Exercise Prescription for Tendinopathy
On this week's episode of The Dance Docs I sit down with Dr. James Gallegro PT who practices with HSS in New York, to discuss exercise prescription for tendinopathy. We dive in to discuss historic treatments for tendinopathies along with some of the current research surrounding PT approaches. We round this episode out looking at the tricky supraspinatus tendon and how to progress a dancer back to full activity.
Exercise Prescription for Tendinopathy
Scientific research changes, we know more things today about the actual tendon than when I graduated from PT school.
Part of my goal is to share this information, open the dialogue to new ideas.
I know as a clinician I have been stuck in the treatment of a dancer with tendonitis/tendinopathy that seems like it is just in a standstill or slowly getting worse.
Review of tendinopathy
For a more in depth review of tendinopathies please check out our previous episode #18 with Dr. Davenport MD
Tendons attach muscle to bone
What is it- Nonrupture injury to the tendon that is exacerbated by mechanical loading and results in impaired loading capacity for future activity.
What changed to overcome the tendons capacity to handle load
Increased intensity
Increased time
looks at the tissue level and the degeneration of the collagen that forms the tendons.
The damage from overload that was tolerated one day can decrease the tolerance to load over the next few days as the tendon continues to repair
How does chronicity come into play?
Are 6-month old tendinopathies to be managed differently from 6-day old tendinopathies? Why?
Continuum cycle-
When we look at this closely tendon injuries live on a continuum cycle where someone can move between the states (maybe until they reach the last one!)
Normal
Reactive
Swelling
Tender to touch
Catch at the point easier to bring back to “normal” tendon
Degenerative
Weaker tendons
Years of overload through the tendons
How long has a dancer been working on the continuum or with tendon pain/discomfort
What was the level of performance
When did you first have discomfort
What were you training for at the time/ what did your rep look like
Were you just taking class or were you rehearsing as well
Was it competition season
How much rest were you getting
How much jumping/lifting were you doing
When did it hurt and how much
Did your pain levels go down
Have you been pushing through this, and for how long?
Patients past medical history or underlying systemic diseases or auto-immune conditions
Diabetes
Celiac
Auto-immune arthritis
Food intolerances
Are these under control?
Historic PT approach to treating the tendon/ tendinopathy
Eccentrics
Where is the current research pointing us to?
Isometrics
Low load high volume (medical exercise therapy)
Heavy slow resistance training
Concentric vs eccentric muscle contraction
Concentric- muscle is shortening and usually lifting against gravity
Overcoming the force of gravity
Requires more force
Eccentric- muscle is lengthening and controlling the lowering against gravity
Losing the battle with gravity
Requires slightly less effort
Many times clinicians will start with eccentric work because you are not having to load the tendon as much to overcome the force of gravity
Better tolerated initially due to decreased load
Isometrics
Activating the muscle but maintaining the limb in the same position
Assist in pain control for a reactive tendinopathy
Good starting point prior to transitioning to eccentrics the to concentrics
Working as a community in getting away from- just do eccentric to actually understanding the progression of exercise and proper loading of the tissue
Research supports most treatment approaches for treating the tendon
What is your approach to treating a tendon/tendinopathy
Transverse / Cross friction massage
Are you doing it for pain control, stimulation of blood flow, to align the tendon fibers as they rebuild?
Decrease pain to allow for tolerance of exercise
Ask yourself if you overloaded the area with stimulation, and decrease the overall awareness
Might want to watch your patient closely when exercising in the clinic for proper form and alignment
IASTM- Instrument Assisted Soft Tissue Mobilization
Use on the muscle belly over the tendon to decrease any uneven pull within the system
Cupping/ w movement
Return slide and glide into the fascial planes
Areas where tendons pass through and need improve glide over bony areas
Great to use silicone cups
Have patient work through range that was painful to see if you can decrease pain and improve mechanics
Can see immediate buy in from patients
Modalities
Class 4 laser- chronic conditions to help stimulate the mitochondrial/ cellular level activity that may be slow due to decreased blood flow
What effect are you looking to have on the tendon,
how are these techniques going to have an effect on your treatment plan that could lead to failure
Want to optimize how the patient moves
If you go searching for research to support most treatment methods you will find it
treatment is like figuring out how much to water a plant, does it need a watering can full (large load) or does it need one ice cube (low load over a long duration)
Manual therapy and modalities have a place when treating tendon injury, but they are not the final solution.
Use them based on the patient in front of you and what they respond to but don’t forget that you do need to properly load the tendon through exercise for full healing to happen
How do you describe a tendon to a patient?
Dr. Kat PT- a tendon is like a rope but realistically it’s like a rope attached to the bone at one end and to rubber bands at the other. We want the force generation to occur at the rubber bands
Dr. James PT- I love the rope analogy - I also use that one with patients all the time. I think it helps patients understand and picture the “pulling” and “tension” that the tendon needs to withstand. What I add to that is two things: climbing ropes of different diameters have different loading capacity - just like your tendons. When our tendons fray though - we are “biological rope” that can heal!
