I'm a physical therapist with 20 years of clinical experience in the sports medicine setting, and have recently started to participate in some research on tendinopathy. I also have plenty of first-hand experience dealing with some of the aches and pains associated with running. In my own profession, there is still some confusion on what is going on with tendon injuries, and I have seen similar questions posted in this forum. I would like to take this opportunity to share what I have learned so that you all will better understand your own injuries and can take an informed stance when you are trying to help yourself.
Inflammation of a tendon (tendinitis) can occur following an acute injry, which might even involve localized micro-tearing. In these cases, rest, bracing, ice, and medication helps, then you slowly get back to your prior training levels. Sometimes, that's the end of the story. Sometimes, however, it goes away for awhile, then the pain comes back. It is in these cases where we think a degenerative process is going on. (tendinosis). Following the original injury, the body tries to heal itself, but it does so in an inferior manner. The resulting repair or scar is not as strong as a normal, healthy tendon would be. This makes future injuries more likely. Imaging shows that you can get pockets of "fresh" inflammation, but the primary problem is degenerative. (Maybe "dysfunctionally-healed" would be a better word...). That's why anti-inflammatory treatments can help, but not always permanently.
There's another change that occurs with degenerative tendinopathies: the blood vessels are different. They are weaker, disorganized, and really don't do a good job bringing blood products to the interior portions of the tendons. That's another reason why degenerated tendons don't heal so well. If you want to embrace your inner nerd and see pictures of this, you can go to googlescholar.com. Type "Kraushaar and Nirschl" in the search bar. The third one down should be "Current Concepts Review: Tendinosis of the Elbow..."
One more thing is that you can have this degenerative process going on and not know it, until one day the tendon becomes symptomatic or even ruptures. One study looked at over 800 spontaneous Achilles tendon ruptures...none of these people had any history of pain: the tendon just popped one day. They biopsied the tissue and found no signs of inflammation. The tendon was degenerative, but the person didn't feel it. This might explain why a person suddenly has a painful area, even though they cannot recall a specific episode which caused it. The tissue might be degenerating, and it just "blows" one day... (Kannus P, Histopathologic changes preceding spontaneous rupture of a tendon. J of Bone and Joint Surg 1991;73-A(10):1507-1525).
So basically, with most tendon problems, to get it better, one needs to manage the dysfunctional scar tissue, get healing blood products to the deep portions of the tendon, appropriately re-model the newly healed structures into something that is strong and functional, and deal with any biomechanical, muscle inbalance or training issues. Some doctors are trying to accomplish the first two goals with techniques like PRP injections. The shock-wave treatment for plantar fasciitis is also thought to accomplish this through a controlled application of micro-trauma. In my practice, I perform a technique called ASTYM, which is designed to stimulate a healing response in these degenerative tendons. ASTYM has a documented success rate of about 90% for most tendon problems.
For those of you who are still awake, I hope this information sheds some light on some of these stubborn problems like infrapatellar or Achilles tendinosis, plantar faciitis and rotator cuff tendinopathy; why they come and go for no known reason, and why they can be so difficult to get over.
ASTYM is a different approach from the tool-assisted friction massage of Graston or Sastm techniques, the use of Starr and GSO tools, or even using the edge of a spoon. To my understanding, the tool assisted techniques are designed to mechanically break down dysfunctional soft tissue, and both healthy and un-healthy tissue can be affected. I am sure that these techniques probably help some people. It can be difficult, however, to make generalizations regarding their success because the treatment can differ greatly between practitioners. To my knowledge, there is little real scientific evidence that this specific approach consistently works. The only article that I know of that specifically studied instrumented cross friction massage showed that it had no long term benefits on healing. (Lonhmani TM. Instrument-assisted cross-fiber massage accelerates knee ligament healing. J Orthop Sports Phys Ther; 2009;39(7):506-514).
