompanied by sleep disturbances, fatigue, memory problems and psychological issues and it is more common in women.
It used to be believed that FM was essentially an idiopathic (no known cause) or even psychogenic (having a psychological component) condition.
However thanks to current research these should be seen as definitively outdated.
Recent research has shown that there is evidence of both systemic inflammation and neuroinflammation in fibromyalgia patients. This is the first time that such an extensive inflammatory profile has been described for FM patients and means that FM seems to be characterised by biochemical changes in the body.
So in addition to hyperexcitability of the nervous system and issues with regulating the sensitivity of the body, chronic inflammation probably plays a role in fibromyalgia.
So if it is a Chronic Inflammatory Condition will nonsteroidal anti-inflammatory drugs (NSAIDs) work?
The researchers concluded that although the results of the present study point to the importance of chronic inflammation in FM, it is important not to jump to conclusions concerning the use of NSAIDs in this pain condition. FM being a chronic condition, it is important to ponder the potential side effects of long-term NSAID use.
The other thing to note is that as most FM patients are women, the possible relationship between inflammation and levels of ovarian hormones in FM patients is also something to think about.
A client I had came to me with disabling pain in the arches of her feet. She found that resting helped but the pain would start as soon as she started walking again. Even a short distance would cause the pain to come back.
Although she wore heels for work a lot of the time and many people were telling her that they were causing the issue, when she did change to smaller heels they actually made things worse!
She felt so upset as she was wanting to get back in to her running (which she had stopped 6 months previously as she thought that could be the cause).
When we assessed her lower legs we found that there was an extreme limitation in her range of motion.
And so her homework was to apply Soft Tissue Releases (self-massage or trigger point therapy) twice a day as well as stretches throughout the day in order to help with her foot pain.
We discussed how the limitations in her calves can cause foot pain and that often where the pain is, the cause is not.
After a few days, pain stopped being a problem and she was actually able to wear smaller heels with no issues (which are better for her body).
So if you're having issues with foot pain give these a try and see if they help*
*If it doesn't or the it keeps returning then there may be something else going on such as a leg length discrepancy, pelvic issues or even a shoulder problem that will be worth getting checked out.
Here are the 10 key concepts from Explain Pain Supercharged extracted by Lorimer Moseley and David Butler. Explain pain is a life changing book for those of us helping people in pain.
1. Pain is normal, personal and always real:
All pain experiences are normal and are an excellent, though unpleasant response to what your brain judges to be a threatening situation. All pain is real.
2. There are danger sensors, not pain sensors:
The danger alarm system is just that there are no pain sensors, pain pathways or pain endings.
3. Pain and tissue damage rarely relate:
Pain is an unreliable indicator of the presence or extent of tissue damage - either can exist without the other.
4. Pain depends on the balance of danger and safety:
You will have pain when your brain concludes that there is more credible evidence of danger than safety related to your body and thus infers the need to protect.
5. Pain involves distributed brain activity:
There is no single 'pain centre' in the brain. Pain is a conscious experience that necessarily involves many brain areas across time.
6. Pain relies on context:
Pain can be influenced by the things you see, hear, smell, taste and touch, things you say, things you think and believe, things you do, places you go, people in your life and things happening in your body.
7. Pain is one of many protective outputs:
When threatened the body is capable of activating multiple protective systems including immune, endocrine, motor, autonomic, respiratory, cognitive, emotional and pain. Any or all of these systems can become overprotective.
8. We are bioplastic:
While all protective systems can become turned up and edgy, the notion of bioplasticity suggests that they can change back, through the lifespan. It is biologically implausible to suggest that pain can't change.
9. Learning about pain can help the individual and society:
Learning about pain is therapy. When you understand why you hurt, you hurt less. If you have a pain problem, you are not alone - millions of others do too. But there are many researchers and clinicians working to find ways to help
10. Active treatment strategies promote recovery:
Once you understand pain, you can begin to make plans, explore different ways to move, improve your fitness, eat better, sleep better, demolish DIMs, find SIMs and gradually do more.
As a Therapist, "It's Going To Be Okay" may be the most powerful words you will ever use.
Belief and hope are powerful treatment tools. Don't ever underestimate them!
The majority of people that come to me with pain will involve some kind of neuromuscular problem. This means that there is an issue with the muscles, the nerves and connective tissue as well as the adjacent areas. And so it is essential for me to have a good understanding of these issues as well as how best to treat them.
