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Getting The Spring Back In Your Step: Understanding & Treating Achilles Tendinitis (AKA Tendinopathy)
Getting The Spring Back In Your Step: Understanding & Treating Achilles Tendinitis (AKA Tendinopathy) 280 474 ResilientRx

Achilles tendinitis refers to painful overuse injury of the tendon that connects your heel to your calf muscles. It impacts numerous people – from athletes in running and jumping sports, to individuals who lead less active lifestyles. The pain and stiffness can greatly impact basic quality of life including activities like walking, exercise, and going up and down stairs. 

Before we dive into common treatments for this issue, it’s worth discussing exactly what it is, right down to how clinicians define and classify it. Having a better understanding of the diagnosis makes for more effective treatment approaches. We’ll start with the changing terminology – it turns out that “tendinitis” doesn’t quite capture what’s happening since the underlying issue is not quite black & white. Without further adieu, let’s break down the evolving terminology and science-backed treatment approaches:

What’s Up with the Changing Terminology?

Let’s first describe the key differences between tendinitis, tendinosis and tendinopathy, because these terms are NOT interchangeable. 

  • Tendinitis has historically been used to describe inflammation of a tendon, with treatments focused on reducing that inflammation. 
  • Tendinosis refers to more degenerative changes and microtears of the tendon, without inflammation present.
  • Tendinopathy is the most broad term that encompasses all tendon disorders, including inflammatory and degenerative features. It can involve inflammatory elements right after injury, but typically it’s more to do with dysfunctional healing and tissue remodeling over time. 

What we have a better understanding of now is that there is a spectrum of issues that can impact tendons, many of which are improper remodeling or healing of the tissue, as opposed to simply inflammation. Treatments (as discussed later) should focus more on remodeling and regeneration of the tendon rather than simply reducing inflammation. We need to get that tissue strong and resilient again!

What Causes Achilles Tendon Issues?

Simply put, it’s an overuse injury from repetitive strain. Micro-tears in the tendon outpace the tendon’s ability to repair itself properly, thus resulting in pain and dysfunction. Things like calf tightness, overpronation, sudden jumps in activity (i.e. couch to 5k), and poor leg strength may contribute over time. 

Most patients do not experience a single event or injury, but rather smaller insults over time. Pain can set in over days to weeks, and may worsen depending upon the person’s activity. So oftentimes a cycle of rest or stopping activity completely followed by resuming activities without the proper interventions in between causes people to stay in this unfortunate pain cycle. Complete rest actually increases tendon dysfunction!

Pain usually goes through a “warm-up phenomenon.” This means that pain can improve with exercise/activity a bit, only to return with a vengeance later on or the next day. This is where a structured program and guidance from an expert clinician is crucial. 

How Does Physical Therapy Get You Back on Track?

Your physical therapist should develop a customized treatment plan aligned with current evidence-based clinical guidelines and your goals (We do at ResilientRx)! Properly dosed strength exercises, mobility training, biomechanical corrections, and guidance on gradual return to activity aim to spark tissue regeneration/remodeling while minimizing flare-ups. Guiding the optimal balance of rest and activity helps manage load demands. It’s an intricate puzzle tailored to each patient. It’s also important to note that rehab will not be PAIN-FREE. It’s actually safe to have mild levels of tendon pain lasting less than 24 hours after activity. We often use a simple scale to monitor pain levels, which helps to dose exercise appropriately and push things forward without compromising progress. Every patient will respond differently, so communication is key.

