The simplest solution is usually the correct one

TheKettleBellPhysioBlog, Exercise, The Kettlebell Physio, Uncategorized0 Comments

Q: If you’re chronically tired and only sleeping 4-5 hours a night, what’s the solution?

A: Sleep.

Occam’s razor – the simplest solution is usually the correct one.

Caffeine, sugar, exercise, deliberately making oneself uncomfortable or distracted are all potentially effective methods of prolonging the inevitable decline in function from sleeplessness however, the solution is simply to just get more sleep! That’s typically the easier, cheaper and more enjoyable option but often people find lots of reasons not to take the easy option and end up frustrated when the band aids don’t work.

The principle of identifying the simplest solution and acting upon it applies equally well elsewhere too, so I read with great interest a recent article of ‘Top Tips’ to help with proximal hamstring tendinopathy (PHT); a condition common among runners.

I feel like I’ve kept up to date with tendon research this past year in particular, and as far as I am aware (and I could be wrong), the only way to upset a tendon is to overload it with mechanical force beyond what it can tolerate. I’ve written about Dr Scott Dye’s envelope of function before but it’s much better illustrated here http://www.richmondrehab.com.au/blog/physiotherapy/the-envelope-of-function; and it applies well to PHT.

Q: If too much LOAD is the cause of an irritated tendon, what would you intuitively think is the solution?

A: Reduce the load.

The ache of PHT is typically localised to just below the buttock at the back of the thigh, close to the bony part you sit on. Sitting directly on it and sitting in a ‘deep’ position with the knees higher than the hips tends to aggravate it, as does sprinting and high step-ups, if you’re into that sort of thing. I’ve had PHT recently and it’s annoying; it came on following an acute overload of my hamstrings pushing a PB (I got there but it cost me physically).

Tendinopathy refers to the tendinous part attaching to the bone, rather than the ‘muscle’ itself, and ‘opathy’ indicates that something about it has changed – think of it as an irritation. If you spend too much time in the sun without sunscreen, that will change too (redness).

With PHT it *may* not be just the tendon itself which gets irritated. The bone and/or bursa may also be irritated – a bursa acts like a natural cushion between the tendon and bone and many would be familiar with the term “bursitis”.

There are other things which can cause pain in the same region, but their presentation should be evidently different, specifically with no obvious history of mechanical overload. *If* you went ahead with some form of investigation and got back a somewhat scary diagnosis of “enthesopathy”, “bone marrow oedema”, or “ischio-gluteal bursitis”, the management really shouldn’t change much. In younger people in whom growth plates are more susceptible (apophysitis and unfused ischial growth plates) it may not be the tendon, but once again, management is unlikely to change as load in both cases will still be an issue; these things simply don’t exist in the absence of an adolescent being very physically active. Active younger people can commonly have similar issues with load at the heel and knee.

When considering imaging, we should be asking ourselves “how will this change my management?”. If the answer is that it won’t, then the test/investigation is probably unnecessary and should not be requested.

Cases of tendinopathy *should* be clear cut. If physiological overload (too much) has caused the tendon to react and become painful, load management is the solution and imaging is unlikely to be helpful and not indicated. The biggest challenge with the enthusiastic active individual is not wanting to cut back and manage the chronic workload to control (and hopefully resolve) their symptoms.

Chronically tired people typically love their sleep, they just prioritise other things ahead of it. For active and competitive individuals, the activity is typically their top priority and they can be very reluctant to do what they may feel is cutting back on what they love doing. Runners don’t jog, they ‘run’. “I’m a runner”. Asking a runner to reduce or change their running can impact their sense of self; their identity.

If load is not managed appropriately, pain can become persistent. Would imaging in chronic cases change management? No. If load is the cause, load is the solution. Heading down a path of medical intervention just isn’t smart.

Clinical trials have failed to consistently identify anything biomechanical in terms of structure or movement as clear risk factors for tendinopathy. Show me someone who’s been told that their weak hip and knee rolling inwards, or limited hamstring length is the reason they’re in pain and I’ll show you as many people in exactly the same circumstance performing at the same level with zero pain.

Searching for the one key ingredient to take the pain of tendinopathy away whilst continuing to maintain an inappropriately high mechanical load is as silly as someone jumping from one brand of coffee to another in search of the one that will stop them feeling sleep – just f’ing sleep!

