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:

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• Reactive tendinopathy
• Tendon Dysrepair (failed healing)
• Degenerative Tendinopathy

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

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

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Classification of Stages must be identified via:

• Clinical picture, and
• Diagnostic imaging

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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.

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

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

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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

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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

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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

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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:

• Cook JL & Purdam CR. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43; 409-416
• Allison GT & Purdam C. (2009). Eccentric loading for achilles tendinopathy – strengthening or stretching? British Journal of Sports Medicine, 43; 276-279
• Malliaras P, Purdam C, Maffuli N & Cook J. (2010). Temporal sequence of greyscale ultrasound changes and their relationship with neovascularity and pain in the patellar tendon. British Journal of Sports Medicine, 44; 944-947

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Are we still missing the boat?

In 1984, a study was published in the Archives of Physical Medicine & Rehabilitation by Spencer et al that took the fitness and rehabilitation worlds by storm. In this study, it was revealed that experimental knee joint effusion resulted in inhibition of the vastus medialis, rectus femoris, and vastus lateralis muscles of the quadriceps. Specifically, it was noted that a minimal threshold of only 20-30 mL of saline was necessary to cause inhibition of the vastus medialis as compared to the other two muscles studies. The results of this paper led to a strong emphasis by many professionals on the importance of vastus medialis obliquus (VMO) training in the presence of knee pain and / or injury.

Vastus Medialis Obliquus

Some of the exercises utilized to train the VMO included:

• Terminal Knee Extensions
• Straight Leg Raises
• Mini-Squats with adduction
• Wall Squats

From the late 90′s to the turn of the century however, anterior cruciate ligament, patellofemoral and iliotibial band injuries were being heavily researched, leading many professionals who were on top of their game down a different path. Thanks to biomechanical research investigating jump-landing mechanics, focus had shifted from the VMO toward the gluteus medius (GMED) and maximus (GMAX) musculature. Some of the common buzzwords associated with such research included dynamic valgus and valgus collapse, indicating that perhaps inefficient GMED and GMAX activation and contractions led to unwanted femoral adduction and internal rotation, and subsequently, abnormal stresses sustained by the knee. What was resulted was an increase in open-kinetic chain Jane Fonda type exercises both in rehabilitation clinics and commercial gyms alike.

Including clam shells and side lying leg raises

With a little more critical thinking however, leading professionals were doubtful of the “benefits” of such open chain exercises. Strength and conditioning coaches, especially, were more interested in a functional approach to training and preferred closed chain exercises to combat the unwanted valgus collapse presentation. Mini band walks, x-band walks, monster walks, and crab walks were only but a few of the exercises utilized by coaches and trainers to train the GMED.

Professor Stuart McGill, considered one of the world’s leading spine biomechanists, thought differently. Through countless hours of data collection both in his lab and on the field, McGill realized that such a relatively tiny muscle as the GMED could not possibly control frontal plane stability of the hip and knee. It was his assertion that since the “core” acts to CONTROL rather than initiate movement, the contralateral quadratus lumborum (QL) must eccentrically contract to hold the pelvis up (i.e. during the swing phase of walking/running), as opposed to the hip abductor moment created by the GMED. I believe these arguments stem largely from his research comparing trunk muscle activation, lumbar spine motion, load, and stiffness of different strongman events and while I assume it will take more evidence for many of you to drop the minibands, please consider that many previous electromyographic studies have failed to include the QL in data collection (1, 2).

Certainly, some of you may be wondering about the role of the GMAX in dynamic femoral internal rotation control. May I humbly suggest that the greatest contribution of this muscle occurs in situations and movements that warrant double leg stance and single leg deep hip and knee flexion.

Special thanks to Ben Bruno for directing me to this video.

Having said all this, in no way am I advocating the use of isolation-type exercises as the staple of rehabilitation and performance training. My objective here is simply to point out that a concentrated focus on the gluteus medius for rehabilitation and training of the knee (for loaded movements) may still in fact be an exercise in futility and that a more dedicated emphasis a little higher up and to the other side may produce more optimal results. For unloaded sports (i.e. running), direct lateral hip emphasis is likely still warranted.

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Here’s a brief summary of the study:

Study Purpose:

• To determine the presence of a relationship between hamstring length and PFJ stress at 3 specific knee joint angles of flexion.

