We Physiotherapists have bastardised all sorts of treatments, tests and techniques in a misguided attempt to follow evidence-based practice. I had another revelation recently that I’ve been doing exactly that…. once again. I’m sure this won’t be the last time either.
In 1996 Paul Hodges and Carolyn Richardson published a paper in Spine(1) which spawned the horrendous core stability nonsense which has plagued us ever since! 2 years later, Swedish researcher Håkan Alfredson published a paper(2) in the American Journal of Sports Medicine which had a similar effect for the treatment of tendinopathy.
If you’ve had a tendinopathy there’s a good chance that you will have been given an “eccentric” exercise with an expectation that this mysterious thing will fix it. They’ve certainly been the most researched form of exercise intervention for tendinopathy.
On the latest issue of PT Inquest(3), Erik Meira and J.W. Matheson discuss a paper(4) published this month on using screening tests to predict injury. In short, it’s not possible to predict an injury. Sports and physical activity generally involve collisions, velocity and mass… and shit happens. Shit still happens even if we’re not physically active.
Erik and J.W. highlight how rarely, if ever, the results of single trials like the Alfredson protocol are ever successfully repeated; that’s not just different cohorts of people – even in the same cohorts. The Alfredson paper showed a good effect in a group of middle-aged recreational male runners. That hasn’t consistently been repeated in similar groups of middle-aged recreational male runners, and it certainly hasn’t demonstrated to be valid in young people, old people, elite runners, females or any other combination of variables. Yet the Alfredson protocol (or someone’s own take on it) is still what you’re most likely to be given as a treatment, which is just ignorant.
We simply cannot take the intervention from a single trial and apply it to different cohorts, different body parts, in different ways, and expect the same outcome. It doesn’t work that way and it’s not good science; in fact, it’s not the scientific process at all. Clinical trials with positive effects give us hope and create opportunities for further research, but consistently in Physiotherapy these things don’t stand the test of time. The Thessaly’s test for meniscal tears for instance seemed almost too good to be true, and that turned out to be the case. But we have to use something, right?
On the whole, Physiotherapists have turned a blind eye to the scientific process in treating tendinopathy, prescribing eccentric exercises as per Alfredon, or isometric exercises to every pathological tendon, be it in the shoulder, elbow, hip, knee or ankle, to every patient. I realised this week that I’ve been applying the same flawed logic in prescribing the isometric exercises.
A 2015 paper(5) published by several of the big names and leaders in pain science and tendinopathy showed an excellent pain relieving effect from isometric exercise with patellar tendinopathy in *6* volleyball players. Ignoring the fact that a sample size of only 6 is far too few to be representative of the larger cohort (of volleyball players), we *cannot* make the assumption that the same applies to anyone else, but we have done. I did. Naugle et al in 2014(6) already identified other variables which could account for the same effect.
So much of what we do is a complex mess of uncertainty that it’s unlikely to ever be close to providing us with any clinical certainty. We have to make the best of what we do have, which really isn’t much.
Jill Cook and Håkan Alfredson were still promoting the eccentric loading protocol in 2007(7) in their treatment algorithm for managing Achilles tendinopathy. But research has moved on since then. In a 2013 systematic review(8) Peter Malliaras concluded “There is little clinical or mechanistic evidence for isolating the eccentric component, although it should be made clear that there is a paucity of good quality evidence and several potential mechanisms have not been investigated, such as neural adaptation and central nervous system changes (e.g. cortical reorganization). Clinicians should consider eccentric-concentric loading alongside or instead of eccentric loading in Achilles and patellar tendinopathy.”
Then in February this year, Jill Cook & Karim Kahn presented a paper(9) at the APTA Combined Sections meeting which shifted our focus on the treatment of tendons yet again (or at least should have). Their findings suggested that tendinopathic tissue doesn’t change with treatment and that instead, our interventions should be aimed at increasing the capacity of the remaining healthy tissue with heavy loading; ‘treat the donut not the hole’, which is an entirely different paradigm to Alfredson’s eccentric protocol and removes much of the complexity. Erik and JW had an excellent discussion about the paper and Cook & Kahn’s presentation at the APTA Combined Sections Meeting(10)
Preceding the APTA presentation, Karen Litzy interviewed Jill Cook(11). Who said this about eccentric exercises (paraphrased from the interview):
– They are deficient in being able to restore full function
– They’re not effective across populations
– We know they’re not great for the younger sprinter or the older person
– They don’t address the strength deficits of the muscle
– They don’t address the strength deficit of the kinetic chain
– They don’t address the motor drive changes
– You *cannot* apply the same clinical reasoning or treatment protocol to every tendon and to the same tendon is a different person; every treatment program needs to be tailored to the individual
– Every tendon is clearly different; you cannot use recipes
– The capacity of tissue is only as great as the load you put through it
– We have lost our clinical reasoning skills.
– We need to know the load through the tendon
– It’s not an inflammatory process; if rest, ice and anti-inflammatories don’t help, it’s not inflammatory and inflammation is not the driving process or creating the pain
– The cause of the pathology is overload
– The pathology and pain are unconnected
– The degeneration doesn’t change; it doesn’t heal.
– There is a lot of cortical inhibition; people will lose strength quickly – strength work needs to be continued for at least 12 months after a return to sports (after which you may be able to give it up), in athletes, it needs to continue indefinitely to maintain tissue capacity).
1. You must have muscle ‘strength’ which can only be achieved with a concentric and eccentric strength program; muscle strength protects tendons
2. You must have the ability to store and release energy utilising FAST movements
3. The rest of the kinetic chain needs to be involved
4. Restore function to the level the person wants; after that, anything goes
Stage 1: isometric exercise for pain relief and reducing cortical inhibition (based on the Ebonie Rio paper – nb: isometric exercises DO NOT increase “strength”!)
Stage 2: Strength program involving the whole kinetic chain
Stage 3: Restore ‘spring’ capacity – fast energy storage
Stage 4: Build endurance
When we talk about tendinopathy, specifically in the hamstring, we’re typically referring to the proximal or distal attachments at the pelvis or knee. The one which rarely if ever gets a mention is the proximal intramuscular biceps tendon. Prof Peter Brukner discusses these(12) presentations which tend to take double the usual 3-5 weeks to recover and reiterates the need for strengthening at the hip (he mentions single leg deadlifts and Bulgarian deadlifts from the hip and Nordic curls are the knee). Full ruptures and avulsions require surgery.
“I’ve learnt that us Doctors know nothing about rehab” Prof Peter Brukner
If a clinician (me included) is offering a blanket prescription of eccentric exercise of a certain number of sets and reps, or even worse only isometric exercise to treat tendinopathy, they’re not going to work because every patient it different and everyone needs to be treated as such. It’s also not evidence-based practice because that’s not what the evidence is telling us to be doing (see above).
It’s no different to assuming that everyone else likes a cheese toasty with marmalade just because you do. I image that combination would be foul.
So there you have it… confusing.
If in doubt, find a Physio who specialises in exercise prescription for rehab and who’s going to prescribe you with something more exciting and USEFUL than just isometric and eccentric exercises!