Tendinopathy rehab: load the tendon, don't rest it

think really the danger is treating the hole itself or treating the tear or treating the area that doesn't really function well. The danger is actually putting off loading the rest of the donut or the tendon itself. It's just a bunch of lost time. And then people will have reoccurring issues that happen over that time. And they're going to slip down into, you know, your, your stage three. So passive care, all good. But a lot of times patients are told to rest as the tear heals itself, creating a larger problem. And so tendons will only be as strong as the chronic demand that you place upon it. This is a timeline of deloading that further degrades the tendon structure. You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now your host, Dr. Sebastian Gonzales. Hey guys, it's Sebastian, your host for the Restoring Human Movement podcast.

Thanks for joining the Movement Movement. If this is your first time in the show, welcome. You've missed a lot. And this show is intended on improving our clinical abilities so we can help our patients even faster. Uh, also too, there is a lot of, um, podcasts in the past where we've done patient friendly ones that the conversation is easy. It's understandable. Hopefully it's just good information that, uh, is lacking on quite honestly, there's lacking good information and updated information on the internet. And so, um, those ones are intended for late public to listen to, and hopefully you guys enjoy that. So, um, but if you have not gone to the archives, uh, there is a ton of great episodes back in the archives that you should be listening to if you haven't already. So, uh, this one today is going to be a solo podcast and it is on a topic that I should have, uh, quite honestly, I should have started investigating a long time ago. I've been familiar with some of these, um, aspects of care, but also too, as I've told my interns on a probably weekly basis is there's a couple gaps in our treatment plan, which is missing. And I'm always looking for them. Um, however, I do believe in the, the concept of just learning at just in the nick of time. And so I think that's, what's happening with this, uh, topic here. So recently I, um, went out of town and I was, I was driving up, I was brainstorming, um, what I should be working on over the weekend. And recently we've been doing some in services at the office, uh, to improve our knowledge and abilities and something that's been coming up quite frequently.

And I'm sure you guys have heard me on the podcast, talk about this a little bit is that, uh, we're good at a lot of things, but don't send us an ankle type of thing. You know, um, I think we do better than most places, I guess probably sound cocky and arrogant, but I think we do better than most places at ankles, or at least knowing when we can't help someone with an ankle. And, um, because of that, I think we needed to address, uh, tendon rehabilitation and just some general parameters around, um, the standard of care currently with tendon rehabilitation, because there's, here's the thing is, um, I really like having something that reduces pain very quickly with people. So they feel like they're in control. And, uh, say we're talking about knees or ankles, like we're starting to get further away from the possibility that there's any type of spinal referred, um, or even, I guess there'd be a, like a derangement, like a McKinney derangement model. And so let's just say, we're talking about a knee. We have, um, a possibility of generally a few things like it based upon your populations. And by the way, I haven't crossed this bridge a lot because a lot of my patients don't have this type of thing, uh, patellar tendonitis, Achilles tendonitis, um, even hamstring tendonitis. A lot of them, they don't have it. And so when we start getting people in like this, it's like, we have to think a little bit harder and it makes me feel uncomfortable. And so finding a first aid is a little bit more challenging for these people, but, um, let's just say we're talking about an, uh, a knee. There's a possibility of referral, spinal referral from the side, like your pseudo IT band, um, like your quad pain and, and, and so on.

