Feed it, Treat it, Hold it, Load it, Move it- Healing Tendinopathy
Geoff Lecovin, MS., DC., ND., L.Ac., CSCS. CISSN
Michael Braccio, DC., DACRB
Tendinopathy is a broad term describing painful conditions that occur in and around tendons in response to overuse.
Research suggests little or no inflammation is present in these conditions, thus treatment modalities aimed at controlling inflammation, such as steroid injections and nonsteroidal anti-inflammatory medications, are generally not effective and may in fact exacerbate the problem by disrupting the healing process.
(Andres, B. M., & Murrell, G. A. C., 2008) (Chan, K.-M., & Fu, S.-C., 2009)
This article will describe an evidence-based protocol to effectively manage tendinopathies, by combining nutrition, manual therapy and exercise:
- Feed it
- Treat it
- Hold it
- Load it
- Move it
Feed it- Protein; Collagen/Gelatin
Musculoskeletal injuries are the most common complaint in active people. Nutritional and exercise interventions that increase collagen synthesis and strengthen these tissues can have a significant healing effect on injury rehabilitation.
In a study by Shaw G, et al., supplementation with 15 g of gelatin combined with vitamin C, increased circulating glycine, proline, hydroxyproline, and hydroxylysine, resulting in increased collagen content and improved mechanics.
The study concluded that adding gelatin to an exercise program improved collagen synthesis and could play an important role in injury prevention and tissue repair.
(Shaw G, et al., . 2017)
Incorporating connective tissue targeted exercises in conjunction with whey protein, gelatin and vitamin C, is an effective way to increase muscle/tendons growth and strength adaptations. Exercises should be done with a lightweight, within a pain-free range of motion and either 6 hours before or after other training.
(Baar, K., 2017)
Treat it- Manual Therapies
Mechanotransduction is the processes whereby cells sense and respond to mechanical stimuli by converting them to biochemical signals that then elicit specific cellular responses, including changes in the expression of proteins, growth factors, transcription factors, and cytokines that can alter tendon structure and cell viability.
Manual therapy could be considered a form of applied mechanotransduction, as it mechanically loads tissue in a controlled manner in order to enhance healing. Essentially, therapy stimulates a chainline of reactions that primes the tissue making it a more sensitive target for nutritional interventions.
(Killian, M. L., et al., 2012)
Some effective forms of manual therapy include:
- Instrument Assisted Soft Tissue Manipulation (IASTM)
- Dry Needling
IASTM is a type of soft tissue manipulation that involves making longitudinal pressure strokes along the course of muscle fibers with a blunt instrument (e.g. Surgical steel). IASTM has been shown to promote fibroblast proliferation, collagen synthesis, maturation and alignment. Individuals with tendinopathies have responded to IASTM with pain resolution, increased range of motion and restoration of normal function.
(Baker, R. T., et al., 2013)
Dry Needling (Intramuscular Manual Therapy)
Dry Needling is a technique using the insertion of a solid filament needle, without medication, into or through the skin to treat various impairments including, but not limited to: scarring, myofascial pain (trigger points), motor recruitment and muscle firing problems.
Myofascial trigger points are believed to be a sequelae to spondylosis (degeneration in the spine) and concomitant neuropathic changes (damage to nerves). Dr. Chan Gunn, a medical doctor from Vancouver Canada, asserts that the neuropathy and radiculopathy that accompany spondylosis irritates nerve roots and can lead to peripheral neuropathy and muscle shortening, both in the spine and extremities.
Many myofascial syndromes, e.g. Achilles Tendonitis, Patellar Tendonitis, Rotator Cuff Tendonitis and Tennis Elbow to name a few, are caused by muscle shortening.
Intramuscular stimulation (dry needling) effectively relieves pain by releasing myofascial trigger points, which in turn relieves paraspinal muscle shortening, pressure on nerve roots, and pressure at joints. In addition, it stimulates the production of platelet-derived growth factor to promote healing and healthier connective tissue.