However, in addition to uncovering and treating whatever neuromuscular impairments are driving a client's symptoms, I believe that it is also vital for me to work with my clients so that can we figure out what OTHER systems might be involved with their pain.
This includes looking into nutrition, sleep, stress, lifestyle, behaviours, thoughts and feelings, hormonal health and so on.
Sure, it's a big time commitment (which is why my initial appointment can take up to 2 hours). Yes it would be easier to just treat the painful area and send them out the door. But what I've observed in my practice is that if you want to successfully treat a person for the LONG TERM then at the end of the day, it's what works. I'm not looking for a quick fix. I don't want to have to see my clients on a regular basis*. I want to educate them on how THEY can look after their own body.
*Yes there are some clients that need regular attention. But these are exceptions and not the rule!
According to The Concise Book of Trigger Points, issues with the Quadratus Lumborum (a deep 'core' muscle responsible for side bending) can lead to symptoms such as:
Holy moly? Seriously?
Actually I can agree with a number of these especially as it's an area I can have trouble with (if I sit too much or neglect my body/ movement).
Using Tennis balls is a great way to help with Trigger points/ low grade muscle spasms. Just ask my clients who have a love/ hate relationship with them ;-)
Check out this video to find out how to release the QL:
I cannot tell you how many times I see people working on the elbow when the elbow hurts.
If you have been suffering with elbow pain try looking at the bigger picture (especially if you have been trying to resolve the issue by dealing with the site of pain….and it's STILL not helping).
After all, the body does not work in isolation.
Maybe the median nerve is tethered or 'tight' which is causing the muscles around the forearm to tighten causing elbow pain.
But then maybe the pec minor is in spasm causing the median nerve to feel 'tight' in the first place.
But then again, maybe it's not the pec minor's fault.
Maybe the QL is not happy which is causing a leg length discrepancy that leads to issues with the pec minor.
So then it's the QL's fault?
Maybe. Or maybe not.
All I do know is that your body does not think in parts so neither should you.
Just because the elbow is painful does not mean that's the cause.
Stop chasing pain and look at the bigger picture.
According to the article (link below), couples can calm each other down, synchronising their breath and even brainwaves and heartbeats, just by being in each other's presence (it can also happen when people sing together or watch a movie together).
Some other interesting points...
⁃ Touch is vital for premature babies
"Researchers also know that skin-to-skin touch not only provides comfort, it contributes to the development of premature babies and helps to regulate their stress response."
⁃ Touch can help partners deal with pain
"The subjective pain ratings were lowest when the partners held hands and highest when they were separated. Their heart and breathing rates also synchronised when they were in the same room together, but when pain was introduced, they only stayed in sync if they were touching; if one was subjected to pain and the partner couldn't touch them, they dropped out of sync, returning again if they were allowed to hold hands."
⁃ Pain is not about damage but about protection
"It was not that long ago that people thought pain was the signal that was sent from the body to the brain," Moseley said. "We now know that pain is a conscious event that serves to protect you, so if you have any safety cue at all it will reduce pain – if it's an effective safety cue. And that's a really potent safety cue having somebody who loves you and who you love holding your hand during a situation where you're getting a lot of danger cues from your body."
⁃ Pain depends on danger and safety cues
"Ultimately pain will depend on the balance between your danger cues and your safety cues. I think the most exciting discovery in pain in the last 20 years is that we can change pain with a whole range of danger and safety cues."
⁃ People with persistent pain can benefit from understanding what exactly pain is and what causes it (not JUST that something is wrong or damaged)
⁃ Pain is gobsmackingly complex. But we shouldn't underestimate the power of care and caring touch
"It's a protective response and if you've got any information telling your brain that the need to take protective action has been reduced, for example you've got a loved one who's in it with you, sending powerful sensory cues through your skin, through a system that is gobsmackingly complex and fearfully and wonderfully effective, so don't underestimate the power of care and caring touch. It's a powerful thing."
Read the full article here:
k here to edit.
Although many people are familiar with the Pec muscles, what they often don't realise is that there are actually 2 of them. The Pec major is the large one that you see blokes in the gym tensing in front of the mirror after working them on a Friday evening before going for a night out ;-)
The pec minor however doesn't get quite as much publicity as it hides completely underneath the pec major. It also has a very different orientation and attachment points which means it does a completely different job to Pec Major.
