jeffcubos.com » Clinical Testing

Dynamic Neuromuscular Stabilization “C”

jcubos — Fri, 23 Dec 2011 22:58:20 +0000

With an all-star cast of faculty, organizers and participants, it wouldn’t be difficult to say that the DNS program held at Athletes Performance – Arizona may be one of the best opportunities for the professional development of rehabilitation-based clinicians in North America.

Ken Crenshaw, Pavel Kolar, Lucie Oplova, Alena Kobesova, Sue Falsone, Rob Lardner, Clare Frank, Kathy Kumagai and Craig Liebenson

Along with the medical staff members of several major league baseball teams, prominent and budding physical therapists and chiropractors, I was fortunate to attend the “C” course, where our knowledge of the system was tested, advanced and enhanced throughout this 4-day learning weekend.

Because the “A” and “B” courses in this program form its foundation, this “C” course not only packages all the DNS principles together seamlessly, but also takes its principles to specific conditions whereby troubleshooting becomes much, much easier.

Now because I am a big fan of learning principles over specific tools and methods, the following information will be based on some of the key points that resonated best with me. My apologies for those that are new to the DNS system and may not be familiar with some of the concepts below. Should this be the case, please check out my review of the “A” course here prior to moving forward.

One of the key tenets stressed in this course was the thorough understanding of the anticipated movements. Knowing what should “come next” and what you should expect, essentially will help guide and gauge whether you are right or wrong in your approach and treatment.
When encountering troublesome hip problems, it may be wise to check the muscle activity and pressurization ability low down in the abdomen (near the groin) to assess for compensation. The body may be robbing Peter to pay Paul. Most, if not always, the goal should be balanced intraabdominal pressure throughout the entire cavity.

This is not a muffin top.

Unilateral hip flexion is dependent on Thoracolumbar junction stability and contralateral hip stability, among other regions.This is based on the concept of the punctum fixum.
Quite often, dysfunctions in neck stability/motor control stem from lower down the body. Just like the glenohumeral joint needs a stable scapulothoracic girdle, so too does the cervical spine. The “cannon from a canoe” concept applies here as well. Again, the importance of IAP cannot be stressed enough here.
In chronic posterior chain dysfunction patients such as achilles tendinopathies, plantar sided foot pain, etc, again it would be more than wise to assess intraabdominal pressure. Trust me.

IAP: It's important, trust me.

Too much concentric activity of the abdominals, pectorals, trapezius, etc may negatively affect the diaphragm’s ability to induce pressurization. The diaphragm and pelvic floor largely play a concentric role. All other muscles (i.e. above), are more important eccentrically.
This is a no brainer, but a muscle’s ability to relax is very important.
Gluteal filling (volume expansion) is important for lumbosacral and sacroiliac stabilization.
Very often a lack of coordination of muscle activity is more important that a lack of strength. Proportion of muscle forces is important.
Hips often do not need surgery, they need to improve their movement patterns.
For stabilization, it is likely more important to simply hold the position (i.e. isometric holds) than dynamic repetitions.
We can learn a lot from sumo wrestlers. They are very strong but rarely bench. They simply do thousands of centrated movements in a slow and controlled manner. Therefore, when working with young athletes, training a high number of centrated movement patterns is likely more important than loading.

DNS and Sumo Wrestling have more in common than you think

It is always important to assess whether the problem is a contralateral pattern dysfunction or that of an ipsilateral pattern.
In high tone/stress individuals, it may be wise to first start with mobilization and/or release. In persons possessing a parasympathetic state, load them up with stabilization.
You can use which ever exercise progression you want, just respect the principles of a) centration and b) support and stepping functions.
“Train the same pattern, only in different positions”
The body’s ability to relax is related to body awareness. A lack of body awareness can be called “Body Blindness” – the inability to know the body, especially with the eyes closed.
Low back (i.e. discogenic) patients with good quality of stereognosis (body awareness) will have a better likelihood of surgical success. Those who lack stereognosis would be wise to improve body awareness prior to surgical referral.

A different type of body awareness

The principles of stereognotic training (which is based on Feldenkrais and Ayres) is slow, precise, repeated and simple movement with high central nervous system control. To me, it is the “recognise” of movement based rehabilitation. The objective is to learn to differentiate movement, controlled relaxation of the body with movement, and progression to higher level positions. Essentially, this may be an excellent intervention for motor morons.
The goal of DNS rehabilitation is not only to improve the integrated spinal stabilizing system, but also to restore stereognosis. Therefore, Tai Chi may be an excellent method of physical activity for patients of all ages. As a side note, I’m really looking forward to Tai Cheng.
DNS is not about the baby, it’s about optimal movement.

