treating tendon problems

TREATING COMMON TENDON PROBLEMS
Standard Medical Care  -vs-  Conservative Care
Tendinosis Treatment

Wellcome Images: V0008265

Other than things like controversial PLATELET RICH THERAPY, which I blogged about a couple of weeks ago, the landscape for medically treating the most common forms of Tendinopathy has remained largely unchanged over the past forty or fifty years.  Sure, many of the names of the drugs have changed, but no honest doctor will admit that the newer brands of NSAIDS are any more effective than the old brands and we are not even discussing side effects yet.  Let’s take a moment and discuss what the scientific literature has to say about these most common forms of treatment for tendon problems.

CONSERVATIVE TREATMENT

  • REST:  Undoubtedly, if you develop a tendon problem, you will have to go through a period of rest.  The length of time that one should rest a problematic joint, however, is a controversial topic.  Everyone has heard the old cliche’, “You would have been better off to break a bone than injure a tendon / ligament“.  Because tendons have a poor blood supply, they heal slowly.  However, rest is a double edged sword that can cause its own unique set of problems.  Believe it or not, loss of or abnormal joint motion actually causes connective tissues to degenerate in much the same manner than overuse does.  This is why there has been so much written about…………..

 

  • STRETCHES & EXERCISES:  This is a great starting point for minor tendon problems.  However, it is certainly not a cure all.  Stretching and strengthening exercises can help heal some of the less severe tendinosis, as long as you are careful to take things gradually. Be aware that in certain cases (ususally more severe cases) stretching can actually make you worse (HERE).

 

  • MODALITIES:  Therapy modalities include things like ultrasound, TENS, and various forms of electric stimulation (we occasionally use a Mens-O-Matic microcurrent machine).  However, the research on these modalities has not really proved that they help Tendinosis heal faster or better than not using them.  My belief is that many clinicians still use these outdated modalities because insurance companies still pay for them.   Truthfully, there is no real downside to trying some of these things to see if they might help you.  Although insurances will not pay for them, there are some cool new modalities on the block that could be highly beneficial for tendon problems.  My favorite is COLD LASER THERAPY.   OXYGEN is sometimes part of my protocol for TENDINOPATHY / TENDINOSIS as well. 

 

  • HEAT / COLD THERAPY:   Ice packs are a common treatment for tendinosis.  Ice helps to relieve swelling and inflammation.  Don’t get an area too cold, don’t put the cold directly on the skin, don’t leave the ice on for more than maybe 10 minutes or so, and don’t use ice right before stretching or exercising (HERE).

 

  • MASSAGE:  When massage is done properly, it can be a powerful tool in the battle against tendinopathy.  The great thing is that with massage, you are actually addressing the degenerated and deranged connective tissue.  No downside, but not a solution for many hardcore tendinosis.

 

  • ACUPUNCTURE:  This stuff has been around for several thousand years.  I used to do lots of acupuncture, but switched to something much more effective about 11 years ago.  But the truth remains, acupuncture helps a lot of people.  However, those with hardcore scarring of their collagen-based tendon fibers will probably get limited results.

 

  • BRACES:  Braces can be a tremendous help in allowing people to function on a somewhat normal basis despite their problem.  Be aware, however, that the more one relies on a brace, the weaker the supporting tissues get.  Do not use a brace unless you absolutely have to.

 

  • ORTHOTICS:  Orthotics can be a Godsend when they are needed and done correctly.  I can assure you that most orthotic products on the market are not great.  And the so-called “custom” orthotics?  99% are off-the-shelf even though you may have gone through elaborate or computerized casting procedures.  After suffering with POSTERIOR TIB TENDINOSIS and a Plantar Fascia problem for a decade, I met Shawn Eno of Xtreme Footwerks on Idaho Springs, CO.  He saved my life!

 

  • PROPER ERGONOMICS:   In this day and age, this should be a given.  Unfortunately, it’s not.  A while back I was treating a UPS driver for a shoulder problem.  He was not improving, even though I could not find any reason he shouldn’t be.  He had me come out and look at his truck.  No lie — the seat was about 6 inches off-set from the steering wheel.  Not good.  If your work area is not fit to your body, problems (including tendinosis) can result.  Another way to avoid tendinosis is to make sure that if you do a repetitive job at work, get cross-trained and periodically swap jobs.