Um, there's also a possibility of like the, the internal derangement, which is like your ACL or your like meniscus type of thing, which usually produces a lot of swelling, especially inside the joint. But then there's also external external is like local, um, tendon issues. And so, um, we have been good at the first two, but really not that great. And the other ones, because we haven't, hasn't really come up that much, or if it does come up that, uh, does come up, it's like, we strike out enough to where the person goes away real quickly, or we have to send them away to somebody else. Um, even with ankles to ankle, same thing. It could be referred from the spine. It could be something like a quote unquote, low grid sciatica. Uh, it could be something that is, uh, internally kind of a mist, uh, let's just say our ankle impingement, which we're not bad at either, but there are the circumstances where it really is like a tendinopathy and that's external to the joint. And so we have not been good at those, uh, with hamstrings, to be honest with you, I feel like most of them, most, most of them that I've experienced are typically spinal referred in some fashion, but high hamstring tendinopathy, same thing. Like I can, I can personally go down the, the, the route of at least what I used to know for hamstrings back in the day, because I did have one that tore. And so I really looked into the, uh, the, the standards back then. So things have changed is a thing. And since things haven't really come to my attention that much, cause I've been looking for them. Um, but also the patients that come in, don't have it. So I haven't been stimulated to really do as much investigation, but since, uh, Sarah, our, um, our, uh, past intern now sees, she sees a lot, like she sees like all runners cause she's a runner. And so now we have the more questions coming up about ankles and Achilles and, um, uh, Ali sees a lot of people with ankles too, they're dancers. And so it's, it's coming up more and more often. And so, uh, I reached out to, uh, Cody D-Mac who a lot of you probably know, or might be students of, I said, Hey, what's your, uh, what's your thing about Achilles tendons, uh, that aren't really swollen too much and that aren't spinal referred. And, and he says, uh, uh, mid range, mid range, uh, isometric loading.

And so I gave him, I did some little questions with him and he sent me some of Jill Cook's videos that were, um, uh, came out about, I think two, three years ago, uh, as well as ebony Rios. And so I went through them and it dug up a big old rabbit hole rabbit hole of what's going on here. And so I thought I would share with you, um, the things that I found, and you can always do your own research too, um, for patients listening to this, uh, hopefully you get an idea of at least, um, where your head should be at and what you should be looking for in regards to care. Um, and if people are kind of going outside of, I don't want to say outside the standard with this, because there are still a lot of things that seems like we need to know about 10 and rehabilitation, but if they're kind of just giving you stretches and basic stuff, I think like you, you need to be finding someone who's at least loading you because the consensus so far is that you need to supply some load. So I wrote a little, I have a little write-up here. Um, I'm going to go generally off of it.

I typically don't do, I don't read stuff on these podcasts, but since this is a newer topic to me, I thought I would just share what I have currently. Uh, I'm sure this document will change over time and it's not available to the public. Uh, this is something we do for internal stuff at performance place. And I've shared it with all the interns and the doctors that, um, are currently working there. That way we can build upon this and help kind of bring this into our five-step system, which again, we believe is very helpful. And so I called this one, uh, tendinopathy thoughts and protocols, uh, for at performance place sports care. So tenant rehabilitation can be, uh, challenge, uh, can be challenging for various reasons. Rightfully so patients tend to focus on pain as an outcome measure. Clinicians should be focused on the reduction of pain and the return of function. Uh, by the way, a lot of this is taken, um, from, um, uh, Jill Cook, uh, taking it from some other research articles.

There was, uh, let's see. Um, like I said, Ebony Rio, there was somebody else here that there was, if you, if you, if you YouTube them, by the way, if you YouTube those videos, uh, you'll, you'll see them and you'll actually, you'll see everything that I'm talking about. It was all from one conference that they, that they had. So I don't want to seem like I'm this, all, this is my original content. I might actually used a little bit, probably a little bit of their jargon too. So I want to give them props, uh, where props are due to. So, uh, please go back to the source. Oh, and so when it comes, uh, so when it comes to it, uh, basically, you don't, you want to walk. Um, let me go backwards here.

I guess clinician should be considered with a return of, uh, uh, reduction of pain and return of function. And when it comes to it, you don't want to walk with a limp regardless of what, if you're in pain or not. Um, and I don't think anybody does, but obviously pain is the first thing that they're concerned with. However, they probably won't be happy if they have a limp, by the way, it's probably important to note that limps really don't hurt. I think we can all agree on that. So, uh, reduction of pain and return of function are, are kind of like different things, you know, but if we actually reduce, uh, uh, if we restore function, we can actually reduce pain, generally speaking. Okay. In this article, I'll be covering what I've learned about tendon pathology and rehabilitation for the Achilles patellar and hamstring tendons. A few theories have been developed over the years. Uh, what causes tendon pathology and pain? The three are inflammation, collagen, tearing, and the continuum model. These theories have been studied. Uh, these theories have been studied, but we don't have any confirmation that any of these theories are really true.

