Blog Post

In the previous two posts in this series, we learned how research over the past 20 years into tendon pain and injury had led to fundamental changes to how we understand what’s going on when someone experiences tendon pain. We discussed the change in terminology used in light of the discovery that inflammation was not a factor in tendon damage, and more recently how tendon injury can be divided into stages along a continuum. This system, increasingly embraced in the contemporary sports medicine community, has also served to simplify treatment choices, as selection is now guided by tendinopathy stage. Importantly, the realization that treatment choice is driven by stage of tendinopathy also tells us why and when a particular treatment may be inappropriate. These are discussed below.

Best practice management of tendinopathy, according to stage:

1. Reactive

From the previous post, we learned that acute, or reactive tendon pain can occur before actual damage is caused to the tendon, and as such, is reversible. It is a time of high metabolic activity, and so it is not considered a good idea to be using treatment techniques that would stimulate this further, such as friction massage or injections. Optimal treatments during either the reactive or acute-on-chronic stage include:

• Tendon unloading or rest – this is the only stage when you might consider resting a tendon
• Isometric or static hold exercises – known to have a pain-relieving effect on acutely painful tendons, can be progressed to very slow, heavy repetitions within specific ranges
• Ibuprofen – not because of its anti-inflammatory actions (since tendinopathy isn’t an inflammatory condition), but rather because of its effect on a compound called Aggrecan. Aggrecan isn’t welcome in tendons, but starts to accumulate in the reactive stage. Ibuprofen, and to a lesser extent other anti-inflammatories like Indomethacin and Naproxen, have a helpful side effect of being aggrecan inhibitors.
• Green tea, fish oil – these compounds are known as anti-oxidants, but additionally they inhibit the formation of another undesirable protein found in reactive tendons called TNFα (tumor necrosis factor alpha if you must know!)
• Doxycycline – primarily used as an antibiotic and anti-malarial, Doxy is also an effective TNFα inhibitor. Requires a prescription. Taking this and Ibuprofen together increases the potency of Doxycyline’s TNFα inhibition effect.

2. Dysrepair

Dysrepair, being an intermediate stage, takes some of its management priniciples from both acute and chronic classifications. Structural changes have started to occur in the tendon, such as a change in the collagen/ground substance mix and the ingrowth of small blood vessels. This is a progression of the ‘failed healing response’

• Exercise therapy during the dysrepair phase, like that in chronic tendinopathy, requires a more formal structure and progression, allowing time for the injured tendon to adjust to the demands that are being placed upon it. Progression from very slow, heavy resistance exercise to eccentric exercise protocols (see below) and alternating high/medium/low loading days
• Medications (see below for more information)
  • Green tea, fish oil and Ibuprofen (the triple cocktail) may still provide symptomatic relief
  • Polidocanol injections, designed to sclerose the new blood vessels growing into the tendon, are often employed during this stage
  • Platelet-rich plasma (PRP) injections are sometimes used during this stage
  • GTN (glyceryl trinitrate) patches, used in the treatment of angina, are sometimes cut into quarters and applied over the area of tendon damage with the aim of increasing local blood flow to the area.
• Massage and manual therapy – applied to the muscle belly, rather than the tendon itself, may play a supplementary role in managing local tightness and tenderness.

Fig. 1 – An example of the graduated progression of loading (strengthening) exercises for the Achilles tendon

3. Degenerative

Tendon metabolism during the chronic or degenerative stage has slowed down quite a lot – there’s not much going on in the tendon by this stage, unless an acute-on-chronic reaction is provoked. Structural damage is nevertheless present, and therefore therapies at this stage are directed more at stimulating repair and remodeling of the tendon.

