How We Treat Tendinopathy, and Why:
Concentric and Eccentric Exercise
A recent study analyzed the treatment effects of eccentric vs. concentric graded exercise in chronic tennis elbow, and found some interesting conclusions. The study found that the exercise programme for chronic tennis elbow should be designed to gradually put load on the affected painful tissue, and stress the eccentric work phase, but need not exclude the concentric work phase; which refutes some earlier tendinopathy research that found concentric exercise to be either worthless or aggravating.
These researchers found both concentric (lifting a weight) and eccentric (lowering a weight) contractions to be beneficial, with eccentric exercises only being only about 10% better. This backs up my own physical therapy protocols where I make use of regular progressive resistance exercise (combining concentric and eccentric contractions). It also helps to explain why some more recent studies, where heavy slow lifting with regular concentric and eccentric contractions, are more effective than eccentric only contractions for the treatment of tendinopathy. The big downside of eccentric only contractions is not that they aren’t effective (as this and almost all studies show they are), but that they are tedious to both coach and perform as the patient has to lift the weight with their good arm and lower it with their bad arm. Also, by using normal combined lifts in physical therapy, patients are learning an effective exercise they can continue indefinitely as part of their fitness program. By contrast, eccentric only exercises are more of a “specialty therapy exercise” that patients rarely would nor should wish to continue after their pain resolves.
Check out Chad’s blog to read more about: The Positive Effects of Concentric and Eccentric Exercises in Patients with Tendinopathy
Electric Muscle Stimulation
Electrical muscle stimulation restores strength and activation in the muscles. In a 2006 study, the use of neuromuscular electric stimulation was used to improve activation deficits in a 62-year-old male patient with chronic quadriceps strength impairments following total knee arthroplasty. When beginning rehabilitation, his left quadriceps strength was 26% weaker than his right and central activation ratio (CAR) of his left quadriceps was 13% lower than his right quadriceps CAR. By the end of the treatment, authors stated: “The patient was able to achieve symmetrical quadriceps strength and complete muscle activation following six weeks of NMES and volitional strength training. An intense strengthening program may have the potential to reverse persistent strength-related impairments following TKA.”
Treatment consisted of reasonably aggressive unilateral leg strengthening with an emphasis on quadriceps for six weeks. On the weaker of his quadriceps they did electric muscle stimulation with two electrodes, 2500 Hz, sinusoidal alternating waveform current at a burst rate of 75 bursts with intensity to the patient’s maximum tolerance.
The researchers used only one channel/ two electrodes on the subjects quadriceps. They used large electrodes making the electric stimulation more comfortable. However, in my experience they would have had even greater recovery if they had placed four electrodes on the quadricep to recruit a greater number of nerves and subsequent muscle fibers. The additional channel on the same quadriceps doubles the muscle fiber recruitment without the increase in discomfort you would get from further increases in current intensity. Also, if the EMS machine has additional channels you might as well put four electrodes on the hamstrings as well, or any other muscle that tests as relatively weak. On most good EMS units those additional channels are there, so it seems a shame not to use them.
Check out Chad’s blog to read more about: EMS for Strength Restoration
Encourage Patients to Continue with Regular Activity
A study comparing eccentric training and the combination of eccentric training with the AirHeel Brace for the management of tendinopathy in the Achilles tendon found that the subject’s FAOS improved significantly in both groups that did eccentric exercise but did not differ with use of the brace. During the 12 week assessment period, all groups performed their regular sport activity. Even with the continuation of the subjects’ regular sport activity, the VAS decreased from 5.1 to 2.9 in one group and 5.4 to 3.6 both eccentric groups (a 43.1% and 34.6% improvement respectively) while use of heel brace did not have a significant effect on pain or function.
This physical therapy study shows the beneficial changes in pain, function, and quality of life with eccentric exercise while allowing subjects to continue with regular sports activity. The ankle brace had no effect on outcomes and I expect much the same to be true with the use of elbow straps with medial or lateral epicondylitis.
Check out Chad’s blog to read more about: Eccentric Exercise and Achilles Tendinopathy
At Absolute Physical Therapy we have adopted a specific protocol for our strength training exercises for treatment of various physical conditions; including tendinopathy. For most of our exercises, we have the patients do three sets (easy-medium-hard) of 15 reps on each set. If the person gets 15 reps with a full range of motion, pain or not, we ALWAYS increase the weight an increment for the second set. If they get 15 reps with full range of motion then, again, we ALWAYS move the weight up for the third set. If the person gets full range of motion on the third set, then the next session we have them start out with their medium weight before and progress from there. We want to quickly (over two to three days) get them to where they are unable to get all 15 reps on the third set. Only then do we stop increasing the weight until their strength progresses. In my experience, three times per week works, but seven days per week works a lot faster.