I’ll assume you’re picking up the subtle hints. We Physiotherapists cannot change what’s happening inside your body with our hands beyond making it “feel” different – it’s biologically impossible. Tendinopathy is frequently made a lot more complicated than it needs to be by the use of passive treatments and complex interventions which simply distract us from the most obvious solution – load. It’s no secret that many leading clinicians suggest that no passive treatment is indicated for tendinopathy because they have zero specific effect on the target tissues.

In helping to manage tendinopathy, the clinical skill and expertise of a Physiotherapist is in providing specific exercise(s) to achieve a specific effect, which includes managing the total load – frequency, intensity, time and type – in addition to providing the necessary education to support the process of appropriate engagement in achieving the desired outcome.

2 years after the ‘core stability’ nonsense kicked off, one small study was published by Swedish Orthopaedic Surgeon Haken Alfredson showing a positive effect with an eccentric loading protocol in the Achilles. As ‘we’ (clinicians) tend to do, everyone jumped on the magic-bullet bandwagon and began prescribing ‘eccentrics’ for every case of tendinopathy. Eccentrics for tendons turned out to be as equally poor as core stability did for back pain. That’s a decade behind us now, although some still have their heads buried in the sand and refuse to move on.

As of 2016, isometric loading has had some good positive effects for tendinopathy at the knee; naturally we’re now prescribing isometrics for everything in the hope that the same applies everywhere (note to self: review this in 2026). As of this year, the focus has shifted from the tissue which has changed as it doesn’t appear to be reversible, to focusing on the remaining healthy tissue to ensure that it has the capacity to do the job. We should be doing this with progressive loading. Funny coincidence don’t you think…

There appears to be very little point (if any), especially in this population with PHT, of trying to ‘isolate’ particular muscles 1) because in some case that’s simply not possible and 2) the human body doesn’t function that way – movements always involve multiple muscles. The more an exercise moves away from the movement pattern we’re wanting to improve, the less applicable it becomes to helping the pattern. Fitness ‘Trainer of the Trainers’ Nick Tumminello covers this really well here http://nicktumminello.com/2014/09/functional-training-separating-the-sense-from-nonsense/ – train the patterns and parts as close as possible to the intended outcome. I understand the reasoning behind a side-lying ‘clam’ but how anyone thinks that would be transferable to running is beyond me.

If you’re considering going down a medical path of injecting cortisone into a tendon, PRP or shockwave therapy (or it’s bastard cousin the Radial Pressure Wave – looks and sounds the same but functions differently – it’s a waste of money!), my advice is simply don’t do it.

If conservative intervention has failed, it’s most likely that something about it hasn’t been correct, rather than your hamstring tendon being special and not responding. Repeating the same thing over and over and expecting a different result is the definition of insanity; is the outcome reflecting you, your therapist, or your irritated tendon? The longer that pain persists, the more likely it is that you will acquire an arguably more challenge problem with the symptom of pain itself in addition to having an irritated tendon which is, has, or will be changing pathologically at a tissue level. It’s important to note that we can have change in the tendon tissue without pain, or pain with no tissue change.

Tendon pain caught early and managed appropriately shouldn’t become problematic. The most significant and likely roadblock to resolution of a tendinopathy is the person with the tendon.

The most recent publication (Aug 11, 2016) from the leading running and tendon big-wigs Tom Goom (aka The Running Physio), Dr Peter Malliaras (PhD), Dr Michael Reiman (DPT) and Craig Purdam outlines an excellent graded loading program and return to activity.

http://www.jospt.org/doi/abs/10.2519/jospt.2016.5986?journalCode=jospt

Your Physiotherapist can help guide you through it, or something tailored to specifically to you and your goals. If you’re putting in a lot of kms on the road each week, that’s usually the first and most obvious way to reduce chronic workload. The work of Dr Tim Gabbett has received a lot of press recently in regards to workload.

http://bjsm.bmj.com/content/early/2016/01/12/bjsports-2015-095788.full
http://bjsm.bmj.com/content/early/2015/10/28/bjsports-2015-094817
https://thesportsphysio.wordpress.com/2016/07/26/whats-beer-got-to-do-with-sports-injuries-a-guest-blog-by-dr-tim-gabbett/

The simplest solution is usually the correct one.

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