With Craig Liebenson, Ken Crenshaw, Pavel Kolar

Dynamic Neuromuscular Stabilization Review DNS A, B, & C - Athletes Performance - November...
Dynamic Neuromuscular Stabilization “B” September 29 - October 2, 2011 - Montreal, Quebec...
Looking at the Literature: Vojta/Dynamic Neuromuscular Stabilization in a Migraine Sufferer Juehring DD & Barber MR. (2011). A case study utilizing...

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Understanding McKenzie MDT – “A”: The Lumbar Spine

jcubos — Mon, 12 Dec 2011 21:08:31 +0000

Having studied under Craig Liebenson for quite some time, I have developed a better appreciation for the McKenzie Mechanical Diagnosis and Therapy system. Seeing Dr. Liebenson relentlessly “audit” his patients, and understanding that this audit forms the foundation of McKenzie principles, the reassessment has become a cornerstone in the management of my patients.

As such, and to gain a better understanding of this system, I decided to host McKenzie “A” – The Lumbar Spine at my clinic.

It truly is more than centralization

Apparently, this was the first course held in Canada that combined physical therapists and chiropractors as delegates. To me this was significant as I have always held the belief that who you are is more important than what you are.

Now the key take away from this course was perhaps the first statement made by our instructor, Audrey Long.

“It’s about applying the right thing to the right patient”

To me, the above statement means conducting a thorough and accurate assessment, applying the appropriate management strategy, and reassessing to confirm the effectiveness of that strategy. So it was clear to me that McKenzie MDT was more of an assessment method than a treatment method.

The second principle learned from this course was another “Craig-ism”…the importance of self-care. That it is very important that we first utilize an active, hands off, approach in order to allow the patient to learn about the treatment experience. Taking this approach promotes independence and a better understanding (by the patient) that they have the power to “make themselves feel better”.

Now it is still considered manual therapy, better decision making is just employed to determine when and when not to put one’s hands on the patient.

One important key to a thorough assessment is the patient history, and understanding why they got there in the first place. Quite often it is what they didn’t do, rather than what they did, but it is also likely related to their tendencies. Do they sit all day? Do they stand all day? Are they constantly bending? Are they constantly twisting? Or…do they have faulty movement patterns?

Maybe it is simply a matter of facebooking and skinny jeans?

In all seriousness, while the philosophy that surrounds this method of treatment lies in the clinical audit process, there is no question that most therapists equate McKenzie MDT to discogenic pathologies. And for good reason.

However, quite often such pathologies, especially of the acute variety, present with pain induced sympathetic overload and/or faulty core function secondary to high threshold strategies.

For the latter, often the patient presents with antalgia and obvious signs including, but not limited to, guarding, sweating, fear of movement, etc. In such cases, for me to put them through repeated movement testing from the get go, may not be the best approach. Some therapists will often use ice, IFC and e-stim, but for me, I would rather unwind the system that’s on lockdown. And by that I mean, decreasing the threat.

Tap into their PNS and the guards will go away.

Patrick Ward recently wrote about the Parasympathetic Nervous System. For me, the methods I often use are crocodile breathing, gentle perturbations rib cage and hip mobilizations, soft bracing as per Stu McGill, reactive neuromuscular training and reflex stimulation…all dependent on patient presentation. And ALL with appropriate (read reassuring) communication.

I will also groove proper hip hinging and thoracic uprighting. But following that, and when appropriate, I would then implement centralization methods. Likely on the first visit but always with respiratory control.

Ultimately though, my goal aside from the above history, would be to understand why the individual mechanically sustained the injury to begin with. And this is where the SFMA fits in…to respect the high threshold strategy. This is also where Stuart McGill’s strategies come in. Sometimes prior to calling off security, and sometimes after. But definitely always.

I admit that I am still having difficulties with my understanding of McKenzie methods. Not only because this method “tissue-fies” many pain presentations, but also because I believe there may be more appropriate ways to assess and “treat” with repeated movement in very acute conditions. Our instructor suggested that, ”we should stick with McKenzie and not mix systems (i.e. stability and muscle imbalances)” and to me, this may not be the best approach. I truly believe that the patient should take priority over the method and therefore, I will continue to do what I feel is most appropriate.