Here’s what the framework for achilles tendinopathy rehab looks like:

  • Early stage: hands-on modalities to calm symptoms such as soft tissue work/massage, joint mobilizations, dry needling and taping. Here we also introduce gentle strength and mobility exercises to start the tissue remodeling process
  • Mid stage: progressive loading via strength exercises to the gastroc and soleus (calf muscles). Isometric and eccentric exercises are advanced to further expose the tendon to more time under tension Stretching may be more tolerated in this phase compared to when symptoms are more acute. 
  • Late stage: we start to move more toward plyometrics exercise and sport-specific or functional training as needed, including more “traditional” strength training principles

The Bottom Line

Tendinopathy rehab is load-related and dose-dependent. We want the achilles tendon to tolerate higher loads over time, so this is a gradual process that requires patience and diligence. The unfortunate truth however, is that progress with Achilles tendinopathy is almost never linear. There will be ups, downs, and plateaus. Sometimes consistent strength training may need to be done for anywhere from 3-6 months before returning to plyometrics. Anti-inflammatories and complete rest are discouraged as this leads to further deconditioning, weakness, and more susceptibility to flare-ups. The good news is that over 75% of tendinopathy patients achieve resolution of symptoms through dedicated rehab and avoid surgery! It can be a long road for many of us, but we’re here for you!

Have you been struggling with Achilles tendinitis or chronic tendon pain in general? Schedule an appointment with one of our Doctors of Physical Therapy to get you back to doing the things you love! CLICK HERE or call 512-777-0330.

References:

1. Magnan B, Bondi M, Pierantoni S, Samaila E. The pathogenesis of Achilles tendinopathy: a systematic review. Foot Ankle Surg. 2014;20(3):154-159. doi:10.1016/j.fas.2014.03.002 

2. Morrissey D, Roskilly A, Twycross-Lewis R, et al. The treatment of mid-portion Achilles tendinopathy: a systematic review. J Foot Ankle Res. 2021;14(1):3. Published 2021 Jan 11. doi:10.1186/s13047-020-00440-5

3. van der Plas A, de Jonge S, de Vos RJ, et al. A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012;46(3):214-218. doi:10.1136/bjsm.2010.083428

4. Rowe V, Hemmings S, Barton C, et al. Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning. Sports Med. 2012;42(11):941-967. doi:10.1007/BF03262301

5. Doral MN, Alam M, Bozkurt M, et al. Functional anatomy of the Achilles tendon. Knee Surg Sports Traumatol Arthrosc. 2010;18(5):638-643. doi:10.1007/s00167-010-1083-7

6. Alfredson H. Chronic midportion Achilles tendinopathy: an update on research and treatment. Clin Sports Med. 2003;22(4):727-741. doi:10.1016/s0278-5919(03)00034-7 

7. Padhiar N, Achana F, Davies A, et al. Eccentric exercises reduce the risk of Achilles tendon overuse injury: a systematic review and meta-analysis. Br J Sports Med. 2021;55(21):1180-1188. doi:10.1136/bjsports-2020-103426

Are Deadlifts Safe To Do With Low Back Pain?
Are Deadlifts Safe To Do With Low Back Pain? 1038 694 ResilientRx

The deadlift is a popular strength training exercise that involves lifting a weighted barbell off the floor to a standing hip position. However, it is also one of the most debated exercises due to concerns about risk of injury, with plenty of misinformation across the internet. Does the evidence support deadlifting for low back pain patients under a professional’s guidance? Is it an all-or-nothing exercise where the risks outweigh the benefits? Let’s unpack these questions and more!

Deadlifts ≠ automatic injury

First, examining injury rates will provide us some insight. Weightlifters do show a higher incidence of back injuries compared to other athletes, with deadlifting as a common precipitating factor(1). Not surprising that the people doing it the most are more likely to face injuries. However, a 2020 systematic review found that in trained lifters, deadlift injury rates are low at just 0-5.9%(2). Aside from good recovery practices that emphasize sleep and nutrition, proper progressive loading and technique can help to minimize injury risk(3).

What about for people with back pain?

Individuals with low back pain often experience limitations in their ability to perform daily activities or participate in recreational or sports-related endeavors. For these folks, research increasingly supports deadlift retraining under supervision. Several studies demonstrate the deadlift can reduce pain and disability when added to physical therapy programs. A 2015 study had patients follow a 16-week rehab protocol of mobility exercises plus hip hinge movements progressing to deadlifts. 83% saw clinically meaningful improvements in pain and function(4). A 2018 randomized controlled trial added deadlifts to standard PT care for 3 months. The deadlift group improved significantly more than controls on pain and disability scores(5). 