That being said, although it is a smaller muscle, it can still be very strong and thick.
The Pec minor attaches to the coracoid process which is an odd little piece of the shoulder blade that sticks out through to the front of the shoulder. It then attaches at the other end to 3rd, 4th and 5th ribs.
So where as the Pec Major is responsible for moving the arm, the job of the pec minor is to pull down on the coracoid process (on the scapular) and to fix the shoulder blade in place whilst the arm then moves. It also moves the scapular downwards.
So you can see that the pec major and pec minor (despite having similar names) actually do very little together. That being said, they are so close to one another and being aware of fascial connections, you really can't move one without moving the other.
But did you know that the pec minor also has another job? Of course it moves the scapula. But remember it is also attached to the ribs so it also plays a part there too. The pec minor pulls up on the ribs to help to expand the chest during breathing, especially during forced breathing such as during high intensity activity, coughing, or sneezing.
This means that when we over-train or have a persistent cough then the pec minor can sometimes become shortened and irritated, leading to pain in the front of the shoulder, referred pain to other areas as well as many other symptoms occurring.
So as the pec minor tightens this can then cause compression of the arteries and nerves just under it. This then causes a restricted blood flow to the arm and hand as well as the pressure on the nerves causing tingling and numbness. When this happens it can often be mistaken for Carpal Tunnel Syndrome.
As the pec minor shortens it can cause a rounded shoulder position. This can then cause a dull ache in the midback due to strain on the posterior muscles. It can also cause a restricted movement in the shoulder when reaching up.
The opposite can happen too. If we constantly sit with our shoulders rounded (as we often do at the computer or at our desk) then this can lead to the Pec Minor becoming shortened. After all, just as structure dictates function, so can function dictate structure.
Trying to stretch this muscle in the traditional sense is usually useless as this can also place more compression on the nerves and blood vessels. And if the muscle is in a shortened protective state for a reason then it's not going to give up it's position lightly.
Instead try using Muscle Energy Techniques or Trigger Point work to release the Pec minor as in the videos. Completing these daily as well as developing strength in the upper back can often may a huge difference.
WHAT IS IT?
The greater trochanter is a bony prominence at the top of the femur (thigh bone) that can be felt under the skin. There is a bursa (a fluid filled sac that eases movement between the bone and other surfaces) situated over the bone and beneath the gluteus maximus muscle. When this bursa becomes aggravated by overuse, it becomes inflamed causing trochanteric bursitis.
EARLY STAGE MANAGEMENT AIM:
IMMEDIATE ADVICE AND TREATMENT:
EXERCISES THAT CAN HELP INITIALLY:
These isometric exercises can help to reduce pain whilst strengthening the muscle. They can also help to reduce any tension within muscles that are tight around that area.
My name is Sarah and I am a (self-confessed) geek. Actually thinking about it, does it still count as self confessed if everyone else knows you’re a geek too? Probably not.
Anyway I digress.
I've been asked on numerous occasions for a list of books, courses, blogs, etc that have shaped how I think and what I do.
So I decided to put out some posts to cover exactly that. (I’m sure there are fellow geeks out there who will appreciate this ;-)
And so I have decided to start off with books that have changed my life. These are in no particular order, literally just the books that come to mind first (or are always there for reference).
They are also not just related to Biomechanics or the body but have helped me develop in so many different ways that I feel the need to share these too.
Here we go...
Book Recommendation #1 : Explain Pain by David Butler and Lorimer Mosley.
"All pain is real, and for many people it is a debilitating part of everyday life. It is now known that understanding more about why things hurt can actually help people to understand their pain.
I simply cannot recommend this book highly enough. It changed the way I think, the way I work with clients, the way I see things in my work and in my life.
It's an essential read for anyone who works with people in pain as well as people who live with pain on a day to day basis.
Actually scrap that, it's an essential read for EVERYONE!
The book itself is a pretty hefty price but it's worth every penny!
There is also a 'Supercharged' version now too although I haven't read a copy of that but it is definitely on my list of books to buy in 2018!
I understand that there are lots of you who are planning on racing this year for charity.
Which means that you're going to want to be as physically fit to withstand the pressures that training puts on your body.
So I have decided that it may help if I offer you some incentive to look after your body SOONER rather than later.