That said, I still have a lot of learning to do but thankfully the manual is close to 200 pages, so I’ll certainly be busy studying over the holidays.

McKenzie Method in Mechanical Diagnosis and Therapy – Part A Spruce Grove, Alberta - December 2-4, 2011...
Movement Patterns of the Lumbar Spine and Sacrum During the Back Squat McKean MR et al. (2010). The lumbar and sacrum movement...
Understanding Pain and Clinical Applications with Lorimer Moseley Recap of this workshop, hosted by Cynergy Education on May...

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Can the FMS be Used for Clinical Assessment?

jcubos — Fri, 09 Sep 2011 04:04:16 +0000

“I had a question about the SFMA and FMS. I know Gray designed the SFMA for patients who have pain, but couldn’t the FMS really be used for the same thing? Based on the clinic audit process that Craig (Liebenson) spoke about, couldn’t the test from the FMS be used to identify dysfunctional movement and then treat accordingly? Craig also said that every exercise is a test, so that is why I thought the FMS could be used on patients with pain, although that was not what is was intended for.”

Before I answer this question, here’s what Charlie Weingroff had to say in our interview several months ago.

“I believe Gray wrote in Movement that you actually can use the FMS to treat pain. I would suggest you must be on your game and quite skilled to be able to cull out if it is pain causing bad movement or bad movement causing pain.

Also consider that the deeper screens to the FMS are designed to bucket mobility vs. stability fixes. When there is pain, it is still challenging to always discern if you are seeing a limitation of some level, or if it’s pain creating the situation. You may be able to diffuse the pain, and the limitations fixes. Or it may not fix.

Also see Brett Jones’ thoughts about the FMS and rendering a diagnosis.

Now for my thoughts. The short answer is, any clinician should be able to use whatever means they want. Craig has his “Mag Seven”, Greg Rose, Gray Cook and the TPI/FMS gangs have the SFMA, and Janda had his own system. And I think we should respect each system…Perhaps that’s why I break the rules and incorporate all three on occasion.

That said, the true intention of the FMS was indeed to identify movement pattern dysfunctions (for pre-participation purposes) and filter out the painful from the non-painful, while the true intention of the SFMA is for the purposes of “peeling back the layers”, if you will, to identify the key dysfunction. Like Charlie said, of course one can use the FMS for the purposes of identifying the key link but I (and he) would caution against this. Reason being is aside from a practicality standpoint, there really are no peel back mechanisms and again, the presence of pain may lead one in the wrong direction. Surely each individual case is different and textbook protocol may need to be abandoned, but we should first truly understand each textbook published before us prior to writing our own.

Back to breaking the rules. Does that mean I’m ready to write my own text? I don’t think so. In fact, I believe I’m far from that. But I feel that I do have a good understanding of each system and well enough to take shortcuts when clinically warranted. But when I hit a roadblock, I go straight back to the map and get my four wheels on that highway that I deviated from. To put it simply, we need to see the forest and not get enamored by the tree right in front of us.

Every exercise IS indeed a test, but I think this principle is most relevant in the self and rehabilitative care exercises that we employ. Additionally, each exercise has its own progression and regression resulting in a continuum of exercises within a database. And finally, each joint complex has its corresponding interdependent relationship with its neighbor that must be taken into account. But ultimately, I believe that we should respect each system as intended. These pioneers have put an insurmountable amount of effort into developing their systems and it would be hard for me to believe such considerations failed to cross their minds. Granted, we as clinicians have all developed from our own educational upbringings and therefore may also have our own assessment and treatment procedures, but when we play in their backyards, I do think we should play by their rules.

FMS Level 2 in Edmonton Edmonton, AB - July 22 - 23, 2011...

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Looking at the Literature: Respiratory Evaluation and Training as an Adjunct to Manual Therapy

jcubos — Wed, 10 Aug 2011 03:29:04 +0000

Study Title: Breathing Evaluation and Retraining as an Adjunct to Manual Therapy

Authors: L. McLaughlin, C.H. Goldsmith & K. Coleman

Journal: Manual Therapy

Date: 2011

Summary:

Here’s a short little study that evaluated the presence of poor respiratory chemistry in patients suffering from neck and low back pain, as well as the efficacy of biofeedback training on chemistry, pain and function. If you are a frequent reader of this blog then you’ll know that trunk muscles have a dual postural stability and respiratory function. You’ll also know that the presence of poor respiratory control may result in faulty thoracic, cervical, and scapular mechanics. Well the authors of this paper took a series of 29 cases with neck and/or back pain who failed conservative outpatient manual and rehabilitative therapy and studied whether or not they possessed poor respiratory chemistry. Such (poor) chemistry was identified via a capnograph which measures CO2 levels at the end of a normal exhale.

