T he Patient: No matter how hard I try to develop a wcllness practice, the number one reason people come to my practice is to help relieve them of pain. I approach the chronic pain patient, the sports injury client, and the difficult cases all the same. I designed my evaluation to assist patients in identifying and working through their own self-imposed movement limitations and. hopefully, reclaim some lost muscular strength, aerobic endurance, flexibility, balance, and body composition. I don't wait for clients to be free from pain before I try my hardest to encourage them into practicing fitness activity, healthy aging principles, and therapeutic lifestyle changes. It remains a mystery why some people excel with my recommendations and others fail to perform well when the stakes are high. So I'm sitting at my desk after taking the history of a 40-> car-old female ninner who described posterior heel pain and lower Achilles pain. She has pain upon waking up in the morning and while moving around for the first 30 to 60 minutes. Her Achilles pain is always present but gets worse at the beginning of her running session, but she gets used to the pain as she warms up. Pain persists at a higher intensity after she stops running for a while. In some other similar patient cases and depending on the severity, the pain will occur sometime after onset of activity only. Her symptoms have been going on for four to five months, which is why I diagnosed her with Achilles tendinopathy. The examination revealed diffuse pain with palpation along the Achilles tendon, not localized to one specific point within the body of the tendon, minimal inflammation, and slight tendon thickening. In this patient's case, tendinopathy is a better term to use for her pain. Tendinopathy includes degeneration and disorganization of collagen fibers and increased ccllularity. This case is the result of an imbalance between the protcctivc/rcgcncrativc changes (recovery, nutrition) and the pathologic responses that result from tendon overuse. The net result is tendon degeneration, weakness, tearing, and pain. Her pain is mostly one sided, so I look for asymmetrical motion in her gait. I am challenged to discover inner movements that she is unaware of doing that have caused this pain. She just wants me to relieve her pain so she can return to her "all out running." In my practice. I make the diagnosis of acute tendinitis if a new and sudden onset of tendon-related pain occurs after excessive activity. In the acute tendinitis cases with an inflammatory process. I encourage rest, lymph taping, supplements, and I let the inflammation "happen." I sec a lot more clients in my day-to-day practice who have painful conditions that develop in and around tendons arising from overuse. Tcndino-sis is tendon pain due to cumulative overload with structural and compositional changes. This term implies more toward tendon degeneration versus "tendinitis." which implies acute inflammation. The Science: Tendon cells (tcnocytes) are characterized by their expression of sclcraxis. both in developing tendon and ligament, as well as in adult human tcnocytcs. Scleraxis expressing cells lead to the eventual fomiation of tendon tissue and other muscle attachments.' This expression is mechanically regulated, showing a reduction following tendon transcction2 and exhibiting a dose-response with increasing strains or repetitions of movement.' Sclcraxis expression is increased during the repair and remodeling stages of tissue healing as the tendon attempts to restore its phenotypc. This attempt to restore normal tendon phenotype follow ing injury is frequently imperfect, leading to mctaplastic or fibrotic change in the injured tendon. Practical Treatment Options: For acute Achilles tendinitis, relative rest is nurturing. I know when I tell athletic clients to rest, they give me a "look" and say something such as. "I already did that when I was on vacation for two weeks" (or whatever stopped them from further aggravating the pain). I have exercise ADD and it's impossible for me to just stop all activities, so I get it! At this stage. I offer gentle yoga as a way to open areas that feel dry. painful, or tight in their bodies. On top of the yoga, my advice to this patient was. "Move safely when you can. move what you can. but you need to stop running for two weeks." Cold - Apply ice only after sports or strenuous activity for 15 minutes. Apply Biofreczc four times a day over the painful tendon area. Manual therapy - The latest adjunct here is called Voodoo Flossing. This involves the wrapping of a muscle group or joint very tightly in a Voodoo Floss Band while stretching or performing certain exercises to improve mobility and strength in the wrapped area. The wrap is put on very tight for only a minute or two to constrict or prevent further inflammation of the joints and connective tissue, as well as constricting blood How fora bit. Once the Voodoo Floss Band (or bicycle inner tube split open or a Thcra-Band cut down the middle) is removed, the blood rushes back in to the area. Forjoints with large amounts of connective tissue, such as elbows and knees, this allows the blood to flush away some of the excess white blood cells that make the inflamed area worse. Modalities - Iontophoresis, ultrasound, electrical muscle stimulation, deep muscle stimulator, and laser. Taping - Compress the lymphatics and soft tissues (use lymph tape, wrap Thcra-Bands around the joint, use isometric muscle contractions, tight clothing, etc.). Elevate - Keep the area elevated when you can. For Achilles tendonopathy. the treatment can include everything previously listed, plus: A discussion of Pharmaceuticals (lots of risks!) and supplements. Orthotics - This is certainly on a case-by-case basis. Manual therapy - In March 2013 at the ACA Rehab Symposium in Orlando. Florida. I heard Tom Michaud say. "People with less than five degrees and more than 15 degrees of ankle dorsiflcxion arc prone towards Achilles tendi-nopathy." In my experience. I sec those with a lack of dorsiflcxion rather than more dorsiflcxion. hence the need for mobilization. Any type of deep tissue therapy and "shock waves" stimulate tendon repair. I continue to read and listen to Dr. Tom Hyde (IASTM). Dr. Warren Hammer (Stecco). Tom Myers (Anatomy Trains), and a host of others leading the way in soft tissue therapy. More recently. I was fortunate to spend time learning with Tjcrk Wander, a physical therapist from the Netherlands who is the most skilled practitioner in radial shock wave therapy (RSW). This is a new therapy for me to use in my practice. RSWT lias been used successfully as an adjunct therapy for more than ten years in Europe treating soft tissue conditions for pain relief and increasing localized circulation. Most of us are familiar with this type of therapy for plantar fasciitis that was a hospital-based procedure. Fortunately. Zimmcr came out with a device that we can use in our practices. The typical recommendation is a RSWT session every five days4. After two months of using RSWT in my practice on numerous clients. I notice that it has greatly improved my clients" muscle tension, nervous system reactivity, and imbalances. RSWT has been particularly helpful with clients experiencing chronic pain that have not had results from other treatments and modalitcs. Stretching - I make sure they stretch the gastrocncmius with the knee straight for 20 to 30 seconds several times throughout the day. Exercise - Eccentric strengthening exercises have always been recommended for tendon conditions. In my experience, eccentric loads onh get eccentric strength. I do advocate using heavy loads, but I base exercise on a patient's threshold. Take it on a case-by-case basis as far as pain experienced during exercises and if they should rest or not rest. With that said, the most popular Achilles exercise, and my favorite, is the eccentric exercise called Alfrcdson. Alfrcdson ct al 1998 eccentric protocol: three sets of 15 reps of eccentric heel drops twice a day. seven days a week for 12 weeks. Get the patient to go all the way up with your eccentrics—full range for both the front and back stress of Achilles injuries. Cue the patient by saying. "Go up on your toes and go down on the floor." Work through nondisabling pain and progressively add weight. Let the patient know that difficult tendonopathy can take from nine to twelve weeks to resolve56. I let my patients know that I am creating a personal program to help them heal and have optimal functioning. Like you. I am always willing to challenge my customary ways of thinking about my work and treatments, my relationships, and I am appreciative that you read this article. References: Cscrjesi P. Brown D. Ligon KL. Lyons GE. Copcland NG. Gilbert DJ, Jenkins NA. Olson EN (1995). Development 121 (4): 1099-110. Macda T. Sakabc T. Sunaga A. ct al. Conversion of mechanical force intoTGF-beta-mcdiatcdbiochemical signals. CurrBiol 2011:21:933—11. Scott A. Daniclson P. Abraham T. ct al. Mechanical force modulates sclcraxis expression in bioartificial tendons. J Musculoskclct Ncuronal Interact 2011:11:124-32. www.ZimmcrUSA.com Alfrcdson H. Pictila" T. Lorcnt/.on R: Chronic Achilles tendinitis and calf muscle strength. Am J Sports Mcd 24: 829-833. 1996 Alfrcdson H. Pictila" T. O" hberg L. ct al: Achilles tendinosis and calf muscle strength. The effect of short-term immobilization after surgical treatment. Am J Sports Med 26: 166-171. 1998 Dr. .Jeffrey Tucker is the 2012 AC M Rehab C 'ounal Doctor of the Year. He is the ACA Rehab C 'ouncil Secretary Treasurer and a certified instructor for the Functional Movement Screen (FMS) workshops. He is also on the education committee for the Hygenic Corporation, and is a postgraduate instructor for the diplomate program offered by the American Chiropractic Rehabilitation Board. 1 Isit his website at www.DrJeffreyTucker.com
