By: Brett Windsor,
Looking further at the Rees article from yesterday, I had a few additional thoughts that I wanted to pass on:
1. No mention of physical therapy as a modality capable of successfully treating tendinopathy. A lot of valuable physical therapy contributions were overlooked, despite the fact that our profession has contributed an extensive amount to the progression of this problem. Eccentric exercises were mentioned through the Alfredsson study, but no direct link to PT.
2. I’m not sure I agree with the contention that we’ve completed eliminated the concept of inflammation from the discourse about tendon pathology. I would certainly agree that we were as guilty as anyone with the excessive focus on the inflammatory aspects, but I think we’ve largely transitioned into a mechanical role with a healthy respect allowing for the possibility of inflammation.
3. No mention in the treatment section of instrument assisted soft tissue techniques…the various methods have garnered some very promising results in the clinical arena and there is some good research beginning to support these claims. Also no mention of the role of manipulation in treatment, for example, Mills manipulation for recalcitrant lateral epicondyle pain.
4. Is it true that the success of eccentric exercise is limited since the Alfredson study? Is that really all we’ve got?
5. There is a lot of talk about the various biochemical/inflammatory/genetic processes involved with tendinopathy, but no discussion on the trigger. Is it over-stimulation? Under-stimulation? There is a building body of knowledge now beginning to suggest that the primary etiology of tendon pathology is actually under-stimulation. Counter-intuitive in some respects…but, read for yourself below. A very interesting read.
Bottom line…got to be careful about not completely eliminating the possibility of inflammation in tendinopathy, but the primary etiology does appear to be under-stimulation leading to degenerative changes and angiogenesis.
Best regards. Brett
naiomt.me 
Hi Brett,
Great topic. I would like to add that it is always an overuse injury…. of an underused tissue. Now, that being said why did the recent middle age runner develop a unilateral midsubstance achilles tendinopathy? Both sides have logged the same mileage. Was there a biomechanical issue putting more stress on that side or not? (See adhesive capsulitis discussion below) Unfortunately, by the time we treat this potentially causative biomechanical issue it may do nothing for the resolution of the present condition which is too far gone.
The view that inflammation was not part of the condition always bothered me, especially when at times ( in epicondylitis or patella tendinitis ) a cortisone injection may resolve the condition completely.
Has anyone used the Alfredson protocol specifically as outlined and had success? The reps are so high that doing those reps in a nonsymptomatic individual could cause a tendinopathy. I have leaned towards the modified Alfredson and then in most cases had to decrease the exercise to every other day to allow adequate rest.
I tend to think there is some process going on in the connective tissue that once set in motion has to run its course to ultimately resolve. With the time frame being very similar to that of a true adhesive capsulitis or plantar fasciitis. Biomechanics may have nothing to do with it. Does the individual who develops insidious onset adhesive capsulitis always have a biomechanical issue that triggers it? I don’t think so.
I would like to hear from any manual therapist who has had insideous onset adhesive capsulitis. As therapist, can we identify the problem early enough in ourselves to prevent the entire process?
I would love to hear your thoughts,
Paul Rouleau PT
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Hi Paul, Great comments…I’d refer you to a 2007 review by Arnoczky. You can get the free full text HERE
I think you’ll fid that the review largely supports what you’re saying. I don’t think the PT profession ever really went so far as to say that the inflammation piece didn’t exist, but rather we acknowledged the fact that it wasn’t as primary and prevalent as we once thought. Under-stimulation is absolutely a huge factor, and as with anything of this nature, it begins with the failure of a single thread. With regards to the protocols for repair, I think there is not enough rest in between bouts of exercise. 72 hours in between should be considered – to allow for time to establish a a positive collagen balance. Good discussion. Brett
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