A Capnograph measuring ETCO2 (normal 35-45 mmHg )

Respiratory retraining was the main intervention in this study, consisting of awareness training, capnograph feedback, and manual therapy to improve mobility. Not only did the results demonstrate that all 29 patients possessed below normal ETCO2 levels, but outcome measures recorded improved in all patients following the intervention.
While most, if not all, of you probably do not own a capnograph, this study does provide good evidence that 1) many of your patients suffering from neck and/or back pain probably also have some level of poor respiratory control, and 2) pain levels can improve following a clinical intervention that includes both respiratory training and manual mobilization.
Unfortunately however, most physical therapy, chiropractic, athletic training, and massage therapy programs don’t include respiratory training techniques in their educational curriculum. So where can one find such information?

Click on this recent blog post of mine to find out!

McLaughlin, L. et al. (2011). Breathing evaluation and retraining as an adjunct to manual therapy. Manual Therapy, 16; 51-52

Functional Capacity Evaluation & Performance Enhancement with Dr. Craig Liebenson - Toronto, Ontario - April 9-10,...
The Balloon: Your New Clinical Tool Balloons, the diaphragm and intra-abdominal pressure....

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More on the Glutes: The prone hip extension test

jcubos — Sun, 01 May 2011 20:36:36 +0000

Several months ago, Paul Bruno DC PhD, provided us with a review of his research activity on Research Review Service. To provide you with a quick and dirty rundown, he essentially described the evolution of Janda’s Prone Hip Extension test and looked at its reliability and validity in determining muscle activation orders. In short, through his research, he found that subjects with and without low back pain demonstrated variable results with respect to the activation orders of the glutes, hamstrings, ipsilateral and contralateral erector spinae and therefore concluded that the clinical importance of this test’s findings were still unclear at best.

For those of you unfamiliar with this test, essentially the objective is to look at the relative onset of firing between the glutes, hamstrings, ipsilateral and contralateral lumbar erector spinae such that in an ideal world, the relative activation of the gluteus maximus and the hamstrings fire first in relation to the erector spinae.

In light of the controversy surrounding this test, Greg Lehman, a dual chiropractor and physical therapist, provided us with an excellent post detailing the current state of the literature on this test as well as some of his thoughts on its clinical utility. In short, while he concludes in his post that for most, a delay in glute max firing seems to be the norm, activation and amplitude of firing can be modified and that abnormal activation patterns (according to this test) has yet to be proven…scientifically…to be dysfunctional.

As such, Andreo Spina also provided his thoughts on the utility of this test and described his preference for glute max testing via modification through testing at approximately 30 degrees of hip flexion. He also discussed the utility of supine bridge testing, ala Stuart McGill, in consideration of the fact that during walking, the glute max tends to “dim down” in activity during hip extension beyond 30 degrees (of flexion).

Many clinicians who utilize the prone hip extension test however, still argue that clinically relevant information can be revealed irrespective of the current state of the literature. This is not surprising since research commonly isolates single rather than multiple variables for scientific scrutiny. Therefore, while it may be too early to throw this particular test out with the bath water, it is important that we be cognisant of the evidence and understand that hip extension motor patterns should be cross-examined via a variety of testing means such as in supine, modified prone, side-lying and upright (half-kneel and single leg stance) positions.

Half-kneeling cable lift exercise is a test

(not a great picture but it was the best I could find)

. .

This is also a test

Why not test AND treat?

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The Role of Diagnostic Imaging for Low Back Pain

jcubos — Thu, 21 Apr 2011 05:13:15 +0000

Study Title: Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care from the American College of Physicians

Authors: R. Chou, A. Qaseem, DK Owens et al.