You see, each year I get so many people right before their events that have become injured, when had they seen me earlier they could have prevented a lot of the pain and stress.
So, if you are booked in to race for charity and you book an assessment or massage with me in January or February then I will give you £10 back for you to put in your charity fund.
How does that sound?
It's difficult helping people when they come to me a week before their event with an injury that they have had for months. If you've got issues now, get it sorted NOW!
Know anyone else who would benefit? Let them know!
Infraspinatus. Meaning "below the spine"
Along with the other rotator cuff muscles, the Infraspinatus is responsible for keeping the head of the humerus in it's socket. And because of this extremely important job, the infraspinatus is possibly one of the most frequently afflicted muscles of the body.
Now the crazy thing is that despite being located behind the shoulder on the scapula, the infraspinatus trigger points actually cause pain in the front the shoulder and quite often feels like it's deep in the joint. It may also travel some distance down the arm as far as the forearm and entire thumb-side of the hand as well as up towards the upper back and neck. The pain can be excruciating.
You may also feel weakness and stiffness in the shoulder which can mean that your arm tires easily. You may have problems reaching behind your back (bra?) and sometimes even reaching behind your head (hair?). Lying on the shoulder can be painful but lying on the opposite shoulder can be worse as the weight of the arm pulls on the infraspinatus even more. Stretching also makes things worse.
Often issues with the infraspinatus can be misdiagnosed as biceps tendinopathy, frozen shoulder, impingement or bursitis.
So what causes problems in the infraspinatus?
Strengthening the infraspinatus (and the other rotator cuff muscles) becomes imperative to avoid reoccurrence which is why massage and strengthening go hand in hand.
Sitting with your legs crossed is bad for you
So yes, sitting crossed legged can create changes that are not always beneficial. That being said, when you look at the research even more, the problem is not really sitting cross-legged, the problem is sitting in ONE position for long periods of time. So sitting in ANY position for too long can cause problems, not just cross legged. What we really need to do is MOVE more often. And if we do have to sit, changing positions regularly is going to be the most beneficial.
You may have come across the terms TENDINOPATHY, TENDINOSIS or TENDINITIS in the past. Maybe you were diagnosed with one or you have heard friends and family being diagnosed. Or you have patients or clients who have come to you with these issues. But what exactly do these terms mean? And what can we do about them?
Well after listening to Jill Cook talk on Physiopedia and then continuing to do a little more research, I've managed to put some information together to help us to understand these conditions in more detail.
SO WHAT EXACTLY IS A TENDINOPATHY ANYWAY?
Well by definition it is “Pain and dysfunction in the tendon”. However this is a term that is often used incorrectly most of the time. This term is actually a clinical diagnosis ("The estimated identification of the disease underlying a patient's complaints based merely on signs, symptoms and medical history of the patient) because we cannot get into the tissue to see if there is degeneration in the tendon to get pathological term (which is based on a laboratory examination or medical imaging). Hence why we go for the clinical term that does not rely on knowing what is actually happening in the tendon but rather how it affects the patient.
Therefore, put simply, Tendinopathy is an umbrella term for someone that presents with pain and dysfunction in the tendon. And this is perfect, because according to research, understanding what is happening within the tendon is actually not that important after all.
What I mean by this is that there are quite a few studies that show that structure does not change very much with treatment but patients actually lose their pain and become much more functional.
This is important to remember which is why I want to say it again…
Patients become more functional and in less pain despite nothing major happening to the structure of the tendon. Therefore again, structure is not that important but it's how the patient feels and can perform, that is important.
SO WHAT IS THE DIFFERENCE IN TERMS OF THE NAMES THAT WE COME ACROSS?
Well, TENDINITIS implies inflammation (-itis means inflammation). However research states that there is very rarely inflammation apart from in the acute stage.
TENDINOSIS means degeneration in a tendon (the state or process of decline or deterioration).
However, according to the Cook and Purdam Model (2009) there are stages that a tendon goes through before becoming a degenerative tendon. This means that Tendinosis usually reflects that end stage disease where the collagen is disrupted.
IS THERE ONLY ONE MODEL TO DESCRIBE TENDON PATHOLOGY?
No this is not the only model out there. I think there are roughly 7 other models of tendon pathology about. But I like the Cook and Purdam model. It just makes sense to me.
LET'S EXPLAIN A LITTLE MORE ABOUT TENDON PATHOLOGY….
