What I like about being in the field of physiotherapy is that there are many trials of treatment going on out there that can quickly be replicated where great promise is demonstrated.
One such set of works that recently became apparent to me involve the clinical challenge that is tendon injury, bringing a strategy that the sufferer can easily apply at home with minimal cost and simple modifiability.
Tendons, if you aren't familiar, are part of muscle and they are the elastic attachments to bone that enable not only joint motion, but acceleration, velocity, bounce, shock absorption and stability of a joint.
Tendons are entirely different to the muscly tissue that drives them and so it is this variation that marks the difference in the recovery times and rehab needs.
Muscle tissue is richly supplied with blood, whereas tendon is not.
Good blood supply makes the world of difference for healing and so most muscle injuries progress quickly and the victim can return to real life in an acceptable timeframe.
Tendon, on the other hand, can be stubborn to resume normal behaviour, and can persist in pain for many months with rest and avoidance of offending activities.
It seems clear that tendon is akin to the child that needs much hand-holding and guidance, staying close to your leg as you attempt to deposit them at their educational institution, whereas muscle recovery is like the child who disappears at the gate first time, waving goodbye and never looking back.
Ebonie Rio is the delightfully-named physiotherapist whose work caught my eye a couple of years ago. It came out of a case of Achilles tendonopathy in a casual basketballer who, according to recent evidence-based therapy of deliberate loading exercise, remained symptomatic and not very much further on than when we first met. The Achilles tendon of a basketballer is constantly launching, landing, backtracking and sprinting, randomly and rapidly over four hectic quarters of game time. He injured his tendon and so took time out to recover but for some reason, with appropriate therapy he was still sore and the tendon remained swollen in the middle. In tendonopathy (dysfunction of tendon) the cells go through a confused healing response, hence the swollen tendon. For an unknown reason, the tissue tries to heal in the wrong way and the tendon gets more blood vessels and the wrong collagen types. This makes it painful and poor at doing its proper job. A bit like replacing steel cables on a suspension bridge with rope.
The reference came from a sports doctor who performs special injections into Achilles tendons with the patient's own blood, a small amount removed, centrifuged and the clear plasma extracted for its wonderful healing effect. In the case of the basketballer, the doctor stated that his approach wasn't as effective as the new approach coming from Ms Rio's work, which I find refreshing, as I appreciate the patient's best interests approach every time I see it thoughtfully applied.
So what is the approach?
Isometric Exercise. Iso meaning same, metric meaning length. Ebonie and her team tested a group of tendon patients with a new approach where the tendon is loaded and held still (isometric - the muscle is not moving, it is holding). They attempt to load it up to a specific percentage of its maximum ability and hold for around 45 seconds. It takes a fair bit of expertise from the therapist to help the patient perfect it and find the perfect dose of force and reps, but if it all goes well, the patient begins to experience pain reduction and can then get further in the traditional loading exercises that they previously were stalled on or perhaps in some cases, experienced recovery without needing the traditional ones. They also found that the brain was changed by this exercise where previously it inhibited the affected muscle, so these simple drills seem to unlock the tendon from its protective parent (brain)!
Some provisos that might be important: the tendon doesn't like being compressed so the right position of the body part where it is not pressing hard against bone is essential. The loads must be calculated carefully, and the sedentary person is approached differently to the athlete. Recovery between exercise is also considerably important.
The beauty of this approach is that it is natural and empowering for the patient. Once more I will imply with utmost subtlety that you need me in your time of darkest tendon performance, so don't then leave it to chance and its inferior dispensing of scar tissue. Physiotherapists no longer fear or dread the neovascularised jellified tissue wreckage that is tendonopathy. Neither should you.
Greg Bell is a physiotherapist practising at Bell Physiotherapy. www.bellphysio.co.nz
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