What is Medical Exercise Therapy
Oddvar Holten early 1960s - Norwegian professional speed skater turned physiotherapist
Originally developed to help injured athletes to feel like they are beginning to train again
Helping athletes with the mental and emotional aspect of dealing with injury and recovery
Have them decrease the load and do lots of repetitions
Based on the concept of “circulatory” training w/ up to 90 reps of an exercise (3 x 30)
If the patients is struggling with 8-10 reps the exercise most likely has too much load for initial loading of the tendon for health and repair
Introduces the concept of “dosing” in exercise prescription
Love the concept of dosing exercise like a doctor may dose a medication
On previous episodes Dr. Emily Noe PT and I discussed dosing exercise in relation to strength/endurance/power in muscles
Strength- 80-90% 1RM, 4-10 reps to fatigue
Endurance- 60-80% 1 RM, 10- 25 reps to fatigue (ACSM <50%)
Power- >90% 1RM, <4 reps to fatigue
3 sets of 30 reps may seem like a lot of reps, but the average dance class has ~250 landings.
If 10 single leg releves is challenging how can a dancer be expected to complete class with full jumps and then go into rehearsal.
Tendons with greater degeneration can still improve but the incremental steps are much smaller and the overall rehab time takes longer.
Periodization
Period of time where an athlete can be completely off
Period of ramping up
Strength training
Sport specific skill training
Pre season
Begin focusing specifically of sport
Period of performance season
Can we actually make periodization acceptable or possible in the dance community?
Supraspinatus tendinopathy treatment
Supraspinatus tendons lies underneath the acromion arch of the clavicle
It is a part of the rotator cuff
Helps to complete raising arm to the side
Can cause impingement symptoms when the arm is lifting above shoulder height
Painful arc below shoulder height is due to length of lever arm
Consider lifting a broom from the end of the handle with the bristles pointed down vs the bristles pointed out to the side
Broom still weights the same but the distance is farther away from your center
If patient has pain with daily movement or they have a painful arc you need to work on deloading the arm
Where to start if patient has pain with daily movement
Deload the arm
Hold onto a pulley with weight and allow the pulley to assist in raising the arm
How much help do you give them
Want patient to be able to complete 20-30 reps with mild fatigue and no loss of form for 2-3 sets
Progress by adding less weight to the pulley (less assistance)
Patient may only be able to complete a few reps without pain or with good form
Beginning to stimulate the tendon without overloading the tendon
Should also be teaching proper scapular mechanics
How can too much load too soon affect the tendon
There is limited space between the acromion process and the head of the humerus where the supraspinatus tendon runs (subacromial space)
Forward rounded shoulders can lead to a decrease in the space
If you exercise a tendon the circumference of a degenerated tendon will increase in diameter proportional to the amount of load
Already small space→ now thicker tendon from increased load → increased irritation and further degeneration of the tendon
Pain should not increase as you load the tendon, could be causing more harm than good
Patients pain should not be increasing more than 2 levels from baseline
Pain should returned to baseline or below within 24 hours
Don't apply the rule no pain no gain- especially when it comes to tendons and rehab
Different when feel discomfort in healthy muscle vs rehabbing an injury
When to begin increasing the load
Moving from rehab to function
Reactive state may require increased modification for normal activities
Use your patients pain levels as a guide with deloaded exercises
May do one or two sets initially with decreased assistance/ slight increase in load
Remember that each time you load a tendon it will cause some breakdown/rebuilding
Progress slowly and with internet
Don't have to redefine all reps and sets
Think about one set with the pulley and one set without and then another set with the pulley
We as PT’s can dose exercise just like a doctor doses medication
Should be able to explain to a patient why the changes are being made
Favorite exercise for supraspinatus tendon
Sidelying shoulder abduction
Includes scapular control
As the patient raises the arm the supraspinatus is in mid-length position allowing the muscle to generate good force
Lever is decreasing in sidelying position
Progress by adding hand weight
Other research on tendinopathy to consider
Glut med
Alison Grimaldi and Angela Fearon Clinical Commentary - JOSPT 2015
Patellar tendon
Breda - BJSM article 2021 - Progressive tendon loading exercise therapy RCT
Rotator Cuff
Østerås, Håvard, Tom Arild Torstensen, and Berit Østerås. "High‐dosage medical exercise therapy in patients with long‐term subacromial shoulder pain: a randomized controlled trial." Physiotherapy Research International 15.4 (2010): 232-242.
Torstensen, Tom Arild, Helge Dyre Meen, and Morten Stiris. "The effect of medical exercise therapy on a patient with chronic supraspinatus tendinitis. Diagnostic ultrasound—tissue regeneration: a case study." Journal of Orthopaedic & Sports Physical Therapy 20.6 (1994): 319-327.
Bio:
James graduated with a Master of Science in Physical Therapy from Ithaca College in 2000 and later completed a Doctor of Science in Physical Therapy from Andrews University in 2015 along with a manual therapy certification (CMPT) from the North American Institute of Orthopedic Manual Therapy (NAIOMT). He has served as a professor of spinal orthopedics, holds a board certification in orthopedics from the American Physical Therapy Association and is currently a Clinical Specialist at The Hospital for Special Surgery in NYC. James has extensive experience treating post-operative and non-operative orthopedic cases, a strong interest in differential diagnosis, motor control and fitness integration. He has worked extensively with patients ranging from performance athletes and professional dancers to weekend warriors and is a Certified Strength and Conditioning Specialist through the National Strength and Conditioning Association (NSCA).
https://www.hss.edu/performing-arts-medicine-collaborative.asp