1 . A workout regimen consistent of both concentric and eccentric exercises.
A newer paper found that regular (concentric and eccentric) heavy lifting did more to improve recovery from tendinitis than did eccentric only exercise. This is advantageous for a number of reasons. The first reason is because concentric/eccentric exercise is more intuitive and simpler to perform than eccentric-only exercise. Secondly, regular weight training is more efficient; you can work both arms at once with regular lifting, but for eccentric you can only do one at a time. Lastly, you never have to decide when to discontinue eccentric exercise and start regular weight training (which is what most people do when they workout) because you are doing it all along. So with research being a bit conflicting, I used both ways for a while. After finding that the combination concentric/ eccentric exercise worked as well or better than eccentric alone, I finally retired my eccentric-only method.
Another study compared the effectiveness of eccentric loading, shock wave therapy, and wait and see-in patients with chronic tendinopathy of the main body of tendon Achillis. In the wait and see group, patients were not assigned any exercise and were strictly testing how much the pain would subside on its’ own with time. Patients were asked to avoid pain-provoking activities throughout the 12-week treatment period, and walking and bicycling was allowed if it could be performed with only mild discomfort or pain. The comparison between eccentric exercise and wait and see and found significantly better improvements in the eccentric exercise group, which is good; as previous research looking at traditional physical therapy exercises were not noticeably better than wait and see.
Check out Chad’s blog to read more about: Eccentric Loading vs Wait and See for Patients with Tendinopathy
2. Complete fast repetitions of weight lifting exercises.
If my physical therapy patients and personal training clients take longer than half a second to lower the weights, I tell them to go faster. Four seconds down is REALLY SLOW and you can’t lift a heavy a weight that slow, so overall training intensity is lessened. Known to just about every weightlifter, powerlifter, bodybuilder, or strength and conditioning coach (but apparently not every researcher) is that nobody strong trains like that. Strong people generally lower their weights (eccentric contraction) in a smooth but swift manner, and if they really know what they are doing, they lift those weights (concentric contraction) as fast as they can.
Our Rehabilitation Approach Displayed in Patients with Shooter’s/ Tennis elbow
A common injury that this exercise regimen works especially well for, is shooter’s elbow. Shooter’s elbow is tendinitis, however even that name is contentious. The “itis” in tendinitis implies inflammation which biopsies reveal is NOT present. The vast majority of the people I know who get tendinitis of the elbow are pistol shooters, but the condition is not limited to them. Tennis players, golfers, and people who get the condition for no apparent reason at all can still learn a lot from this blog as the principles and techniques of treatment are identical as I draw upon tendinitis research from all sports.
Since adopting the above protocol the treatment has always worked. Even so, I do tell people that I see two kinds of responses, both great but the first obviously better. The first is that the pain goes away completely in a few weeks (maybe three to six) the person is a lot stronger and able to do everything without pain. The second common response is that the pain gets 90% better in three to six weeks. Strength and activity are fully restored, but there is still a little nagging pain (maybe a 1-2/10 with activity) that can last as long as six months. The second is the worst case, if I tell people about it from the start they all agree it’s still a good outcome. As a therapist I have driven myself nuts trying to get rid of that last bit of pain, but now I tell people that it’s normal and to just stick with their exercises. Once strength has been restored and plateaus, I tell my patients they can reduce their training frequency to just two to three times a week. Eventually, they will notice they haven’t had any pain in a while and their elbow is no longer tender to the touch.
I find the pain decreasing rapidly with daily exercise to be so consistent, that if it does not work I start to question my diagnosis. So if pain increases a bit from one day to the next that’s not a big deal. If it’s getting worse week after week, that’s a red flag you should consider getting checked by a physician. A common method of grading appropriate exercise and activity is to limit the weights you use and the amount of sporting activity (in this case shooting) to that which causes a five out of ten pain or less. There is no research that says greater pain is too much, and in fact many of the successful studies told people with Achilles tendinitis to keep running so long as pain was not “debilitating”. A five out of ten on a pain scale might be overly cautious, but I think it’s a reasonable guideline. If I find any other bit of research that changes my advice I’ll be sure to blog about it here.
Check out Chad’s blog to read more about: Rehabilitation of Patients with Shooter’s Elbow
How We Don’t Treat Tendinopathy, and Why:
Why We Don’t Recommend a Resting Period
A study that I commented on in my blog conducted an experiment to evaluate if continued running and jumping during treatment with an Achilles tendon-loading strengthening program has an effect on the outcome. Achilles tendinopathy is a common overuse injury, especially among athletes involved in activities that include running and jumping. Often an initial period of rest from the pain-provoking activity is recommended.