• Injections – depending on the school of thought, injection therapy may comprise an effort to get the tendon to heal, initiate a scarring response, or to selectively ablate small blood vessels growing into the tendon.
• Platelet-Rich Plasma (PRP) – increasingly popular in the US, this involves taking a patient’s own blood and spinning it in a centrifuge to extract all the good bits like growth factors and healing promotors, then injected back into the tendon, with the aim of stimulating healing
• Prolotherapy – involves the injection of something like dextrose into the tendon, essentially to irritate it and generate a scarring response. Also used in the treatment of damaged or lax ligaments.
• Polidocanol – has the effect of killing off the additional blood vessels that are known to grow into the tendon during this stage. These vessels are considered by some to be a source of pain within the tendon.
• Cortisone – the use of steroid anti-inflammatories is no longer recommended, as they have been shown to weaken the tendon structure (predisposing to rupture) and also since tendinopathy is no longer considered an inflammatory condition.
• Extracorporeal Shock Wave Therapy (ESWT) is currently more popular in Europe and Australia than it is here, but there is a growing body of research that suggests it is helpful in treating chronic, recalcitrant cases of tendon pain that have proven resistant to other conservative therapies. The device used emits an acoustic pulse that stimulates tenocyte (the cell that drives tendon metabolism) activity in the damaged tendon. The treatment is mildly unpleasant but takes only several minutes.
• Massage and manual therapy – not considered to play a significant role in the management of tendinopathy, but may provide some symptomatic relief of local tightness and tenderness.
• Exercise is the most potent stimulus for tendon remodeling. Since the rate of change in tendons is much slower than that of muscles, it is critical that any therapeutic exercise program be progressed carefully and structured so that the tendon has enough time between loading efforts to adapt (sets, repetitions, frequency)
• A popular program is the eccentric exercise protocol developed by the Swedish researcher Hakan Alfredsson. It seems to be more effective with damage to the middle of the tendon as opposed to where it joins with the bone.
• Often sufferers of chronic tendinopathy have developed strength deficits or muscle wasting, which needs to be addressed through appropriate strengthening exercise programs
• Once a patient has progressed to impact loading activities – jumping, hopping, running – the exercise program can be progressed to include alternating high/low or high/medium/low load days
• A final, important component of exercise therapy with degenerative tendinopathy is the appreciation and correction of any biomechanical or movement pattern anomalies that may be contributing to the onset or maintenance of the problem. An experienced physical therapist, with their understanding of biomechanics, tissue pathology and exercise is ideally placed to deal with these kinds of issues.

Indeed, alongside the medical doctor, the sports physical therapist plays a major role in the effective management of all the different stages of tendinopathy. Occasionally some tendons may require surgical intervention, but the majority of cases can be effectively treated with a combination of the correct type and progression of exercise and prudent use of medication.

This summer KIMA will launch a new service called AposTherapy: a unique bio-mechanical device individually calibrated by a specially trained physical therapist to reduce compressive load and improve control of painful joints.This technology is not only reducing but eliminating pain in patients across the globe with chronic degenerative conditions.

What you need to know:

• It uses a biomechanical device that looks a lot like a regular shoe
• It’s used to alter compressive forces sent upward from the ground through painful or dysfunctional joints
• It helps to retrain the muscles surrounding the joint to improve their timing and coordination of contraction
• It’s one of the few treatment approaches that combines changes in joint loading and retraining of the neuromuscular system in a single device
• There’s no extra time or supervision required to train with the Apos device
• It’s an investment!

AposTherapy has been around, formally, since 2004 when co-founders, orthopedic and sports medicine physicians, Avi Elbaz and Amit Mor opened their flagship center in Israel.  Since then, Apos has spread to the UK, Singapore, and, more recently, the United States.  This therapy has been so successful in its initial locations, that it’s even gained coverage by Israeli and UK insurance companies.

Here in Manhattan, we’re lucky enough to be situated next door to the AposTherapy US Headquarters and Training Center. I recently completed the AposTherapist training course and am able to provide this innovative therapy to our patients here at KIMA.  In case you’re unfamiliar with AposTherapy, I want to share a bit of what I learned about the science behind the biomechanical device and how it’s applied.

How does it work?

Before my formal introduction to AposTherapy, I’d heard the device described as an orthotic you wear on the outside of your shoe.  Although this is a simple way to describe the concept, it really doesn’t hit on exactly what the device is all about.  An orthotic repositions the foot to realign the bony framework, normalize tissue loading, and facilitate efficient mechanics and stability during standing and walking.  Clearly, these are all positive effects.  Perhaps the only downside is that, once the orthotic comes off, you’re left with the original problematic malalignment, preventing you from wearing certain types of shoes, doing barefoot activities, etc.

Unlike an orthotic, the Apos device doesn’t realign the foot itself.  Instead, it uses proprietary “Pertupods” to change your foot’s center of pressure and, thus, the ground reaction forces traveling up from the ground compressing painful joints.  Not only is your pain reduced by altering these compressive forces, but the Pertupods are also convex to varying degrees, which requires that the wearer control a very small degree of instability.  If this sounds scary, let me explain how our bodies respond to a slight instability like the one Apos uses.  In the presence of pain, the muscles surrounding a joint tend to “brace”.  For purposes of discussion, you can think of bracing as almost a splinting of the joint caused by co-contraction of the opposing muscles surrounding it.  For example, if the quads and hamstrings contract simultaneously, the result is a braced knee that’s difficult to bend or straighten.  Imagine controlling for an instability with a braced joint.  You can’t!  In order to control for the instability introduced by the Pertupods, the body must normalize tone in the relevant muscles and produce coordinated contractions of flexors and extensors, resulting in improved joint motion and lubrication, less pain, and more effective training.

