Blair Dinsdale, MPT
Physiotherapist NRG Athletes. Therapy. Fitness
There are a lot of different approaches when it comes to treating individuals who suffer from Muscular and tendon related pain such as a tendinitis. Approaches range from the use of modalities such as ultrasound, acupuncture, and deep friction massage, which c an all be good for helping reduce pain, but when it comes to addressing the underlying deficits these modalities will usually do not have significant long-term effects for a true muscle pathology. When it comes to exercise therapy and tendinopathies possible treatments include stretching, eccentric exercise (loading muscles while they are lengthening) Isometrics (muscles staying the same length while under tension) and Heavy Slow Resistance Training “HSR” (slow contraction of the muscle using both concentric and eccentric phases)
There are a lot of misconceptions about a tendinitis, and a lot of people regard this as an inflammatory condition, but what researchers are is that initially there are repeated inflammatory cycles, but what happens with these repeated overload cycles is that structural changes occur such as thicker tendons that have disorganized and weak tendon fibers, hypervascularity, and areas of cell death in pathological tendons 1 but actual inflammatory molecules no longer persist in a chronic tendinopathy.
In simple terms when it comes to tendinopathies essentially muscles and tendons have lost their ability to handle load/activity sufficiently due to the degradation of the tendon. So, what do you need to do to treat tendinopathies. The Answer is to load the injured tissues in a graded manner to make the body responds and adapt to stresses placed upon it. This is where I am going to pick a beef I have in the therapy world regarding deep friction massage. The proposed mechanism I learned in school of this treatment is flawed in my opinion. How I was taught this worked is that by rubbing on a tendon we created blood flow and break up adhesions and promote reorganization of the collagen matrix of the tendon. To me this doesn’t make sense as the amount of pressure to create true tissue deformation in most muscles is ridiculously high. For example, to create 1 percent compression of the Fascia Latae it would take 925 Kg 2. How I explain this to people is that to create strength in your bicep in order to do a bicep curl you wouldn’t expect rubbing your bicep to improve its strength, the same goes for Deep Friction Massage, rubbing a tendon doesn’t make it stronger. Tensile load created by exercise causes adaptation as that is the primary function of a tendon. There is very little evidence that supports the benefits of Deep Transverse Friction Massage in the long term.5
So when it comes to long term outcomes in tendinopathy resistance training is what generally helps. And for the most part, as long as you are loading with resistance, you will see benefits, although some forms of loading seem superior to others in certain cases, such as HSR over eccentric training for Patellar tendinopathy 3 or eccentric over concentric graded exercise for chronic tennis elbow4. But regardless of the loading exercise used there were still improvements seen in both exercise groups in the studies mentioned above. For tendinopathy, it essentially comes down to time under load, so when in doubt, load it, your body is strong and incredibly capable of positive adaptation when we challenge ourselves and when we challenge ourselves physically and mentally we generally feel better.
About the Author: Blair Dinsdale is a Physiotherapist at NRG Athletes. Therapy. Fitness. He is a big believer in the power of exercise and aims to empower those he works with through education and exercise
Scott, A., Backman, L. J., & Speed, C. (2015). Tendinopathy: update on pathophysiology. journal of orthopaedic & sports physical therapy, 45(11), 833-841.
Chaudhry, H., Schleip, R., Ji, Z., Bukiet, B., Maney, M., & Findley, T. (2008). Three-dimensional mathematical model for deformation of human fasciae in manual therapy. The Journal of the American Osteopathic Association, 108(8), 379-390.
Kongsgaard, M., Kovanen, V., Aagaard, P., Doessing, S., Hansen, P., Laursen, A. H., … & Magnusson, S. P. (2009). Corticosteroid injections, eccentric decline squat training, and heavy slow resistance training in patellar tendinopathy. Scandinavian journal of medicine & science in sports, 19(6), 790-802.
Peterson, M., Butler, S., Eriksson, M., & Svärdsudd, K. (2014). A randomized controlled trial of eccentric vs. concentric graded exercise in chronic tennis elbow (lateral elbow tendinopathy). Clinical Rehabilitation, 28(9), 862-872.
Loew, L. M., Brosseau, L., Tugwell, P., Wells, G. A., Welch, V., Shea, B., … & Rahman, P. (2014). Deep transverse friction massage for treating lateral