 

  • PROPER NUTRITION / SUPPLEMENTATION:  Although last on the list, proper nutrition is certainly not the least!  The very first piece of advice that I can give you for any and every health problem is to eat a healthy diet.  Most of us have no idea what this really means, and are totally unaware that synthetic foods (foods not based on WHOLE FOOD NUTRITIONAL PRINCIPLES), are actually horrendously degenerative.  The best work on this phenomenon is Dr. Weston Price’s classic text, Nutrition & Physical Degeneration — you can see a review by Steve Solomon online.

WHOLE FOOD VITAMIN C stimulates Type I collagen synthesis.  Unfortunately, all the studies that have been done on Vitamin C and tendons have been done with Synthetic Vitamin C (Ascorbic Acid).  Remember this because studies have shown that adding Synthetic Vitamin C to injured tendon cells actually causes them produce abnormal collagen, as opposed to normal collagen.  Any time you take a single nutritional compound out of its whole food nutritional complex, remove all the co-factors and synergistic nutritional compounds, and then manufacture a high-dose fractionated synthetic in a lab, you are unlikely to get the results you are hoping to get.

Glucosamine Sulfate with Chondroitin is a wonderful supplement.  However, because it is more for cartilage issues, it tends to work well for degenerative osteoarthritis.  It will probably not help much with tendinosis.  And although Tendinosis is not an inflammatory problem, natural anti-inflammatory herbs such as garlic, ginger, tumeric, boswellia, bromelain; and anti-inflammatory fats such as PHARMACEUTICAL GRADE FISH OIL can make a huge difference, as can an ANTI-INFLAMMATORY DIET.  Lots of theories on why this is, but I am not sure that anyone knows for sure; other than the fact they have the capability to block pain.

NON-CONSERVATIVE TREATMENT

  • ANTI-INFLAMMATORY MEDICATIONS:  Non-steroidal anti-inflammatories would not be expected to help tendinosis since it is an injury of chronic degeneration —- not INFLAMMATION. However, these drugs (just like the anti-inflammatory nutritional compounds above) will often relieve pain.  Just remember that the pain relief is usually short-lived, and that studies have shown that some NSAIDs actually impede the healing process, which is the last thing needed with tendinosis.   For more information, read the article from a 2002 issue of the British Medical Journal called Time to Abandon the “Tendinitis” Myth.

 

  • CORTICOSTEROID INJECTIONS:  Cortisone injections have been shown to cause adverse effects on the collagen-based tissues in the area of the injection.  Tendinosis is a chronic, degenerative, injury that can’t be cured with CORTICO-STEROID INJECTIONS.  Corticosteroids actually degenerate connective tissues and slow collagen formation.  Corticosteroids are anti-inflammatory medications —- and tendinosis is not an inflammatory condition!   Doctors think cortisone reduces pain by reducing or blocking other irritating biochemical substances that occur as part of the injury process. 

 

  • PROLOTHERAPY:   This one deserves to be right up there with PRP.  I realize that there are people being helped by this treatment, but I have yet to meet them (I have met some people really messed up by prolo).  Prolotherapy involves injecting a sugar solution into the injured area.  The sugar causes irritation to the tendon which is hoped to promote healing via a local “Inflammatory” response.   Although sugar is a fairly benign substance, it can provoke reactions that have the potential to leave people worse instead of better.  I have spoken with numerous people who have gone the Prolo route.  I have never one time personally met a person that has good things to say about it.

 

  • SURGERY:  Surgery is a last resort for tendinosis.  There are few studies that show positive results for surgery.  If you want to get a more realistic and accurate picture of people’s experiences with tendinosis surgery, I would suggest that you check out the online support groups and message boards.  You will certainly find some people that surgery has helped.  You will also find a slew of people whom surgery has made worse. 

WHY SO MANY ITEMS IN BOTH SECTIONS OF THIS LIST TEND TO BE
LARGELY INEFFECTIVE

They’re not effective because they’re not dealing with underlying causes.  Tendinosis is characterized as a tendon whose collagen tissue is deranged and degenerative.  When the old model of “inflammation” is used to treat this problem, people get, “short term benefits with long term problems“.  And the kicker is that none of this is really new information. 