Now it's important to note that Tendon pathology is not a single disease. It is not JUST about degenerative tendons. As the model states, there are stages that the tendon goes through before ending at that degeneration. And it's actually these other stages that we come across more often.
So firstly there is REACTIVE TENDINOPATHY. This is actually a cell based response where by Proteoglycans (specialized protein molecules that are found around cells and in the joints of our bodies) disrupt the matrix (which is a collection of molecules that are secreted by cells that provides structural and biochemical support to the surrounding cells)
SO IS REACTIVE TENDINOPATHY A PATHOLOGICAL CONDITION?
Yes this is pathological because there is enough matrix change and cell change to actually cause pain. There is also enough change that we can see it on an image, you can actually see the changes in the tendon. But the good news is that it is reversible. So any changes are not absolute to the tendon.
WHAT SETS OFF THE REACTIVE STAGE IN A TENDON?
Load. Or more accurately, OVERLOAD. There is no doubt that nearly every tendon presentation to a clinician or therapist will be traced back to an overload of some description. Therefore if you unload the tendon then it can reverse in the reactive stage.
SO DOES THE TENDON GO THROUGH ANYTHING ELSE BEFORE BECOMING REACTIVE?
Actually there is some research that shows earlier stages than reactive tendinopathy where we see transient change in tendons (meaning that it lasts only for a short time and is impermanent). And again knowing that tendons respond to load, if we unload them at this first stage then we can sometimes recover within hours to days. This stage isn't reactive it is simply an adaptive part of a load response in tendons. Which means that this Transient stage is NOT pathological but a reactive tendinopathy IS pathological.
SO WHAT HAPPENS IF WE DO NOT UNLOAD THE TENDON?
If we do not unload the tendon, if we strap it up, take ibuprofen and continue to do whatever it is that is causing the problem in the first place then the condition continues to progress which means the cell and the proteoglycans will continue to disrupt the matrix. The more disrupted the more the stages are progressed. Therefore the level of matrix disruption will determine whether it is in the REACTIVE stage, DYSREPAIR stage (dys- meaning abnormal, bad or ill) or a DEGENERATIVE stage. The more matrix disruption the more it moves from Reactive to Dysrepair to Degeneration.
WHAT HAPPENS IN THE DEGENERATIVE STAGE ?
The Degenerative stage is where there is a substantial disruption of the matrix. And chances are that it has been there for months to years. Sometimes many years. (Although occasionally they do develop in less than a year). However there is not much research on how long it takes for a tendon to become that disorganised.
So in the Degenerative stage the matrix is disorganised, the collagen is no longer parallel, there are different types of collagen in the tendon and it becomes 'mechanically deaf'. Which means that we cannot load collagen that has no structure as it is not load sensitive. And once the tendon enters this stage it's pretty difficult (if not impossible) to reverse that change once it has occurred. But please don't panic because this is not something we need to worry about. Recent research by Sean Docking's show that this is something we adapt to (but that’s for another post!)
The one think to note is that if we have a truly degenerative tendon then chances are we're actually not going to have many problems simply because they tend not to be painful. Again the Degenerative area is mechanically silent or 'deaf' and so does no longer respond to load and so do not get pain the same.
WHAT CAUSES THE PAIN?
Now when it comes to pain, as we have discussed so many times on this page, the cause really is the great unknown!!
However one thing that we can tell from limited research is that pain in a tendinopathy is probably due to substances produced by the cells that are activated by the overload. So as the tendon becomes overloaded the cells respond to this overload by producing substances. These substances then stimulate the nerves that drive the nociception ( which is the sensory nervous system's response to certain harmful or potentially harmful stimuli).
But as we already know, pain is a super complex subject so there will be so many other factors involved too.
SO BACK TO DEGENERATIVE TENDONS…
In degenerative tendons the normal part of the tendon that IS tolerating the load is doing very well (you will have 'normal' parts even if you have a degenerative tendon). So people with degenerative tendons will often have lumpy bumpy tendons and may have had a bit of pain occasionally, but they don’t present as pure degenerative tendons because there is no reason for them to come in as they are not painful.
BUT WHAT IF THE 'NORMAL' PART OF THE TENDON DOES BECOME PAINFUL?
Well this is what is referred to as a REACTIVE ON DEGENERATIVE. This is where a degenerative tendon is overloaded and the normal part of the tendon that is left actually becomes reactive.
