Confessions of a Podcast Addict

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