(Gunn, C. C., 1996) (Gunn, C. C., 2001)
Chronic tendon dysfunction responds well to manual therapy. Joint mobilization and manipulation have been shown to improve mobility and range of motion, decrease pain, increase strength and improve function.
(Jayaseelan, D. J., et al, 2017) (Paungmali, A., et al, 2003).
Hold it- Isometric Exercise
An isometric exercise is a type of muscle contraction where there is no change in the muscle length of joint angle. This type of muscle contraction has been shown to have an analgesic effect on tendon related pain. Generally a heavier isometric contraction is necessary to stimulate analgesia, with the current recommendations being between 50 to 70 percent maximum voluntary contraction.
Performing isometric exercises targeting the patellar tendon has been shown to produce an analgesic effect for 45 minutes post exercise. If training during rehab is necessary (e.g. for an upcoming competition or in-season), isometric exercises can be used before training to reduce the pain.
For programming, isometric exercises should be held for 30-45 seconds for 3-5 repetitions depending on an individual’s tolerance to load. Mild pain during the isometric contraction is acceptable, as long as the pain does not remain elevated after 24 hours and does not interfere with sleep.
(Rio, E., et al., 2015) (Lewis, J., et al., 2015) (Park, J. Y.,et al, 2010)
Load it- Concentric and Eccentric Exercise
As isometric exercises becomes better tolerated, the exercise program can transition to concentric and eccentric exercises to increase the load on the tendon. Traditionally, exercise programs have focused on the eccentric component of muscle contractions, but the benefit of isolating eccentric contractions has recently been challenged.
A systematic review on loading programs for achilles and patellar tendinopathy found no evidence that isolating eccentric contractions produced better outcomes. Therefore, concentric and eccentric contractions can be included in the rehab program. This aids in simplifying the rehab program, potentially increasing treatment compliance.
The amount of load placed on the tendon appears to be more influential than the type of muscle contraction. Loading the tendon should begin with slow, heavy concentric (3-4 seconds) and eccentric (3-4 seconds) contractions.
Rehab should progress following to strength training by gradually increasing both the load on the tendon and the speed of contraction. As previously mentioned, the loading on the tendon should not exacerbate pain for the 24 hours following the exercise session.
(Blume, C., et al, 2015) (Malliaras, P., et al, 2013) (Beyer, R., et al, 2015)
Move it- Integrative and Sports specific
After a sufficient foundation has been built in the load it stage, the exercise program can progress to integrative and sports specific movements. These quick, dynamic movements help the tendon to adapt to the loads experienced during sport. Because of the intensity of these movements, at least 48 hours of rest between exercise sessions is required initially. This allows enough time for the collagen of the tendon to respond to the higher loads placed on it.
Minimizing the difference in loading from rehab to sport is important for a successful return to sport. Sudden increases in loading on the tendon, as seen when an athlete returns from an injury, can predispose an athlete to re-injury. Therefore, the rehab program should focus on the loads the athlete will experience in the “move it” phase.
(Mascaró, A., et al, 2018) (Blanch, P., et al, 2016)
- Consume 15 g of gelatin or collagen peptides with juice (vitamin C source) and whey protein 1 hour prior to therapy and/or exercise.
- Have Manual Therapy performed 1-2x/week for 4 weeks.
- Contrast hydrotherapy: Alternate heat 3 min with cold 1 min 3x (3x/day).
- Corrective Exercise:
- Isometric exercises: 30-45 seconds (50-70 %) for 3-5 repetitions
- Strength training: 3-6 sets for 6-12 repetitions, 3/0/3 tempo.
– Progress to integrative and sports specific movements.
Smoothie Recipe For Tendinopathies
- 1.5 cups orange juice
- 1 cup spinach
- 1 medium beet
- 1 cup frozen blueberries
- 1 banana
- Whey Protein 20 g
- Collagen Peptides 10 g e.g. https://www.primalkitchen.com/collections/collagen-protein/products/collagen-peptides
Andres, B. M., & Murrell, G. A. C. (2008). Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon. Clinical Orthopaedics and Related Research, 466(7), 1539–1554. http://doi.org/10.1007/s11999-008-0260-1
Baar, K. (2017). Minimizing Injury and Maximizing Return to Play: Lessons from Engineered Ligaments. Sports Medicine, 47(1), 5-11.