Therefore we know that the degenerative area is what is described as 'mechanically deaf' meaning that it does not change its structure very much, but that we DO get a reaction in the normal part of the tendon (which is why discussing the reactive stage is so important).
Now you should be able to understand that is why we're only going to have problems with Reactive tendons and the Reactive on Degenerative. We won't have much trouble with just Degenerative Tendons.
HOW LONG DO THESE TAKE TO SETTLE?
So on one end of the spectrum, a true reactive tendon will mean that a patient may come in with extreme pain. These tend to be younger athletes who have had an abusive overload causing the tendons to become really swollen and sore. These settle much more slowly than Reactive on Degenerative tendons and can take somewhere between 4-8 weeks to really ease up.
And on the other end of the spectrum you have reactive on degenerative tendons which tend to happen in older people (Although yes they can happen in young as you can actually have Degenerative tendons at a very young age but generally tends to be someone who has had a lot of load on their tendon over the years). The overload that they have done is not as dramatic as our Reactive tendons (usually) and they tend to have had a history of tendinopathy. These settle much more quickly than Reactive tendons and will really become a lot less painful in somewhere between 5 and 10 days.
Therefore if the patient has rested for a week and comes back feeling better then you know that is a Reactive on Degenerative tendon simply because a reactive tendon won't settle that quickly.
SO WHAT SHOULD WE DO IF SOMEONE HAS A TENDINOPATHY?
Well in a true Reactive Tendinopathy, again because they are (usually) young and because it’s a new injury, we can recover it but we need to unload them from whatever caused the problem in the first place.
But one of the critical things about treating tendons is never to rest them completely. That being said it's also important to maintain a load that is not going to irritate the tendon. This is why Isometrics (Muscle energy techniques that I share a lot on my page) are brilliant. All of a sudden we have an exercise tool that we can use in the painful tendons, that work well with the tendons. It means that we can therefore look to settle pain with an isometric load and still continue to keep SOME load on the tendon.
We also need to make sure that they are taken off the high level energy storage loads that usually create the problem (running/ sprinting/ box jumps/ double unders/ etc) and monitor how many times a week they are active. Simply put, we need to really make sure that we pull the load down just under the capacity of the tendon (without the tendon flaring up!).
In our Reactive on Degenerative ones, they will settle relatively quickly so you don’t have to do very much to settle them. Again as above, reduce the load (probably for a few days). But what you do have to do after that is then improve the capacity of the tendons (make them stronger) so that simple overloads don’t keep stirring them up. So to stop this happening again we need to build the capacity in the tendon so that any load that we do is under their capacity. So it's about maintaining the balance between what the tendon is capable of tolerating and the load that we put on it.
WHAT ABOUT ECCENTRICS?
Now eccentric exercises (focusing on the lowering phase of a move) have been all the rage for years when dealing with Tendinopathies. But where do eccentrics come in these days?
Actually it seems that it depends who you ask. But if did maybe ask Jill Cook, who is one of the leading experts to pay attention to when it comes to Tendinopathies, she believes that eccentrics come "nowhere in isolation".
She also states that we should use isometric exercises (where there is no movement during contraction) for pain relief and to release cortical inhibition. Then we use isotonics which have an eccentric component to it, then use fast exercises which is more towards energy storage (which is probably a faster eccentric load). Then she suggests moving on to energy storage and release loads (which are the loads that really affect tendons negatively). But we should never isolate eccentrics anywhere along the treatment spectrum.
The important thing is that if we are aiming to return capacity to the tendon then basically, Eccentrics alone just won't do it. After all, we can't expect to be able to sprint if all we have trained to do is slow eccentric exercises. Otherwise we're asking a muscle and tendon to tolerate sprinting after we give it slow steady exercises. Let’s face it….it just won't do it (and it doesn't make sense). We actually have to train it to do the loads and to tolerate the loads that we want to put on it. After all, I can't think of too many sports or activities that use JUST eccentrics, can you?
SO WHAT PROGRAMME DO WE NEED TO FOLLOW?
Unfortunately, there is not a recipe programme because every person with a Tendinopathy is going to be different. We can't treat an old lady with Achilles soreness the same way we treat a young athlete with Achilles tendinopathy. Again we simply cannot have one go to programme.