Tendinosis, sometimes called tendinitis, or tendinopathy, is damage to a tendon at a cellular level (the suffix “osis” implies a pathology of chronic degeneration without inflammation). It is thought to be caused by micro-tears in the connective tissue in and around the tendon, leading to an increased number of tendon repair cells. This may lead to reduced tensile strength, thus increasing the chance of repetitive injury or even tendon rupture. Tendinosis is often misdiagnosed as tendinitis due to the limited understanding of tendinopathies by the medical community.” Tendon researcher and orthopedic surgeon, Dr. GA Murrell from an article called, “Understanding Tendinopathies” in the December 2002 issue of The British Journal of Sports Medicine.

The American Academy of Orthopedic Surgeons has provided a new classification of tendon injuries….  In the microtraumatic tendon injury the main histologic features represent a degenerative tendinopathy thought to be due to an hypoxic [diminished oxygen] degenerative process. The similarity to the histology [study of the cells] of an acute wound repair with inflammatory cell infiltration as in macrotrauma seems to be absent.  A new classification of tendon injury called “tendinosis” is now accepted.  Tendinosis is a term referring to tendinous degeneration due to atrophy (aging, microtrauma, vascular compromise). Histologically there is a non-inflammatory tendinous degeneration due to atrophy (aging, microtrauma, vascular compromise), as well as a non-inflammatory intratendinous collagen degeneration with fiber disorientation, hypocelluarity, scattered vascular ingrowth, and occasional local necrosis or calcification.”  Dr. Warren Hammer, board certified Chiropractic Orthopedist (in practice since the late 1950′s), from a 1992 column in Dynamic Chiropractic.

WHAT WORKS THE BEST?

After spending the first half of my time in practice using modalities, exercises & stretches, acupuncture, and CHIROPRACTIC ADJUSTMENTS, to treat people with chronic tendinopathies, I have modified what I do.  Of course I still prescribe home stretching and exercising, and I still find Chiropractic Adjustments to be an important part of some tendon protocols, but I have revamped my core tendinosis protocol.

  • LOW LEVEL / COLD LASER THERAPY:  Other than icing at home, this is really the only modality I use in my office.  HERE’S WHY.

  • VERY SPECIFIC NUTRITIONAL SUPPLEMENTS:  When studies show that nutrition does not work well for certain things, they are usually right.  However, what these studies almost always do is to take an isolated nutritional compound and then use a synthetic version as their “Nutritional Supplement”.  There are two problems with this.  Firstly, no matter what anyone tries to tell you, Synthetic Nutrition is not the same as WHOLE FOOD NUTRITION.  Secondly, you simply do not ever find isolated chemicals in nature.  You find entire nutritional complexes being used in synergy with numerous other nutritional complexes. Trying to use a synthesized version of one chemical found naturally as part of a nutritional complex is a recipe for failure.  The best supplement for tendons is LIGAPLEX by Standard Process.  Ligaplex is made from cold-processed connective tissues of organically raised beef.  It gives you the raw material for your body to actually produce the collagen-based tissues it must produce in order to heal injured tendons, ligaments, or FASCIA — a problem which is frequently seen alongside Tendinosis.

  • SCAR TISSUE REMODELING:   Because these tendon problems are almost always “Degenerative” and not INFLAMMATORY, simply taking anti-anflammation drugs is not going to help over the long haul.  The thing that must be accomplished is to break down these degenerative areas and microscopic adhesions.  This is what the better part of this website is all about.
WARNING   WARNING   WARNING
SYSTEMIC PROBLEMS
I have to warn you; if your problem is a Systemic Tendinosis (HERE or HERE), all bets are off with the protocol above.  This is because you likely have a “Whole Body” INFLAMMATORY or AUTOIMMUNE process of some sort going on.  If you have bilateral tendinosis, or tendinosis at multiple sites, your chances of the problem being systemic increase dramatically.  So doc, if my problem is systemic, what am I supposed to do?  The very first thing that you can do is to clean up your diet.

Try nothing but organic meats and vegetables for a few weeks (no fruits for now) —- almost like an Atkins Diet Induction Phase or PALEO DIET (heavy on the vegetables).  This way you not only cover a likely GLUTEN INTOLERANCE, you cover the potential for CROSS REACTIVITY as well.   A great starting point for everyone trying to figure out whether or not they have SYSTEMIC PROBLEMS can be found by following the link.

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