Study Population:

• 16 recreationally active males divided into two groups based on knee joint angle-measured hamstring length.

Methodology:

• A biomechanical model incorporating knee joint angle, knee extensor moment, and PFJ contact area was used to quantify PFJ stress.
• MRI and 3D motion analyses were also utilized in this study.
• A one-way ANOVA to determine the variations in PFJ stress between the 2 groups (with and without reduced hamstring length) was used.

Main Findings:

• Patellofemoral Joint stresses differed significantly between the two groups at specific angles of knee flexion.
• No significant differences in hip angles between the two groups.

Clinical Application:

• This study demonstrated that subjects with reduced hamstring lengths have increased PFJ stress during various positions of the squatting movement.  As a result, such a decrease in length MAY contribute to the pathogenesis of various conditions relating to the knee.
• These results enable us to consider another factor when managing those with knee pathology.

For a complete and “evidence-informed” understanding of the study, check out my review. I have obviously left out specifics from this study in this post as Research Review Service is a paid membership site. However, if you would like more information, please do not hesitate to ask.

Photo source

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*note: the above link for RRS is an affiliate link

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Sure surgical interventions are dependent on the goals and functional capacity of the individual but most of us generally correlate surgery with ACL injuries, no? I mean, I thought PCL and MCL injuries were the only ones that didn’t require an operation (that was sarcasm by the way).

Well Roos (a prominent knee researcher) and colleagues recently published a paper on non-elite athletes, outlining that there were relatively little differences between in functional capacity and return to physical activity between their control and experimental groups.

Here’s an excellent summary of the study’s findings.

Surgery Might Not be Needed for ACL Tears.

To read the full paper, click here

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This is a fantastic issue with topics such as Thoracic Outlet Syndrome, Neurodynamic testing for Carpal Tunnel Syndrome, and Reciprocal Inhibition (stretching), among others. I highly recommend anyone and everyone in manual therapy and rehabilitation to check it out.

On another note, I just received word that my case study on “costochondritis” has been accepted for publication. That makes two papers in press…AWESOME!

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Part 2: The research behind the technique

Part 3: What is P.A.I.L’s™ and how is it used in this system?

Part 4: Assessment techniques, and how the system sets itself apart

For more information on Functional Range Release and any of Dr. Spina’s other seminars, please visit Functional Anatomic Palpations Systems.

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What we need:

• Dorsiflexion mobility

Why we need it:

• Minimize stress on knee

How we can get it:

KNEE:
What we need:

• We need to realize that the knee is often an innocent bystander

Why we need it:

• We need to realize this because the research says so

How we can get it

• We can achieve optimal knee mechanics by looking both above (the hip) and below (the ankle) this joint.

HIP:

What we need:

• Saggittal plane mobility
• Extension strength

Why we need it:

• Minimize stress on lumbar spine

How we can get it:

• Glute Bridge
• Glute Bridge – Marching
• Glute Bridge – 1 Leg

What we need:

• Frontal & Transverse plane dynamic stability

Why we need it:

• Minimize dynamic valgus at knee and dynamic internal rotation at knee

How we can get it

• Side Lying Abduction
• Clam Shells (Hip – External Rotation)
• Mini Band – External Rotation
• Airplane (I’ll get a video of this up soon)

LOW BACK / CORE:

What we need:

• Antirotation, Antiextension, Antilateral flexion STABILITY

Why we need it:

• To be able to transfer forces THROUGH not TO the “joint” (aka Core”)

How we can get it:

• Antirotation: “Pig on a Spit” Roll
• Antiextension: Front Plank series including the Body Saw
• Antilateral flexion: Farmer walk / Suitcase carry

What we need:

• Lumbar intersegmental stability

Why we need it:

• To be able to transfer forces THROUGH not TO the “joint” (aka Core”)

How we can get it:

• Effective “core activation” methods

THORACIC SPINE:

What we need:

• Rotation & Extension mobility

Why we need it:

• Lumbar relief & Shoulder mobility

How we can get it:

SHOULDER:

What we need:

• Scapular stability

Why we need it:

• Shoulder mobility

How we can get it:

For those of you who are unfamiliar with this approach of looking at the body, please have a look at Coach Boyle’s The Joint by Joint approach and FITS Toronto’s 5-site Integrity

Anatomical photos courtesy of Primal Pictures

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A recent study published in the Journal of Strength and Conditioning Research, examined the electromyographic activity (EMG) of various muscles during the squat exercise when performed using the Smith machine as well as using free weights. This was performed as a follow up to a 2005 study by Anderson and Behm that demonstrated higher EMG activity of the quadriceps muscles during the Smith Machine squat.