So, uh, again, um, my interpretation of what I heard, I can always be wrong on these things too. Uh, tendon inflammation. Let me start with this. So the, the inflammatory theory of tendon pathology is simple. Uh, and a lot of patients will grasp it very simply too. And personally, I think that's the reason why it's still around. Inflammation occurs at the tendon creating pain. However, tendons have very few inflammatory cells, uh, and inflammatory mediators. Inflammation seems to exist in the tendon, but it doesn't appear to be the primary driver of tendon pain itself. Uh, since this seems to be the case, uh, it may take, it may be better to stop giving, uh, um, a lot of icing and things like that as a treatment plans, by the way. And since this seems to be a case as well, it's probably better to stop using the terms as tendinitis and tendinosis, rather probably something like tendinopathy makes better sense. I personally like to say issues.

Um, but the reason why this might be a good idea to go away from is because if tendonitis is a term, it insinuates that there's an inflammatory condition. And if it seems like an inflammatory condition is not the actual problem going on, then why are we doing this? You know? So tendinopathy seems like a better call. Uh, I think tendonalgia, by the way, if you use that one, that generally means tendon pain because alga is pain. So maybe that's when we go with two, uh, collagen tearing theory. So the collagen tearing theory has been, uh, relatively debunked, uh, from a theoretical perspective. Um, especially if the tendon is in a normal state, like normal things are happening within the tendon. So since the tendon is, uh, intimately, uh, intertwined with the muscle it's attached to the musculoskeletous junction and the bony attachment. Um, what we do know is that when there's a load put through this system, uh, the area that's probably going to get compromised first is going to be the one that tolerates less, less load. And, uh, collagen is pound per pound.

I've heard this before somewhere else is pound for pound stronger than steel. And so it's really strong. Normal collagen, uh, within a tendon is not going to tear. And so instead we can see the weaker areas that tolerate less load will probably tear instead. Muscle and tendon would probably sustain an injury before a healthy call it before healthy collagen would, um, within the tendon collagen is extremely, extremely strong. And as I said before, pound for pound stronger than steel, uh, it's impossible to tear quote unquote normal tendon. Joe Cook mentioned in her work that this theory is not the starting point of tendon pathology, unless there's some of the type of probable predisposing factor that would degenerate normal tendon quality. Now, the third one is the Cook and, uh, perdom content continuum model, which I actually had to look this up. So I don't even know it was a thing. And this is why I think updating our information over time is important. Uh, probably a lot of you listening, you're like, dude, like, yeah, this was an old, old news. I had no idea.

I'm pretty sure the dynamic system theory back then I was like, someone proposed it to me. I'm like, dude, that is crazy. That's good. And someone else was like, yeah, I've seen this. You know, we're all different stages here. Uh, so this model cells within the tenant tendon, uh, tendinocytes, uh, have, uh, exaggerated response to an acute load that that tenant was not really conditioned for the cell. The cellular response is what signals small proteins called proteoglycans to accumulate within the cellular matrix, which then makes it swell. Since the cellular reaction is what starts the swelling is in the first place is probably the thing we want to address as we move into a treatment plan.

And so it really comes down to load management strategies is how we're going to manage this problem with people as discussed in the prior section. Inflammation does not appear to be the driver of the condition. So anti-inflammatory treatments won't typically help funding. This is how I feel like most people I've met are, are, um, managed, you know, um, even with some of their injections and so on. So we'll probably address that later, by the way, she has a good section in there about, um, uh, injectables PRPs and so on. Uh, I didn't cover all that in this because it wasn't, uh, it just, I think we just general, I generally covered it because this is more for our conversation points with patients. Um, why does cellular response?