Journal: Annals of Internal Medicine

Date: 2011

Summary:

My full review of this paper was recently posted on Research Review Service but since I feel strongly about its message, I thought it would be a good idea to provide you with a brief introduction. In concert with the high incidence of low back pain in today’s society lies a relatively high rate of requisitions for diagnostic imaging of neuromusculoskeletal conditions pertaining to the lumbar spine. Unfortunately, the appropriateness of such imaging studies may be questionable at best for many of these conditions owing to the fact that the outcome of care often leads to similar results in those patients who have undergone “routine” imaging and those who have not regardless of whether such tests were performed. Certainly, such imaging may be required for those patients suffering from severe and / or progressive neurological deficits as well as for those presenting with serious underlying conditions however, more often than not, those patients presenting in general family, chiropractic or rehabilitation practices may do well without the unnecessary doses of radiation and costs to the health care systems. This best practice advice paper provided by the Clinical Guidelines Committee of the American College of Physicians provides the medical reader with a summary of the current literature pertaining to the utility of diagnostic imaging for low back pain and advises on the rationale behind evidence-informed decision making when a patient presents with low back pain symptoms. Utilizing results from high-quality studies, suggestions are made for cost worthy diagnostic protocols and advice is given on the potential harms and benefits of radiological procedures. Additionally, a valuable summary for patients has also been provided of which can be easily accessed here.

R. Chou, A. Qaseem, DK. Owens et al. (2011). Diagnostic imaging for low back pain: Advice for high-value health care from the american college of physicians. Annals of Internal Medicine, 154; 181-189

Movement Patterns of the Lumbar Spine and Sacrum During the Back Squat McKean MR et al. (2010). The lumbar and sacrum movement...

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FMS Level 2 in Edmonton

jcubos — Thu, 14 Apr 2011 13:00:32 +0000

For those of you who are in the fitness, coaching, or health care industries, I wanted to give you a heads up that there will be a Functional Movement Screen Level 2 workshop here in Edmonton in July. Please note that you must have completed Level 1 in order to attend.

July 22 – 23, 2011

Click here to register.

For more information on the Functional Movement Screen, go to www.functionalmovement.com

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Dr. Liebenson in Toronto – April 2011

jcubos — Sun, 10 Apr 2011 03:27:31 +0000

For those of you who attended Dr. Liebenson’s course this weekend in Toronto, here are some previous posts of mine that may provide you with a brief summary of the principles he espouses.

Enjoy!

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High Ankle Sprains

jcubos — Sat, 12 Mar 2011 04:41:18 +0000

A high ankle sprain is a high ankle sprain is a high ankle sprain right?

Um, not really!

A high ankle sprain can be an injury to any or all of the following:

The distal anterior tibiofibular ligament (ATIFL)
The distal posterior tibiofibular ligament (PTIFL)
The transverse ligament
The interosseus ligament
The syndesmotic recess
The synovium
The plica
The intermalleolar ligament
and may include a fracture to any of the osseous structures

There are certainly no shortage of structures in this area and therefore, assumption that the injury is sustained solely by the ATIFL is simply a dart thrown with a blindfold.

For example, upon suspicion of a syndesmotic injury, it is important that specific clinical tests are utilized to determine in fact whether or not such injury was sustained. Dr. Pajaczkowski does a nice job in this case report of summarizing four orthopaedic tests including the squeeze test, the external rotation stress test, ligament palpation, and passive dorsiflexion. It is also important to assess the proximal tibiofibular joint to determine the possible presence of a fracture or ligamentous injury.

Following this, should imaging be required, an x-ray is commonly the first line of defense to determine the presence of osseous damage. Among the studies required, the entire tibia and fibula must be examined to identify whether or not a fracture of the proximal fibula is present. Additionally, stress views are commonly performed since traditional anterior-posterior and oblique views may not fully demonstrate an increased tibiofibular clear space. One specific injury commonly missed is a fracture of the posterior malleolus.

While access to MRI may be limited for some, its clinical utility is generally of extreme importance for optimal management since specificity of diagnosis = specificity of treatment. This imaging modality will likely provide the medical team with direction of care through the identification of the specific tissue(s) involved (as per above). Since there are too many structures to discuss, more information on diagnostic imaging of these injuries can be obtained from the articles by Molinari et al, Williams et al, and Hermans et al.

From a rehabilitation perspective, treatment is typically a product of the specific grade of injury sustained. Naturally, the P.R.I.C.E principle, medication, and modalities may take precedence although it is not uncommon for early active range of motion to be employed. Certainly, addressing dysfunctional and non-painful patterns will prove valuable yet the focus must not be taken away from basic tissue healing principles. To my knowledge, a randomized control trial for the rehabilitation of such injury has yet to be performed although several papers have identified successful rehabilitation protocols in the management of this injury. For a detailed outline of rehabilitation protocols for this and other orthopaedic injuries, you may be interested in obtaining Clinical Orthopaedic Rehabilitation by Brotzman and Manske.