The major difference between this and that of its predecessor was that a weight equal to an 8RM for EACH exercise (to facilitate relative intensity) was utilized in comparison to a fixed, absolute weight for both exercises used by Anderson and Behm.

EMG activity was collected for the following musculature:

• Tibialis Anterior
• Gastrocnemius
• Vastus Medialis
• Vastus lateralis
• Biceps Femoris
• Lumbar Erector Spinae
• Rectus Abdominis

A relatively low “N” was used: 3 men, 3 women.  All were active in sports and familiar with the use of both free weights and the Smith machine.

The average absolute EMG activity for the free weight squat was:

• 34% higher from the gastrocnemius
• 26% higher from the biceps femoris
• 49% higher from the vastus medialis

Interestingly, no significant differences in EMG activity of the trunk musculature were found between the two exercises. I will keep my opinions to myself on this, especially when only 6 subjects were used.

Additionally, I was both surprised and disappointed the authors failed to include the gluteal musculature within this study since hip extension is one major component of the squat exercise.

My Thoughts:

These findings likely represent a increased stabilizing role of the above musculature for the hip, knee and ankle during free weight squats.

• Gastrocnemius for ankle stability
• Gastrocnemius for knee stability (Don’t forget that the gastrocnemius not only crosses the ankle joint but the knee as well!)
• Vastus Medialis for knee stability
• Biceps Femoris for hip stability (Again, its unfortunate Gluteal activity was not recorded)

Your Thoughts?

*Here’s a video I found of squatting with pretty decent technique. The trunk and tibia are parallel, he’s in neutral spine, he doesn’t sandwich, and his weight is relatively back on his heels. Not sure about the guy doing dips in the background though!

Photo source

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“Certain athletes are at higher risk of knee pain and non-contact knee injury than others.”

End of post.

(just kidding)

The above statement is well known but unfortunately, not many of us know exactly why. Thankfully, the American Journal of Sports Medicine gave us some input into the biomechanical reasons some athletes are at risk of patellofemoral pain syndrome (sorry Mike) and potentially at risk of non-contact ACL injury. The information below is taken from two VERY recently published papers from the large scale Joint Undertaking to Monitor and Prevent ACL Injury (JUMP-ACL) study. This study examined the biomechanical variables involved in a jump-landing-rebound task.

Biomechanical Factors Potentially Involved with Risk of Non-Contact ACL Injury

• Lower knee and hip flexion motion (saggital plane kinematics)
• Higher knee valgus and hip adduction angle (frontal plane kinematics)
• Greater internal knee and hip internal rotation moment (transverse plane kinematics)
• Greater internal knee and hip extension moment and anterior tibial shear force (saggital plane kinetics)
• Greater internal knee valgus and hip adduction moment (frontal plane kinetics)
• Greater vertical ground reaction force
• Women

Biomechanical Factors Potentially Involved with Patellofemoral Pain Syndrome

• Decreased hip abduction, knee flexion, and knee extension strength
• Lower knee extension moments
• Greater navicular drop
• Decreased peak knee flexion angle
• Women

This is what I think:

• Women are more important than biomechanical factors (they are actually more important than many things in life)
• Athletes need to learn to absorb the landing (land with the toes and roll back onto the heels in one fluid motion)
• Athletes need to eccentrically control the lower extremity from collapsing in when landing (don’t land knock-kneed)
• Feet should be shoulder width apart
• Spine should be neutral and the core should be stiff
• Athletes need to spend some time on the glute/posterior-chain eccentrics

The preceeding information was derived from the two most recent issues of AJSM. It is strongly suggested that for a complete understanding, readers view the papers in their entirety as Padua et al was based on validating the Landing Error Scoring System and Boling et al interestingly found higher hip ER strength and lower ground reaction forces as risk factors.

