Jill Cook is a name synonymous with tendinopathy, as is Craig Purdam, Dr Peter Maliaris PhD and Dr Ebonie Rio PhD, among many others.
‘Tendinopathy’ refers a pathological change in tendon tissue associated with various degrees of pain, irritability and capacity to function. Typically, it is related to load and a failure of the tendon to appropriately adapt to or heal in response to an applied load; usually too much.
In 2009 Dr Jill Cook PhD and Craig Purdam proposed a model of the continuum of tissue change associated with tendonopathy. It quickly became a reference standard for therapists diagnose and guide their treatment plans and it continues to be used as such today. For reference, the three phases of the continuum are 1) reactive, 2) disrepair, 3) degenerative.
Perhaps the most well-known management of tendinopathy involves a heavy loading protocol proposed by Dr Haken Alfredson PhD in 1998, which remains popular today. As often happens, the initial trials of the Alfredson protocol appeared to be very promising. As clinicians and patients alike are always on the look-out for the best and most effective treatment, the Allied Health community enthusiastically grabbed it with both hands and ran with it; reminiscent of ‘core stability’. The same thing happened with the Thesaly’s test for meniscal damaged; it look almost too good to be true when the first study was published, but has quickly become mediocre. Eccentric loading has its place, but since its initial over-enthusiastic uptake, it too hasn’t been able to live up to the hype. Specifically doing eccentrics aren’t necessary
As research into tendinopathy continues and our understanding of tendinopathic tissue evolves, here’s a summary Jill Cook and Prof Karim Khan’s recent presentation of the paper ‘Pathological tendons maintain sufficient aligned fibrillar structure on ultrasound tissue characterization (UTC)’ Docking SI, Cook J. Scand J Med Sci Sports. 2015 Jun 9. doi: 10.1111/sms.12491. [Epub ahead of print] presented at the American Physical Therapy Association’s Combined Sections Meeting held in Anaheim at the end of February.
• Tendinopathic tissue is disorganised; likened to the hole in a donut. The hole in the donut analogy simply reflects an area of altered tissue in the tendon – there are no holes!
• The volume of healthy normal tissue remains the same
• An ingrowth of nerves and blood vessels (seen on imaging) is inconsequential and not correlated with pain
• Strategies intended to alter the pathological tissue are ineffective; pathological tissue does not change. We treat the donut not the hole
• Anything intended to kick-start a healing process or re-model tissue is ineffective and misguided
• The tendon as a structure is not weak; it has the same amount of good-quality, normal tissue
• Tenocytes (tendon cells) thrive on load; prolonged rest periods are really unhelpful
• Management should be aimed at increasing the load capacity of the normal tissue to make it more robust; not ‘fixing’ or correcting the damaged part
• If we’re aiming to improve the healthy tissue:
– Massage techniques (cross fiber frictions etc.) aren’t helpful. “feeling better” afterwards doesn’t fix anything.
– Using tools to poke, scrap or “break things up”, isn’t helpful
– Injections aren’t helpful
– Stretching isn’t helpful
• Extremely uncomfortable techniques which create a ton of pain trigger the release of endorphins which temporarily desensitise an area but does nothing to fix the damaged tissue or improve the healthy tissue
• These tendons have too much blood flow (due to the increase in blood vessels) so increasing blood flow is not a concern
• Stretching and compression cause irritation i.e. applying heavy eccentric loads (Alfredson protocol) doesn’t fit the model of avoiding stretching and compression when the ankle is in dorsiflexion.
• Loading should be done in a position of comfort; i.e. avoiding the heel drop off a step.
• Phase 1 (most irritated): long duration, heavy isometrics; 5 cycles of 45s isometric holds followed by 2 minutes of rest, 2-3x/day; for pain relief and decreasing sensitivity
– Patients with tendon pain often don’t show signs of central sensitisation. Tendons can become sensitised and irritated, even chronic/persistent, without the features of central sensitisation. Sensitisation and central sensitisation are two different things and not all persistent pain is central sensitisation
– Isotonic (heavy slow resistance) exercises also provide pain relief but not for as long
– If pain does not reduce with isometric holds, it may not be tendinopathy
• Phase 2: Heavy slow resistance in mid-range i.e. avoiding stretch and compression e.g. 4 sets of heavy slow heel raises for the Achilles, not off the edge of a step. Aiming for failure between 6-8 reps; it’s too heavy if the patient is unable to reach 6, too tight if they can reach 9 reps
• Phase 3: Using the stiff component (load transfer in tendons comes from stiffness not elasticity)
– 25 single leg calf raises
– Include compression – full-range, explosive loads: jumping, hopping etc.
– Pain should be stable; not ‘sharp’
– Pain tolerable, not pain free
A painful degenerative tendon has less capacity to tolerate load – build it up!…or is it simply excessive load which the patient shouldn’t be trying to tolerate in the first place which simply requires better management?
ps. As mentioned our post of March 2, Jill Cook started the push for the term tendinitis to be phased out as these are not inflammatory conditions.