A must have for rehabilitation clinicians

Unfortunately, the recovery time line for high ankle sprains are longer than that of “traditional” ankle sprains but hopefully the above information will facilitate a more optimal approach to the management of this injury. Certainly, T.D. Forss and Chris Davie have their work cut out for them but I have no doubt they are more than familiar with such injuries (they are very common in ice hockey) and will have Taylor ready to go for the 2011-2012 season.

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Looking at the Literature: Reinjury Following Acute Hamstring Strains in Track & Field

jcubos — Fri, 11 Feb 2011 02:44:03 +0000

Study Title: Reinjury After Acute POsterior Thigh Muscle Injuries in Elite Track and Field Athletes

Authors: N Malliaropolous, T Isinkaye, K Tsitas & N Maffulli

Journal: American Journal of Sports Medicine

Date: February 2011

Summary:

Through one simple omission, this article provides little value. As you may be aware, the biarticular nature of the hamstrings seems to put this muscle group at higher risk of strain than monoarticular musculature. Since previous research has demonstrated reinjury rates as high as 34%, the objective of this cohort study was to determine whether a specific clinical assessment may be able to provide indicative factors of possible reinjury following an acute hamstring strain. 165 elite track and field athletes with first-time strains were evaluated in this prospective study. The specific clinical assessment utilized was a 4-grade classification system of hamstring injury based on active range of motion (AROM) – the greater the AROM deficit, the greater the severity of injury. Interesting classification system if you ask me! All athletes followed the same standardized plan of management following their injuries although the rehabilitation protocol was not described. Based on this classification system, it was revealed that athletes who suffered a grade II hamstring strain demonstrated a significantly higher risk of reinjury than those who suffered a grade I, III, and IV injury.

Unfortunately, the results from this study mean very little to me since the rehabilitation protocol administered was not provided. One of the highest risk factors for reinjury is previous injury so it is clear that in non-contact sports, many rehabilitation and sport conditioning professionals are missing the boat when it comes to return to play. Therefore, in my opinion, a grading system based on AROM has little value compared to a well designed return to play rehabilitation and conditioning strategy as it pertains to minimizing the risk of reinjury following acute hamstring strains in elite track and field athletes.

Malliaropolous N et al. (2011). Reinjury after acute posterior thigh muscle injuries in elite track and field athletes. American Journal of Sports Medicine, 39(2); 304-310

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Diagnosis and Management of Tendinopathies

jcubos — Sun, 30 Jan 2011 21:34:29 +0000

The following is a review of several of Craig Purdam’s presentations on tendinopathy at the recent 2011 Pan Pacific Conference for Medicine and Science in Sport, held in Honolulu.

Craig is the head of physical therapies for the Australian Institute of Sport and had a wealth of information to share during the weekend. I was very grateful to be in attendance.

Craig proposed that the pathology and the response to treatment are different in the various tendinopathy presentations and therefore interventions should be dictated by the specific pathology. More specifically, that there exists a continuum of tendon pathology. Namely:

Reactive tendinopathy
Tendon Dysrepair (failed healing)
Degenerative Tendinopathy

Craig stressed that rather than looking at the above as three distinct phases, that a continuum should be kept in mind.

Source: http://bjsm.bmj.com/content/43/6/409/F1.large.jpg

Classification of Stages must be identified via:

Clinical picture, and
Diagnostic imaging

Stage characteristics:

Reactive Tendinopathy

Pathology: Non-inflammatory proliferative response secondary to acute tensile or compressive overload (i.e. too much too soon). Note that tensile forces cause also compression (think of an elastic band narrowing in width (compression) as it is being stretched (tension). Tendon thickening results, presumably as a protective mechanism. Upregulation of large proteoglycans, resulting in increased binding with water, accounts for the observed swelling
Diagnostic Ultrasound: Cleaving of collagen (longitudinal separation) as exhibited by diffuse hypoechogenicity
Demographic: Common in younger athletes (i.e. a lengthy basketball tournament) or in the young deconditioned athlete who is now exposed to moderate load exposure.