It was seen that both groups had an rapid increase in function in first six weeks and more steady improvements thereafter. Both groups improved statistically equal in regard to both pain and function, but absolute gains in the resting group were a little higher with VISA-A score increasing from 57 to 75 at six weeks and 91 at one year. The exercise group improved from 57 to 70 at six weeks and 85 at one year. One could argue the rest helped a little but the continued exercise group improved nearly as much in spite of continued exercise and would otherwise be better able to maintain and or further improve fitness/sports performance rather than a decline in health/function from lesser activity.
Downside of this study, is that it did not state how active either group was before or after the six week differential period, so it’s hard to say how this adapts to various activity levels. In light of the in season elite level volleyball players, it does seem improvements can be seen in pain and function even with intense and prolonged additional exercise. This study also used both concentric, eccentric, and plyometric types of exercises in their program indicating that the combination of contractions types is effective in treating Achilles tendinopathy.
Check out Chad’s blog to read more about: Continued Sport Activity During Rehab for Achilles Tendinopathy
Why We Don’t Use Ice
A study investigating whether an exercise programme supplemented with ice is more successful than the exercise programme alone in treating patients with lateral elbow tendinopathy, no significant differences in the magnitude of reduction between the ice group and exercise group at the end of treatment and at the three month follow up were showed. The exercise programme, consisting of eccentric and static stretching exercises, had reduced the pain in patients with LET at the end of the treatment and at the follow up whether or not ice was included.
Interesting in that this is the only study that has used ice as a variable (in tennis elbow or any form of tendinitis / tendinopathy) and found it had zero effect, good or bad on outcomes. Pain dropped a lot in a short time period which could be due to effectiveness of the exercise protocol, which was novel (taking 30 seconds to lower the weight) or due to the avoidance of aggravating activities.
Check out Chad’s blog to read more about: The Insignificant Effect of Ice After Exercise in Patients with Tennis Elbow
Why We Don’t Use Ultrasound or Soft Tissue Mobilization
In a paper I wrote, I originally said I would do some ultrasound and soft tissue mobilization after the exercise to help make the patient feel better in the short-term. I don’t do either anymore as I don’t think they add much (if anything) to the healing process. Plus, I notice once a person does their exercises they usually feel better in the short term anyway. Generally they do a set of an exercise that works the injured tendon and it hurts a little. If they have good form I move up the weight and they do another set and it hurts a little, but often less than the first set. If they had good form on the second set I move up the weight again and usually they tell me the heaviest set feels the best. They are generally no worse as a result and often report feeling just as good as when they got the ultrasound and massage. After 2-3 days of this the exercises hardly hurt at all, in spite of the fact that I am increasing their weights every visit until they cannot get 15 good reps. That’s the sweet spot for training: where you are training to failure on the 3rd set.
Check out Chad’s blog to read more about: Eccentric Exercise vs Ultrasound in Patients with Achilles Tendon Pain
Why We Don’t Recommend Cortisone Shots
People like cortisone shots because they do make the pain go away in the short-term, and if you are lucky it stays away. However in the mid- and long-term, people who have cortisone shots often relapse, shown by this study where a group of people who have cortisone are consistently worse off than if they did nothing. So my first bit of advice, especially for patients with shooter’s elbow, is DON’T GET A CORTISONE SHOT, EVER! If it hurts, think of it more as an annoyance rather than a debilitation. If you do your exercises properly it won’t hurt very much, for long anyway.
Why We Don’t Recommend Low Level Laser Therapy
In this randomized control trial, the clinical effectiveness of adding LLLT to eccentric exercises for the treatment of Achilles’ tendinopathy was not demonstrated. Four weeks out, the placebo/sham treatment group improved MORE than the laser group, which was the same thing researchers commented on in the Anodyne study for neuropathy. I expect worse healing rates for both studies are likely just bad luck/chance/coincidence, but had chance gone the other way, I would bet dollars to donuts that the pro laser folks would be trumpeting the “positive trends” that didn’t quite reach statistical significance.
Something else that caught my attention, is that the LLLT treatment and research seems really contentious. I expect the yeah sayers to blow off negative findings like this study, by likely saying the researchers are biased, however, the primary author in this paper, Steve Tumilty, really looks like he was a true believer. Tumilty did a pilot study in 2008 that also found no significant differences, and in 2010 he was the primary author on an extensive review and meta-analysis on LLLT for tendinopathy, which I thought was fairly biased in favor or laser therapy being effective in spite of clearly conflicting research. In his review he noted that 25 trials of laser therapy and tendinopathy, that 12 trials showed positive effects, while 13 didn’t.
Check out Chad’s blog to read more about: Low Level Laser Therapy Deemed Ineffective for Tendinopathy