Baker, R. T., Nasypany, A., Seegmiller, J. G., & Baker, J. G. (2013). Instrument-assisted soft tissue mobilization treatment for tissue extensibility dysfunction. International Journal of Athletic Therapy and Training, 18(5), 16-21.
Beyer, R., Kongsgaard, M., Kjaer, BH. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy. The American Journal of Sports Medicine, 43(7), 1704-1711.
Blanch, P., Gabbett, TJ. (2016). Has the athlete trained enough to return to play safely? The acute:chronic workload ratio permits clinicians to quantify a player’s risk of subsequent injury. British Journal of Sports Medicine, 50, 471-475.
Blume, C., Wang‐Price, S., Trudelle‐Jackson, E., & Ortiz, A. (2015). COMPARISON OF ECCENTRIC AND CONCENTRIC EXERCISE INTERVENTIONS IN ADULTS WITH SUBACROMIAL IMPINGEMENT SYNDROME. International Journal of Sports Physical Therapy, 10(4), 441–455.
Chan, K.-M., & Fu, S.-C. (2009). Anti-inflammatory management for tendon injuries – friends or foes? Sports Medicine, Arthroscopy, Rehabilitation, Therapy, and Technology : SMARTT, 1, 23. http://doi.org/10.1186/1758-2555-1-23
Clark, M., & Lucett, S. (Eds.). (2010). NASM essentials of corrective exercise training. Lippincott Williams & Wilkins.
Dunning, J., Butts, R., Mourad, F., Young, I., Flannagan, S., & Perreault, T. (2014). Dry needling: a literature review with implications for clinical practice guidelines. Physical therapy reviews, 19(4), 252-265.
Gunn, C. C. (1996). Treating myofascial pain. Acupuncture in Medicine, 14(1), 20-21.
Gunn, C. C. (2001). Neuropathic myofascial pain syndromes. In Bonica’s Management of Pain (pp. 522-529). Lippincott Williams & Wilkins, Philadelphia, PA.
Jayaseelan, D. J., Kecman, M., Alcorn, D., & Sault, J. D. (2017). Manual therapy and eccentric exercise in the management of Achilles tendinopathy. Journal of Manual & Manipulative Therapy, 25(2), 106-114.
Killian, M. L., Cavinatto, L., Galatz, L. M., & Thomopoulos, S. (2012). The role of mechanobiology in tendon healing. Journal of shoulder and elbow surgery, 21(2), 228-237.
Lewis, J., McCreesh, K., Roy, JS., Ginn, K. (2015). Rotator cuff tendinopathy: navigating the diagnosis-management conundrum. Journal of Orthopaedic and Sports Physical Therapy, 45(11), 923-937.
Malliaras, P., Barton, CJ., Reeves, ND., Langberg, H. (2013). Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Medicine, 43(4), 267-286.
Mascaró, A., Cos, M. À., Morral, A., Roig, A., Purdam, C., & Cook, J. (2018). Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy. Apunts. Medicina de l’Esport, 53(197), 19-27.
Park, J. Y., Park, H. K., Choi, J. H., Moon, E. S., Kim, B. S., Kim, W. S., & Oh, K. S. (2010). Prospective evaluation of the effectiveness of a home-based program of isometric strengthening exercises: 12-month follow-up. Clinics in orthopedic surgery, 2(3), 173-178.
Paungmali, A., O’Leary, S., Souvlis, T., & Vicenzino, B. (2003). Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Physical Therapy, 83(4), 374-383.
Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med, bjsports-2014.
Shaw G, Lee-Barthel A, Ross ML, Wang B, Baar K. 2017. Vitamin C-enriched gelatin supplementation before intermittent activity augments collagen synthesis. Am J Clin Nutr 105: 136-143.