Tendon Dysrepair

Pathology: Failed attempt at healing (greater tissue matrix breakdown) results in matrix disorganization and further collagen separation. Changes are more focal and increased thickening is certainly present
Diagnostic Ultrasound & Doppler: collagen fascicle discontinuity and focal hyoechogenicity, as well as increased vascularity
MRI: swelling and increased signal intensity
Demographic: May be secondary, but not limited, to chronic overload in young athletes. In older athletes with less adaptive, stiffer tendons, this stage may develop with lower loading exposure

Degenerative Tendinopathy

Pathology: Perhaps the most clearly described stage in the literature. Cell death is apparent, as well as matrix disorganization, vascularity, and little collagen. Reversibility of pathology is minimal
Diagnostic Ultrasound & Doppler: Hypoechogenicity and vascularity
MRI: Increased tendon size and intratendinous signal intensity
Demographic: Primarily in older athletes but may present in chronically overloaded tendons of young elite athletes. Focal nodularity with or without general thickening. Typical history of repeat bouts of tendon pain with short-term relief. Injury often returns with changes in tendon load. Rupture may occur.

For ease of interpretation, the above continuum is divided into:

Reactive/Early Tendon Dysrepair, and
Late Tendon Dysrepair/Degenerative

Cornerstones of Rehabilitation:

Confirmation of actual tendon involvement
Stage identification
Symptom and function quantification via outcome measures
Load modification via training alteration and biomechanical efficiency
Load progression
Pharmacological and Modality interventions

Considerations:

Mono-therapy is rarely successful
Tendon unloading must only be reserved for significantly “hot tendons” and must be performed for only short periods of time. Otherwise may result in decreased tissue strength

Rehabilitation Principles:

Unloading interventions – i.e. biomechanical efficiency
Priority given to muscle wasting – need hypertrophy
Early rehab – static and slow
Speed progression
Volume progression of functional activities
Late rehab – elasticity
Load management

Treatment Strategy:

Reactive Tendinopathy:

Load management
Slow tempo
Moderately heavy loads with full recovery between sessions
Inner range then outer range
Isometric
Downregulate sensitization – you do not want to push this stage and aggravate further

Tendon Dysrepair:

Gradually increase length (outer range)
Introduce Speed and Contractility
Undulate loading in 3 day (High, Low, Moderate) cycles

Degenerative Tendinopathy:

Introduce Contractility and Elasticity
Load undulation
Eccentric progression
*Note that this is the only stage where eccentric exercise was suggested. Perhaps this may shed some light as to why eccentric exercise has demonstrated mixed-results in tendinopathy rehab. Are some of you utilizing rehabilitation modality at the wrong stage?

*Note modalities such as cross-friction, therapeutic ultrasound, and shockwave are only appropriate in the Late Tendon Dysrepair and Degenerative Tendinopathy Stages

*For (hopefully) obvious reasons, I have intentionally omitted recommendations pertaining to pharmacological treatment..

Purdam has authored and co-authored numerous articles on tendinopathy but perhaps three of the most significant ones you may be interested in are:

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Looking at the Literature: Return to Play in Sport

jcubos — Thu, 27 Jan 2011 08:43:26 +0000

Study Title: Return-to-Play in Sport: A Decision-Based Model

Authors: DW Creighton, I Shrier, R Shultz, WH Meeuwisse & GO Matheson

Journal: Clinical Journal of Sport Medicine

Date: September 2010

Summary:

For those of you involved in sport medicine, here is an excellent example of scientific insight into the factors that may influence and determine Return to Play decision making. This paper, authored by individuals at Stanford University, McGill University and the University of Calgary, details the all important, multifactorial decision making process of allowing an athlete to return to “full participation in sport without restriction”. Through a literature synthesis, a model that included the Evaluation of Health Status, Evaluation of Participation Risk, and Decision Modification was proposed. While the authors noted that the ability to quantify several decision elements may be limited, they suggested that decision modification must only be considered once participation risk is determined.

Although seemingly short and straightforward, this paper provides comprehensive insight into the variables that must be considered by those in a priviledged position to determine whether or not an athlete is permitted, let alone mentally and/or physically capable of, returning to sport.

Complete resolution of symptoms “cannot be considered in isolation” when determining return to play

Creighton DW, Shrier I, Shultz R, Meeuwisse WH & Matheson GO. (2010). Return-to-play in sport: A decision-based model. Clinical Journal of Sport Medicine, 20(5); 379-385

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