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Scientific knowledge expands daily. This article was published in 2008. I started this blog 3 days ago…THEREFORE…the information you are about to read MAY contain concepts that are obsolete…READER DISCRETION IS ADVISED!

The following is a summary of the IOC current concepts statement published in the British Journal of Sports Medicine last year. Contained within this summary are the general principles that were established based on decades of research pertaining to ACL injuries in female athletes.  Since the amount of potential factors associated with injury are plentiful, this review is limited to only those concepts with conclusive evidence.

Epidemiology

• As a whole, ACL injuries most commonly result from non-contact mechanisms
• Although the rates of ACL injury in men and women are similar in professional sports, younger female athletes are at higher risk (than aged- and sport-matched males)
• Along with men’s spring football, women’s gymnastics, soccer, and basketball have the highest injury rates per 1000/athlete exposures.
• Consistent with most sports, injury rates are higher during competition

Risk Factors

• There is an association between intercondylar notch width and risk of ACL injury. Females generally have smaller notches than males and therefore, likely a smaller ACL. It has been suggested that these ACLs may have lower linear stiffness, fail earlier in elongation, absorb less energy, and fail with lower loads.
• The relationships among the presence of sex hormones within the ACL and oral contraceptives with ACL injury risk are still inconclusive.
• Women appear to be at greater risk of ACL injury during the pre-ovulatory phase.

Mechanism of Non-Contact Injury

• Injuries most often occur when landing from a jump, cutting, or deceleration.
• Kinematic analyses have revealed that women land with less knee flexion than men. Women also maintain higher knee extension and valgus during stance phases of running and cutting. Finally, women also display higher quadriceps EMG activity during max loading. Therefore, a straighter knee and higher quadriceps activation likely contribute to the injury mechanism. Other components include anterior translation, dynamic valgus in near extension, increased trunk motion, and a high load placed on the leg or foot that is away from the body’s COM.

Evaluation

• Key components of diagnosis include: sudden knee pain during high intensity activity, inability to resume play, “popping” sensation, haemarthrosis.
• The course of ACL injury classifies the injured into copers, adaptors, and non-copers.
• ACL reconstruction does not warrant surgical management of the injured MCL.
• The meniscus is associated in approximately 50% of ACL injuries. Note: Mike Reinold recently posted an excellent blog (by D. Lorenz) on meniscal testing here.
• A thorough examination searches for articular cartilage, ligamentous, and bony/bone marrow lesions.
• The pivot shift test is best for ruling in ACL injury. The Lachman test is best for ruling out ACL injury. (It is also the most accurate).
• Patient-administered questionnaires should be used as an outcome measure and quantified scores should be kept separate from categorical variables (good/excellent).
• While the incidence of injury in girls increases at puberty, there is a potential risk of growth disturbances with prepubescent operative management.

Rehabilitation

• Although the restoration of full knee extension is important in initial stages of rehab, ROM should be compared with the unaffected knee to determine normal ranges (hyperextension may be the norm in some patients).
• OKC training should be introduced and progressed cautiously, commencing between 90 and 40 degrees.
• CKC exercises recommended at the commencement of rehab. Early weight bearing and mobilzation are safe.
• A minimum of 3-4 functional performance tests should be used for evaluation.
• Return to play should be goal-based (not time-based)

Prevention

• Most prevention programs utilize neuromuscular and proprioceptive training to alter the dynamic loads placed on the tibiofemoral joint
• Henning was the pioneer in neuromuscular training for ACL injury prevention (just thought I’d add that in, dude deserves his props!)
• Program intervention generally takes a minimum of 4-8 weeks in order to impart its desired effect.
• Programs should be implemented as early as possible (age) and those that use minimal equipment are generally more successful
• In jumping sports, proper landing involves softly landing on the forefoot, rolling back to the rearfoot, two-feet landing, and knee and hip flexion engagement.
• In cutting sports, dynamic valgus should be avoided as the “knee over toe” position should be emphasized.
• Programs should be incorporated as a regular warm-up, should also include strength, power, plyometric, and agility exercises
• The drop vertical jump test is a good way to identify those at risk.

There you have it. My generalized summary of the IOC current concepts statement. Since published research on ACL injuries literally come out daily, please be reminded that some of the above concepts may have been updated.

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