My name is Dan Alcorn, and I am
addicted to podcasts. Just ask my wife, and don’t be alarmed by the reflexive
eye roll. There is never a moment of podcast silence in our household. My
podcasts come in all shapes and sizes – sports, politics, psychology, history,
and my favorite, human performance. What better way to spice up your daily
chores of making breakfast, packing lunches, cooking dinner? My podcast
playlist has grown so long that I have adopted drastic measures to listen to
them all…1.5x speed! Just when Rebecca thought I couldn’t find a way to make my
podcast habit more annoying! Recently, I was listening to a podcast interview
with the tendon guru, Jill Cook, which was a perfect supplement to a tendonopathy
discussion we just completed in the Jackson Clinics Upper Extremity Athlete
Fellowship (I never turn down an opportunity for a shameless plug of the
Jackson Clinics Upper Extremity Athlete Fellowship). Look at this Mount Rushmore
of Shoulder Nerds!
(If you would like more
information on how to join this cast of misfits please reach out to me)
I digress.
In this podcast interview
(Healthy Wealthy & Smart by Karen Litzy)6, Jill Cook does a deep dive into the
how and why of tendonopathy rehabilitation. The old school way of thinking was
to treat tendonopathy with daily eccentrics for 12 weeks and this will help
with pain1. Newsflash - Eccentrics are not enough! An eccentrics focused
program under-trains the strength/load tolerance demands of the injured tendon
and muscle – we need full isotonics. Eccentrics can be helpful by working end
range strength but a more comprehensive approach to tendon rehabilitation must
be taken.
*Disclaimer – you cannot treat
all tendons the same – there is no cookie cutter approach to treatment – but
the general process to comprehensively address tendon dysfunction involves 4
stages:
The Program:
Stage 1 - Isometric exercises to provide pain
relief. Isometric exercises are important during the first stage of rehab,
when the patient is in a state of elevated pain, which will impact their
ability to participate in a strength training program. Current evidence shows
that a heavy, loaded isometric knee extension (85 % of a maximum volitional
contraction) can be beneficial for up to 45 minutes of pain relief2
in patellar tendonopathy. What better way to spend your 45 minutes of pain
relief than improving the load tolerance of your injured tendon? The key with
the isometric exercise is the load dosage (heavy) and the time dosage (long). This study included 240 seconds of time spent
in the isometric hold, BUT, you can
divvy this time up in any variety. You may choose to crush your patient with 6
sets of 45 second holds, or if you are feeling generous, you can break the
exercise up into 24 sets of 10 second holds – the pain inhibition results are
the same. The key is the total time, how you spend it seems to be of less
importance. Take home message –
perform these exercises early in a rehabilitation program when pain levels are
high or early in a treatment session to allow for better participation in a
session.
* An isometric external rotation contraction into the wall can also be performed - remember an 85% maximum contraction is the goal.
Stage 2 - Isotonic exercises – These
exercises should include the entire kinetic chain as well as isolated
strengthening of the muscle/tendon of interest. Most programs should be at
least 12 weeks in length and should include a progressive loading strategy,
while avoiding sharp increases in pain. This
is the meat and potatoes of your rehabilitation program. I will refer you
to my previous blog posts (Balance the Shoulder and The Name of the Game is
Progress) for ideas on progressive loading strategies and program design.
Stage 3 - Restore speed based contractions
of the muscle/tendon and the kinetic chain. All muscles contain some percentage
of fast twitch muscle fibers, so make sure that you are including speed based
exercises as a component of your rehabilitation program. Depending on the
muscle and person, your quantity of speed based exercises will vary. Fun fact –
56% of rotator cuff muscle fibers are fast twitch fibers3 – train
them accordingly.
George Davies
recommends 3 strategies to recruit fast twitch muscle fibers4. The
first strategy is through max intensity effort (this strategy is not
necessarily practical for the injured population). Strategy two includes the
use of electrical stimulation to supplement your exercises. Strategy three is
what we will include in this blog post – fast movement patterns, through
medicine ball tosses (this can also include perturbation training through rhythmic
stabilization or body blade exercises).
Stage 4 - Restore endurance of the muscle/tendon
through high repetition exercises. Choose a few of your exercises and scale
back the weight while ramping of the rep count (think 20-40 reps per set).
The Take Home:
According to the research of Seth
O’Neil5, one of the biggest risk factors for a future tendonopathy
is the history of a previous tendonopathy. Don’t discharge your program upon
cessation of pain! You are only 25% of the way home and your patients will
likely reinjure themselves. You must also restore strength, speed and
endurance.
How do you restore speed of
contraction in your patients? How do you restore endurance? I would love to
hear from you!
References:
1. Alfredson H, Cook J. A
treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med. 2007 Apr; 41(4): 211–216.
2. Pearson SJ, et al. Immediate and
Short-Term Effects of Short- and Long-Duration Isometric Contractions in
Patellar Tendinopathy. Clinical Journal of Sport
Medicine. Publish Ahead of Print, AUG 2018
3. Lovering RM, et al. Fiber
type composition of cadaveric human rotator cuff muscles. JOSP, 38:674-680,
2008.
4. George Davies - A Master Clinicians
Approach to Advanced Concepts in Examination and Treatment of the Shoulder
Complex – 2016
5. Seth O’Neil – Achillestendonresearch.com
6. Health Wealthy & Smart Podcast Episode 201 - Busting Tendinopathy Myths
6. Health Wealthy & Smart Podcast Episode 201 - Busting Tendinopathy Myths