These benefits are thought to occur because deadlifts dynamically load and strengthen the spine’s supporting musculature in a safe, controlled manner(6). Proper form also trains coordinated hinging movement patterns useful for everyday activities. Simply put, the deadlift is a functional exercise for all!

Ideal strategies to consider when utilizing the deadlift in a rehab program

  • It may be helpful to supplement a client’s program with graded loading and baseline mobility, stability, and movement pattern training (7)
  • Use low loads and high repetitions if needed initially – no maximal lifts early on, especially to clients new to this lift (8) 
  • Closely monitor form, provide cues, and avoid overloading (9)
  • Equally as important to the above, allow the client to safely explore nuances in technique and positioning. This will build confidence and adaptation to the exercise while building injury resilience. 
  • Progress slowly over 8+ weeks up to heavier loads based on response (10)

While more research is still needed, evidence indicates deadlifts can play a helpful role in rehab for low back pain under proper PT guidance and load management. No exercise is ever risk-free, but deadlifts performed correctly offer unique benefits that may outweigh their potential risks for select clients.  

If you have a new or nagging injury or are not sure where to start, book a FREE discovery session (in person or virtual) with one of our Doctors of Physical Therapy!

Please note: The content in this blog is intended for educational purposes only and is not medical advice. See a healthcare professional if you have any questions about your individual needs.

References:

1. Raske A, Norlin R. Injury incidence and prevalence among elite weight and power lifters. Am J Sports Med. 2002;30(2):248-256. doi:10.1177/03635465020300020601

2. Calhoon G, Fry AC. Injury rates and profiles of elite competitive weightlifters. J Athl Train. 1999;34(3):232-238.

3. Siewe J, Rudat J, Röllinghoff M, et al. Injuries and overuse syndromes in powerlifting. Int J Sports Med. 2011;32(9):703-711. doi:10.1055/s-0031-1277207

4. Kim D, Cho M, Park Y, Yang Y. Effect of lumbar stabilization and dynamic lumbar strengthening exercises in patients with chronic low back pain. Ann Rehabil Med. 2015;39(1):110-117. doi:10.5535/arm.2015.39.1.110

5. Steele J, Bruce-Low S, Smith D. A Rehabilitation Program That Integrates Modified Resistance Training and Motor Control Retraining in Chronic Low Back Pain Patients Improves Muscular Endurance, Strength, and Pain: A Randomized Controlled Trial. BioMed Research International. 2015;2015:1-8. doi:10.1155/2015/30764

6. McGill S. Low back stability: from formal description to issues for performance and rehabilitation. Exerc Sport Sci Rev. 2001;29(1):26-31. doi:10.1097/00003677-200101000-00006

7. Hales M, Johnson BF, Johnson JT. Kinematic analysis of the powerlifting style squat and the conventional deadlift during competition: is there a cross-over effect between lifts?. J Strength Cond Res. 2009;23(9):2574-2580. doi:10.1519/JSC.0b013e3181bc191a 

8. Schoenfeld BJ, Grgic J, Ogborn D, Krieger JW. Strength and Hypertrophy Adaptations Between Low- vs. High-Load Resistance Training: A Systematic Review and Meta-analysis. J Strength Cond Res. 2017;31(12):3508-3523. doi:10.1519/JSC.0000000000002200

9. Swinton PA, Stewart A, Agouris I, Keogh JW, Lloyd R. A biomechanical analysis of straight and hexagonal barbell deadlifts using submaximal loads. J Strength Cond Res. 2011;25(7):2000-2009. doi:10.1519/JSC.0b013e3181e73f87

10. Contreras B, Vigotsky AD, Schoenfeld BJ, Beardsley C, Cronin J. A comparison of gluteus maximus, biceps femoris, and vastus lateralis electromyography amplitude in the parallel, full, and front squat variations in resistance-trained females. J Appl Biomech. 2016;32(1):16-22. doi:10.1123/jab.2015-0194

Can the Meniscus Heal without surgery?
Can the Meniscus Heal without surgery? 900 600 ResilientRx

