An email from Darin:
"Hello Dr. Kelsey
It is not uncommon for us to receive clients with tendonosis. I recently had a conversation with a podiatrist about one of his clients suffering from achilles tendonosis. He was curious about what therapists can do using forms of exercise to "restart" the inflammatory process in a tendon. I
told him we like to use eccentric loads to accomplish this purpose. Consequently, he sent us the patient. However, I still struggle with giving the proper dosage of eccentric work. If I initially hit them with some eccentric work, should I back off for a while and use higher volumes of concentric work with low fatigue indices to manage inflammation? I have a hard time wrapping my mind around what frequency and duration to use with eccentric tendon drills. I never struggle with inflaming them! But, how do I best manage afterwords?"
Thanks,
Darin
Thanks for the question Darin. Here's how I think about this problem.
What I choose to do for tendonosis depends on the severity of the problem. We use a staging system similar to Nirschl's (we created a more generic version for use on problems in addition to tendonosis) to help us classify the severity (below is Nirschl's):
Phase 0: No pain or soreness
Phase 1: Stiffness or mild soreness after exercise activity. Pain is usually gone in 24 hours.
Phase 2: Mild stiffness and soreness before activity which
disappears with warm up. No pain during activity, but mild soreness
after activity that disappears within 24 hours.
Phase 3: Same as above with mild pain during activity which does
not alter activity, disappearing in 24-48 hours. Counterforce bracing
may be considered here as well as mild anti-inflammatory medication.
Phase 4: Mild to moderate pain before, during, and after
exercise which alters the exercise or activity. ADLs are affected.
Phase 4 is indicative of some level of tendon damage.
Phase 5: Moderate or greater pain before, during, and after
exercise or activity, forcing the patient to discontinue the exercise.
Pain is experienced with ADLs. Usually reflects permanent tendon damage
Phase 6: Phase 5 pain that persists with complete rest. Pain disrupts ADLs, many activities have to be eliminated.
Phase 7: Phase 6 pain with disruption of sleep on a consistent basis. Pain is aching in nature and intensifies with activity.
The purpose of training is to optimize healing. Movement is required to stimulate the tissue, synthesize proteins, promote collagen formation and extend capillary beds. The objective is to increase strength in the entire leg. A stronger leg helps absorb more force. In addition, and this is another discussion, mechanics play a role. In other words, I want to get as much "ideal" motion of the hip, knee, and ankle. But, back to the training, the type of training needs to be targeted to the stage.
For Stage 4 or lower, we'll start with 30 to 50 repetitions per set with moderate fatigue to promote a vascular response. Once that dosage is tolerated (meaning no increase in symptoms), we'll increase the load. As the Stage lowers, we'll then progress to 8-15 reps per set with high levels of fatigue. It's in these stages that you can use eccentric loads effectively. At this point, people often hurt for 24-48 hours. I usually don't get too concerned as it is a normal training response. The key is to "edge" the client. By "edging" I mean progressing them whenever you can. Sometimes within a week, you can push a client from Stage 5 to Stage 2. You have to pay attention to what they say and what their loads are in the session.
For Stage 5 or higher, we'll use very low loads and much higher repetitions (instead of counting the reps, we use a timer) in the 70-100 range. This requires special equipment to reduce the loads (so in the case of Achilles Tendonosis, a Total Gym). This is to reduce symptoms, promote a healing response, and lightly load the tendon. It's what we refer to as Primary Active Recovery.
I have taken clients in Stage 4 or lower and induced an inflammatory response but it's risky. You have to create a very solid "frame" with the client. He or she needs to understand that the purpose of the procedure is to jump start the healing process but that it will hurt and may hurt for several days or even weeks. So, the client needs to trust you. If you deliver too much energy through the drill or manual procedure (which techniques like Graston often induce an inflammatory response), you end up with inflammation run amok.
I did this more often several years ago but now, I would try to simply move people down through the Stages. I guess I'm more patient now. Find the Stage that best describes the problem, then choose drills that best match the Stage.
I hope this helps. Thanks again for the question.