We need to give exercises specific to an individual person and the demands that they place upon their tendon. This is where we want to end up. But we’ve got to progressively increase the load from what the person is able to tolerate, what the tendon is able to tolerate when we first see them and gradually increase the load up to what the person needs to be able to tolerate when they are returned to their chosen sport or activity.
So that’s what we need to find out. What can the person currently do? And what do they need to be able to do? Then we'll go from A to B over a period of weeks to months. Of course that progression will be different for every single person because everyone is different, which is why we need to be taking into account personal circumstances, presentation and risk factors.
But please note that this is all about building up the capacity of the tendon GRADUALLY. It's also where the Acute:Chronic Workload Ratio created by Tim Gabbett comes in perfectly to allow us to do this with less risk of injury. But again that's another post.
WHAT ABOUT IMAGING? ULTRASOUND? MRI?
Again according to Jill Cook, so many of us are far too dependent on pictures. And as already discussed above, structure doesn’t make a big difference in how we should be treating Tendinopathies especially with those people in the degenerative spectrum.
So even if someone presents with horrible looking Tendinopathy on their ultrasound or MRI, the treatment shouldn't really change that much. It's more important to assess the patient well, working out what they want and then developing an individualised programme to reflect their goals.
HOW SHOULD WE TEST OR ASSESS A PATIENT?
This one is simple. We need to assess their function, particularly their high end function. Their tendons will be strained by energy storage and release loads so we need to look at how good they are at that.
All of this is so critical to assessing and then managing a tendinopathy. As discussed above there is not much point in looking at the pictures and there is no point in poking the tendon as neither of those can give us anything that we can actually work off.
We actually have to work out what the capacity of the tendon is, how the muscle tendon unit and the kinetic chain are doing and then work on that to restore function.
We are looking for the relationship between increasing the load on the tendon and pain. Therefore we will increase the load on the tendon to a point where we don’t want to do it anymore because we have had quite substantial pain from it and THIS then gives us a good understanding of what the base ability of the tendon is.
So for some people it may be a double leg heal raise for a tendinopathy on a person who hasn’t done much loading and has a tendon pain going up on to their toes with two feet. If that's the case then we're not going to assess much more than that. But we may get someone else who eventually gets to hopping and change of direction stuff to elicit that pain and to elicit that level of function.
Basically what this means is that even assessing the function of the tendon is highly individualised.
WHERE DO BIOMECHANICS COME INTO THIS?
Although there is very little evidence that biomechanics are much of a player in the ONSET of tendinopathy, there are a couple of tendons where biomechanics are much more important. Glute medius tendinopathy can be linked to biomechanics as can tibialis posterior in older people where the foot posture is really critically important.
That being said, on the whole, a person's Biomechanics may change BECAUSE of tendinopathy causing their function to change rather than their biomechanics causing the tendinopathy (but of course there are exceptions).
But whatever the reason, we will have to restore those biomechanical changes at the same time as dealing with the tendinopathy issues. They should not be treated exclusively. One CAN influence the other and so we might as well address them together.
With all this being said, it is important to focus on the individual. We are looking at bringing them back to their individual 'normal' function that they require, which means it will be individualised (as always).
When it comes to Tendinopathies it's important to not get sucked in to simplistic models of assessment or management recipes. We need to assess the person in front of us and treat them appropriately. We need to remember that everyone is different and that we should manage our patients to reflect that.
I also believe that education is key for patients (isn’t I always!). Educating them on the stages of Tendinopathy, how the body adapts to it (including the fact that degeneration is not a problem!), the causes of tendinopathy, how to load appropriately and how pain and function is not related to pathology. The more we know the more equipped we are at sorting these issues out.
Fear. It’s quite possibly the number one factor I have to work with on a day to day basis. Especially when it comes to lower back pain. Which is why this article “Making sense of fear in people with low back pain” is so important.
Some interesting points raised...
“Fifty percent of the general population believe pain in the back means that the back is damaged.”
“Around ninety percent believe that ignoring pain can damage the back.”
“Seventy percent believe there is ongoing weakness in the back following an episode of low back pain.”
“The experience of LBP can feel threatening and scary for many people.”
“Contrary to popular beliefs, the spine is a strong structure and serious underlying structural causes of LBP are rare.”
“The association between common MRI findings such as disc degeneration and disc bulges and LBP disability is weak.”
“What people believe and do about their LBP has a strong influence on how long the pain will last and how disabled they will be by it.”