If you’re a visual learner, like me, take a look at this video by Apos on “How it Works”:

What do I do with it?

Now that you know how the device works, let’s talk about how you’d go about using it.  Again, for purposes of comparison, I’ll use the orthotic (simply because it’s the tool I hear most commonly compared to AposTherapy).  Unlike an orthotic, the Apos device doesn’t have to be worn every time you’re on your feet to see the benefit.  You’ll begin with a treatment time of about one hour per day and you’ll train in the every-day scenarios where you typically experience pain; for example, standing up from your desk chair to walk to the printer.  AposTherapy creates a proprioceptively rich environment (like walking on grassy terrain) even when you’re in the office, helping to re-educate your muscles to support the bony framework in the way they naturally should.

We keep initial treatment times low because our goal is to improve motor control.  Let me clarify this a bit.  Training to improve motor control is a bit different from training to improve pure strength. I consider strength training a privilege earned from developing good motor control in a given pattern.  For example, you’d better have good motor control in a body-weight squat pattern before you load on additional weight for a barbell back squat.  I want you to imagine the circumstances under which you’d try to learn and execute this perfect body-weight squat.  Obviously, performing rep after rep will lead to fatigue and, eventually, crummy form.  Much like training for motor control of this perfect body-weight squat, in the Apos device we’re looking for fewer, more pristine reps which aren’t clouded by pain or fatigue.  To this end, your AposTherapist will ask you specifically to NOT wear the device beyond the time laid out in the treatment plan.

To see a great example of how AposTherapy can be used as part of a wellness program to develop optimal health, have a look at these former NFL players and Navy Seals being introduced to the device:

How successful has it been?

According to an independent telephone survey conducted by Network Research in November of 2009 including 150 AposTherapy patients in the UK, over 95% of patients are satisfied with AposTherapy, the majority say it exceeded their expectations.

The concept behind the device’s methodology as well as the application of the device itself have been significantly researched in the short time this type of therapy has been available.  Currently, AposTherapy’s greatest body of evidence is in it’s treatment of knee osteoarthritis although it’s application in the treatment of chronic nonspecific low back pain and hip osteoarthritis have been thoroughly researched as well.  See the evidence here: http://apostherapy.co.uk/en/healthcare-professionals/medical-research

If you’d like to hear it from the patients themselves, have a listen!:

So how much am I going to have to invest?

Beginning with your in-depth 1.5 hour initial evaluation, AposTherapy lasts for one full year and includes five follow-up sessions with your AposTherapist as well as the Apos device itself.  The follow-up sessions will each involve an updated computerized gait analysis, re-evaluation, an updated treatment plan and, if necessary, re-calibration of the device.  This full year of treatment costs less than a year of physical therapy treatment and can be broken into smaller installments if desired.

If you’d like to know more about AposTherapy, give us a call at KIMA Center for Physiotherapy & Wellness at 212-686-3101.

If you suspect you may have a temporomandibular joint dysfunction (TMD) the following information may be helpful for you. In this blog article we’ll try to explain what we evaluate when assessing the TMJ (temporomandibular joint) for TMD (a temporomandibular dysfunction).

Your ability to open your mouth (technically termed mandibular range of motion)

The normal range a person’s mouth opens is about 40 to 50 mm (around 3 finger-widths). If you are only able to open your mouth to fit just about two fingers or less, then you have a limited range of motion for jaw opening.  Observe yourself in a mirror as you are opening, can you open in midline?  If you notice a deviation or deflection to one side with opening, it indicates a dysfunction caused by either a muscular imbalance or TMJ disc pathology.  Other movements to look at are the ability to protrude your jaw (jut your chin out) the normal range of motion for this movement is 3-6 mm and again you should be able to do this in midline, without a shift to the right or left otherwise you are looking at a muscular imbalance or disc pathology.  Also observe your ability to move your jaw from side to side this should be about 10 to 14 millimeters in each direction symmetrically. Do you hear sounds when you open, close, protrude or move laterally? A clicking sound when opening or closing your jaw are indications of a disc problem a crunchy sound is more likely arthritic changes in your joint (“arthritis”).

Evidence of teeth grinding (one common parafunctional habit associated with TMD) or clenching

Examine your teeth and check for indication of wear that may be caused by teeth grinding. You will most likely know if you have a habit of grinding your teeth but some people do this at night only and are not aware of it however the wear on your teeth will not lie. If you clench your teeth verses grind them you might see vertical cracks in your teeth. The tongue may have “scalloping” features meaning it has teeth indentations on its borders. This is a result of constantly sucking hard on the tongue which has the same effect as clenching while not actually damaging the teeth, this habit can place unnecessary pressure on the jaw muscles. One result of too much chewing and sucking on the cheeks’ inside is the formation of a white line or “linea alba” on the inner side of the cheek.