In stark contrast, the goals of ASTYM treatment are to activate the body's healing mechanisms and stimulate the regeneration of tissue, and there is evidence to confirm ASTYM's effectiveness in the medical literature. There are too many articles to list here. If you are interested, you can check out: http://www.astym.com/professionals/evidence.asp. ASTYM accomplishes regeneration by delivering measured doses of pressure and sheer forces in patterns particular for each diagnosis. The certification process insures consistent delivery of the technique and consistent results among practitioners. In addition, because ASTYM is performed in rehabilitation settings, therapists can address compensatory and/or contributory issues throughout the entire kinetic chain. (Biomechanical issues, tightness/weakness patterns, etc).
In the early phases, it could be said that the techniques might have been similiar. However, some of the early studies on rabbit tendons showed that too much pressure caused some damage, specifically, calcium deposits in the tendons. For that reason, the developers moved away from the early methods and refined the technique into what is being performed today. There is another difference that, as a physical therapist, I appreciate. The developers of ASTYM are physicians, researchers, and physical therapists, and they are still actively involved in the technique. That means that experts are continuing to refine the treatment as research and outcome mesasures emerge. In addition, if I have a question: for example, if a patient does not respond as expected, or perhaps has a medical condition and I wonder if the treatment is appropriate, there's someone I can immediately contact and get answers. As a therapist, I want to know that my treatments are safe for my patients and are up to date, and this group has helped me with that..
I can understand that if you watched a video on You-Tube, the methods might look similiar. In my practice, I have treated several patients who previously underwent Graston technique, and they all have stated that the methods, their response, and the subsequent results were different.
I'm sorry I came across that way. I have treated a number of tri-athletes in my practice and have enjoyed "talking physiology" with them....I have found this group to be very well informed on how to best treat injuries and have enjoyed the "give and take" of sharing ideas with them. Reading these forums also helps me to understand how best to treat them, as the running I do does not compare to the training intensity I see with all of you.
There are so many mis-conceptions out there regarding the best way to treat tendon pain. Most doctors and physical therapists know that the current research supports that this is primarily a degenerative or dysfunctional healing problem, yet they continue to treat it with anti-inflammatory methods. Sometimes those methods help, but most of the time, the pain just comes back. So, we all just continue to exercise with the pain, using our straps, tape and Advil. Those of us who treat injured athletes may not have all of the answers just yet, but at least there are people performing legitimate research on how to best manage the actual pathology, rather than just providing temporary relief.
ionlylooklazy - 2010-01-21 2:56 PM What does patellar tendonitis feel like? A dull ache around the knee cap? In any specific location or can it be on multiple sides?
In my experience with patellar tendinopathy, people usually complain of pain at the lower point of the kneecap, and it is often tender with moderate pressure. Sometimes the top of the kneecap can hurt as well. Pain along the sides of the kneecap can be something else. For example, I see alot of people who develop fibrotic tissue in the joint capsule experience pain there.
I wish my PT would figure out what's up with me. I don't feel like they are treating the cause of the problem and while I'm not a doctor, PT, or anything in the medical field my gut tells me I don't have hamstring tendonitis. I really want to trust my PT but it seems like things are getting worse and telling someone you can continue to run/bike doesn't seem right to me. So I agree with the you about just treating it as anti-inflammatory. It sucks and feels like $40 a pop is a waste when I've seen -20% (yes that is negative) improvement in 3 weeks.
Thanks Suezee, that was an informative read. You are quite right, tendon issues are often discussed on here and elsewhere as so many athletes suffer from these issues. I developed Bi-cipital and Rotator-cuff Tendinitis (or was it osis?) from playing tennis in college and the latter sometimes now bothers me when swimming. I am keeping notes from your posts and will refer to them next summer when it comes back!
I have been getting ASTYM treatments for my patella femoral issues. My MD called it chondromalacia but I guess that and PFS are one in the same?!?
Anyways ASTYM has made a big difference for me. Especially because I had previously gone to a different PT who treated the same injury with all anti-inflamatory treatments with no success.
If you have an injury that seems to always be around even as a 'dull roar' I would suggest treating it with something new. ASTYM has been the answer for me and will probably help others as well if they give it a chance.
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2010-01-19 11:14 AM
21
Southern California
Subject: Is it tendinitis or tendinosis?
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