When it comes to knee injuries, meniscus tears are a very common diagnosis and occur across multiple age groups. It’s estimated that the annual incidence of meniscus tears ranges from 60 to 70 cases per 100,000 people. The menisci are two C-shaped pieces of cartilage that play a vital role in cushioning and stabilizing the knee joint. Meniscus tears can occur generally in 2 ways: due to acute trauma or due to degeneration. Acute injuries involve twisting or impact while degenerative tears can occur due to factors such as lifestyle, general health (comorbidities), prior injuries, and genetics. Approximately 35% to 50% of individuals over the age of 65 have meniscus tears. In contrast, traumatic meniscus tears from sports or other physical activities are more frequently seen in adolescents and young adults. For both traumatic or degenerative tears, individuals can experience pain, swelling, limited mobility and impaired function.

It may seem that surgery is the only answer to fix these issues, however emerging research suggests that conservative management is a very viable alternative to surgery in MANY cases. In this blog, we will delve into the topic of meniscus tears and explore the growing body of evidence that supports conservative management over arthroscopic surgery. In fact, outcomes tend to be the same, if not better, when people rehab their knee instead of jumping right to the operating table.

Conservative Management: The Evidence

A robust body of research exists that shows the effectiveness of conservative management is just as good, if not better, than arthroscopic knee surgery, which includes physical therapy (exercise), activity modification, and pain management. Briefly summarized below are some key research findings in support of a conservative approach:

The FIDELITY Trial:
FIDELITY (Finnish Degenerative Meniscal Lesion Study) trial evaluated the outcomes of arthroscopic surgery versus sham surgery (placebo) for degenerative meniscal tears. The results revealed that there were no significant differences in pain or functional improvement between the two groups at 12-month follow-ups.

ESCAPE Trial:
The ESCAPE research group looked at nonobstructive degenerative meniscus tears in patients over the age of 45, and compared arthroscopic partial meniscectomies to physical therapy. They found no significant or clinically relevant difference in knee function at 5-year follow up between the two groups. The findings of this trial support the recommendation that exercise-based physical therapy should be the preferred treatment over surgery for degenerative meniscal tears.

The METEOR Trial:
The Meniscal Tear in Osteoarthritis Research (METEOR) trial focused on patients with meniscal tears and knee osteoarthritis. The study compared the outcomes of arthroscopic surgery with those of physical therapy alone. Surprisingly (or not surprisingly), the results showed that physical therapy alone was as effective as surgery in improving pain and function at 6-month and 12-month follow-ups.

The Benefits of Nonsurgical Treatment

Conservative management offers several advantages over surgery for meniscus tears, including:

Avoiding unnecessary risks: Arthroscopic surgery carries inherent risks such as infection, blood clots, and anesthesia complications. Opting for conservative management reduces exposure to these risks.

Cost-effectiveness: Surgery can be costly, especially when factoring in pre-operative assessments, post-operative care, and rehabilitation. Conservative management offers a more cost-effective alternative.

Preserving meniscal tissue: The menisci play a crucial role in knee function and joint stability. By avoiding surgery, there is a higher chance of preserving the meniscal tissue, reducing the risk of long-term complications such as osteoarthritis. In fact, patients who undergo meniscectomies increase their likelihood of needing total knee replacement down the road.

Faster recovery: Surgery typically requires a more extended recovery period, involving restricted movement and rehabilitation. Conservative management allows patients to engage in tailored physical therapy programs that can promote faster recovery and return to normal activities.

Summary

Surgeries (even simple, less invasive ones like knee arthroscopies) always come with potential risks and complications, and could lead to accelerated progression of knee osteoarthritis later in life. Individuals with significant, obstructive meniscus tears (i.e. knee locking) may still require surgical intervention. However the research is very convincing that most meniscus tears, especially degenerative, are better treated with a nonsurgical approach and that arthroscopic surgery is not superior to physical therapy intervention.

Have you been diagnosed with a meniscus tear or have ongoing knee pain? Schedule an appointment with one of our Doctors of Physical Therapy to get you back to doing the things you love! CLICK HERE or call 512-777-0330.