Palpation

Masticatory muscles (chewing muscles) such as the suprahyoids (located beneath the chin), medial pterygoid (found beneath the jaw angle), masseters (cheek), and temporalis (from your temple up into your hair line) should be evaluated for hypertonicity (medical term for tension) or tenderness. Comprehensive evaluation of the temporalis and the masseters require intraoral palpation. For testing the stretching capability of the masseter muscle, the practitioner places their thumb inside your cheek with the rest of their fingers remaining outside; and gently squeezes the cheek and presses their thumb out into the cheek at the same time. This procedure should to be pliable and painless. To feel the temporalis tendon for any tenderness and protrusion close to where it’s attached, the practitioner slides the finger through the superior gums, in between the coronoid process (an extension on the mandible) and the maxilla.

Accessory Joint Motion (important secondary movements within the joint )

As with every healthy synovial joint, the TMJ joint needs to have a pain-free and springy feel. Synovial joints are mobile joints that are lubricated by a substance called synovial fluid making the connected bones in the joint move effortlessly. Both Temporomandibular joints move simultaneously making it imperative for both joints to possess the same mobility. If one joint is less mobile than the other, this may cause excessive torque on one side that may result in ligament strain on that side. Both TMJs should glide anteriorly and gap with distraction and, moreover, should possess a small amount of lateral accessory, medial and posterior motions. The gapping of the TMJ can be evaluated through light palpation of one TMJ using the fingertips, while applying downward pressure using the other hand on the mandible through the thumb on the lower molars. When distraction has been evaluated, you can apply similar hand placement for assessing anterior glide. This is done by pulling forward mildly on the mandible. Similar hand placement can also be applied for lateral, medial and posterior glide evaluation.

The information we are sharing in this blog post is not meant as medical advice or for self diagnosis in any way. It is simply for informational purposes. TMJ disorders and TMD are conditions that require the attention of a trained medical professional.

If you suspect you suffer from a TMJ or TMD dysfunction, contact your healthcare practitioner or give us a call.

Some patients that come in to see us at KIMA have been in pain for quite some time; others have more acute presentations. A question we commonly ask both groups of people is “have you done anything for this so far?”, and a common response would be “rest & a bit of stretching”.

Whilst it is true that giving your body’s tissues some time to settle down after an injury or flare-up of symptoms can be greatly useful, there’s often a little more to it. Problems with rest and/or stretching as the primary treatment method arise when one of the goals is to restore normal activity or function to an injured body part. In certain cases, rest can actively make things worse.

The disconnect usually arises because reducing activity levels makes sense when you’re in pain, but most people when they recover want to get back to their previous level of activity, which almost always is more than when you’re symptomatic.
This is where the physical therapist’s unique expertise in rehabilitation exercise comes to the fore. No other medical profession has the combination of training & knowledge of anatomy, pathology and tissue healing with how they relate to exercise, movement and restoration of function than physical therapists.

All your skeletal muscles have a specific role or purpose. None are there by accident. Some produce high forces and purposeful movement, while others are there simply to hold things together and provide stability. Both require different forms of exercise to get the best out of them.

Areas of perceived tightness within the body may feel that way not simply because the tissues are shortened, and therefore need to be stretched out. A feeling of tightness can occur in a muscle that is fatigued, or overused. If a muscle is tired, or has become weak (perhaps because of a period of extended rest??) then training, not stretching, is the most appropriate way of managing it. Alternatively, fatigue or overuse in a particular muscle may be because it is struggling to substitute for another muscle group that is not doing its job properly. The type of training that works best depends on what the particular muscle’s role is. Some exercises are subtle, involving small movements or forces, as this is considered the best way to develop control over a movement. Others will focus on more traditional notions of strength and power, for those muscle groups that need that.

This knowledge lies at the core of the physical therapist’s skill set – the ability to assess and diagnose sources of musculoskeletal pain and injury, knowledge of underactive, overactive and substitute muscle activation patterns and the role they play in the patient’s problem, and the ability to prescribe the most appropriate type of exercise for a given stage of healing and recovery.

Rest and stretching have their place in the management of certain musculoskeletal conditions, as does the skilled application of hands-on manual therapy techniques. But the key to making a full and complete recovery, and the area in which physical therapists have no peer, is to restore optimal functioning of the neuromuscular system.