References:

Hede, A., Jens|n, D. B., Blyme, P., & Sonne-Holm, S. (1990). Epidemiology of meniscal lesions in the knee: 1,215 open operations in Copenhagen 1982-84.Acta orthopaedica Scandinavica. 1990; 61(5): 435-437.

Goyal, D., Keyhani, S., & Lee, E. H. (2012). HHS public access. Annals of Internal Medicine, 156(12), 945–957. doi: 10.1059/0003-4819-156-12-201206190-00006

Paxton, E. S., Stock, M. V., Brophy, R. H., & Lubowitz, J. H. (2013). Meniscal repair versus partial meniscectomy: A systematic review comparing reoperation rates and clinical outcomes. Arthroscopy – Journal of Arthroscopic and Related Surgery, 29(3), 872–880. doi: 10.1016/j.arthro.2012.12.022

Englund, M., Guermazi, A., Roemer, F. W., Aliabadi, P., Yang, M., Lewis, C. E., … Nevitt, M. C. (2008). Meniscal tear in knees without surgery and the development of radiographic osteoarthritis among middle-aged and elderly persons: The Multicenter Osteoarthritis Study. Arthritis and Rheumatism, 58(3), 810–816. doi: 10.1002/art.23293

Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., … & Järvinen, T. L. (2018). Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Annals of the rheumatic diseases, 77(2), 188-195.

Hwang, Y. G., & Kwoh, C. K. (2014). The METEOR trial: no rush to repair a torn meniscus. Cleveland Clinic Journal of Medicine, 81(4), 226-232.

Noorduyn, J. C., Van De Graaf, V. A., Willigenburg, N. W., Scholten-Peeters, G. G., Kret, E. J., Van Dijk, R. A., … & ESCAPE Research Group. (2022). Effect of physical therapy vs arthroscopic partial meniscectomy in people with degenerative meniscal tears: five-year follow-up of the ESCAPE randomized clinical trial. JAMA Network Open, 5(7), e2220394-e2220394.

Does Icing for Injuries Work?
Does Icing for Injuries Work? 1920 1080 ResilientRx

Most of us at some point in our lives have probably sprained an ankle or twisted a knee, and were inevitably given the advice to “RICE” (Rest, Ice, Compression, and Elevation). We’ve also been advised to take anti-inflammatory medications such as ibuprofen. This has been the go-to self treatment for minor injuries for as far back as many of us can remember. However, this method has evolved into something different, the details of which may surprise you.

Based on some newer research, the RICE method may not be the most effective way to treat acute musculoskeletal injuries. In place of RICE, the new proposed acronym is PEACE and LOVE: Protection, Elevation, Avoid Anti-Inflammatories, Compression, Education and Load management, Optimism, Vascularization and Exercise. This updated approach offers more detailed guidance, which we outline below.

Protection

This involves taking steps to prevent further injury and reduce pain. Options such as bracing, taping, or crutches will limit range of motion and deload the affected area, to allow things to calm down as the healing process begins. Outside of assistive devices like the ones listed above, protection also entails scaling back or temporarily refraining from activities that may irritate the injury such as sports or certain exercises. It is important to note that protection does not mean complete inactivity or bedrest as we will discuss a little later in the process.

Elevation

Elevation of the affected area is still a key part of early injury recovery. Elevating the region helps to reduce swelling and pain, which helps facilitate the body’s healing process. It is recommended that the injured area be elevated above the heart whenever possible to promote blood flow and reduce swelling.

Avoid Anti-Inflammatory Modalities

The advice to take anti-inflammatory drugs such as ibuprofen has long been coupled with the RICE method. The PEACE and LOVE approach advises against this, specifically with higher doses and longer duration of use  This is because the various phases of inflammation activate white blood cells that initiate tissue healing and repair (neutrophils and macrophages, for example). If possible, it may be beneficial to avoid anti-inflammatories such as ibuprofen, to allow your body’s natural processes to do their job. This also includes the use of ice. We believe that ice can certainly be useful for pain relief, but prolonged and excessive use with the intention to reduce inflammation, is not ideal because it has the potential to delay or disrupt revascularization and the arrival of those tissue-healing white blood cells. Use ice sparingly for pain management and try to wean off quickly.

Compression

Compression, like elevation, has remained an important component of early injury management. Compression helps to manage excessive swelling of the joints and hemorrhaging (bleeding) that has occurred in the soft tissue. It can provide general support to the injured area which may make it more comfortable to start moving and weightbearing, further facilitating the healing process. Compression should be applied gently and not be too tight, as excessive pressure can impede blood flow and cause some discomfort.

Education

Unlike the RICE method, which simply recommends rest, the PEACE and LOVE approach emphasizes the importance of active recovery strategies. It is important to understand the role of early movement and not rely excessively on passive modalities. Things like manual therapy and electric stim can be useful in reducing pain and swelling, but they should be used as supplements to exercise and load management. Education also entails encouraging the individual to avoid the mindset of “needing to be fixed” which can lead to overtreatment, and instead empowers them with knowledge and clear expectations for recovery.

Load Management

For nearly all patients with musculoskeletal problems, an active approach that includes movement and exercise is beneficial. Mechanical input (load, weightbearing, etc.) should be encouraged as early as safely possible along with resuming normal activities as soon as possible. Optimal loading means we are engaging and using the affected area without exacerbating pain. This promotes tissue repair and tolerance, which leads to restoring the individual’s function as a whole.

Optimism

Injuries can impact all aspects of a person’s life, including their mental health. Maintaining a positive outlook and belief in one’s ability to recover can have a significant impact on the healing process. Research has shown that patients who are optimistic about their recovery tend to have faster and more complete recoveries. There can be many mental and emotional barriers to recover, especially for someone who leads an active lifestyle. Don’t ever be afraid to ask for help or talk to someone if you are ever dealing with depression or fear after an injury.

Vascularization

Vascularization, or promoting blood flow to the injured area, is also crucial in the PEACE and LOVE approach. Blood flow helps to bring oxygen and nutrients to the injured area, which are essential for the healing process. The previously mentioned strategies of elevation, compression and load management can help promote vascularization. Even moving parts of your body that are uninjured are helpful throughout the recovery process. Another very important strategy that will promote vascularization is exercise, which is discussed next.

Exercise

Last, but certainly not least, is exercise. Exercise is crucial for a number of reasons, from promoting blood flow and swelling reduction, to strengthening the muscles and joints around the injured area – all of which lead to improved function and less pain. It is important to consult with your physical therapist or physician before starting any exercise program, as the type and intensity of exercise will depend on the specific injury and the stage of recovery.

We feel that compared to the traditional RICE method, PEACE and LOVE is more beneficial because it provides more detailed guidance when recovering from injuries, promotes a more active recovery approach, and creates an advantageous environment for the body’s natural processes to perform their duties.

Here are some additional quick tips:

  • Ice is still okay to use, especially if it helps reduce pain. We just may not need to ice for extended periods of time, multiple times per day after an injury. Your time is better spent moving within your tolerance, even if it’s not the directly injured area early on. Use ice sparingly and try to wean off as quickly as possible.
  • When the goal is pain reduction for non-acute injuries, either ice or heat is fine to use – whichever you find more soothing.
  • Pain-free aerobic exercise should be initiated within several days after a musculoskeletal injury if possible, to promote blood flow and boost mental/emotional well-being. When in doubt, always ask your PT or other healthcare provider

For ankle sprains in particular, consult with your physical therapist or other healthcare provider if you have any questions on whether or not you will need an Xray. Here are some helpful tips from Dr. Nick’s Instagram!

If you have a new or nagging injury or are not sure where to start, book a FREE discovery session (in person or virtual) with one of our Doctors of Physical Therapy!

References:

Dubois, B., & Esculier, J. F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British journal of sports medicine, 54(2), 72-73.

Please note: The content in this blog is intended for educational purposes only and is not medical advice. See a healthcare professional if you have any questions about your individual needs.

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