Why does cellular response happen? Well, in simple terms, your body and tendon was not ready for the activity. The body adapts over time. It's important to note it adapts over time, over time. I always stress this to my patients. It adapts over time. So don't spike your activity too much because then you end up having maybe things like this, you know, uh, not necessarily a small spike, but it could be just a weekly spike too. Um, tendons, bones, muscles, and even nervous system function in this way. They adapt over time. Uh, our body can and will adapt if you give it, uh, if you do not give it more than it can handle, at least in a small bite-sized piece, which is where the value of good programming and coaching comes into play. Uh, when tendons, uh, when tendon injuries occur, you have basically surpassed your load tolerance. Okay. Short spikes and activity push the body outside our quote unquote functional envelope, which can create injuries like tendinopathies exceeding your body's load capacity within a single bout of activity or a weekly accumulation can trigger the cells or the tendon cells to react in, in the aforementioned way. So let's not blame the cells.

The cells are basically what you want it to do. Like they're adapting, they're trying, you know, favorably over time. And the cells are also what we're going to use to fully recover as well. So don't blame the cells, not their problem. Uh, we just have to manage, uh, what stimulus we're giving them. And so this model proposes three overlapping stages of tendon injuries. Uh, the it's the active tendinopathy, the tendon disrepair and the degenerative tendinopathy stages. It's challenging to know which stage your tendon is really in. Um, but there are a few general rules that we can kind of use to figure out what it's in. So stage one, which is the reactive tendinopathy normally results in intense pain and swelling, uh, in, uh, is, uh, more swelling is present and typically triggered by a large jump in activity intensity or volume. Also, this might be the first person, uh, first time the person has ever experienced this type of pain and typically starts to linger for four to eight weeks. By the way, I hope you guys, uh, give me, uh, I feel like the game popcorn, you know, in middle school, um, I've, I've, I've, I wrote this like, uh, like all this weekend. I've never actually read it, uh, out loud. It's funny. It reminds me of like in high school, there was a, uh, a book that I read called Sid Hartha. I still don't know who the main character was because I never really said his name out loud. And so we do that reading thing, right? And I couldn't say his name. So there might be a couple of words in here. I might stutter over, uh, stage one tenants can return back to normal tenants within a few weeks. If the right steps are taken to modify provoking activity before reloading the progress in a progressive fashion specific to that tendon, um, reactive or disrepair slash degeneration tendinopathies, which is stage two typically, uh, has less apparent, uh, apparent swelling in pain is less intense. Uh, it won't be the first point. First time the person experienced this type of pain and it tends to trigger with less intense activity as well. Uh, it also tends to improve on its own within a couple of days, like let's think three, four days or so. Stage two tenants, uh, uh, uh, occur when people ignore their pain and keep poking the bear. In the stage of disrepair, the tenant begins to thicken and attempt to self-repair and protect itself. As cells continue to respond to overload, proteoglycans continue to accumulate and draw water within it, which further disorganizes the collagen structure within the tendon. So this process continues until stage three, if not addressed, um, with a deloading to reloading type of treatment plan. Okay. Degenerative tendons are stage three and tends to really not hurt, which is funny how that kind of works, huh? Like, like the more advanced doesn't really hurt. So chew on that one. Uh, so does treatment change the structure of the degenerating tendon? Degenerative tendons do not seem to change with treatment. The structure of the tendon as found in images will not change, but thankfully patients do fully recover after being diagnosed with degenerative tendons. They, they do have traumatic reduction or traumatic, um, dramatic, I think I'm looking for that one, dramatic reductions and restoration of function regard, regardless of fixing the actual tendon structure itself or not. Degenerative tendons tend to be thicker in overall tendon, uh, with overall more tendon tissue than a normal tendon. I want you to pay attention to this section. You might have to rewind a couple of times, by the way, because I had to think about this when I was reading it. So degenerative tendons tend to be thicker and overall more tendon tissue than normal tendon. Having more tendon tissue clinically makes sense since degenerative tendons appear to be thicker on examination. Interestingly though, degenerative tendons were found to have actually more healthy tendon tissue than a normal tendon. That's right. Degenerative tendons are larger.

They have more bad tendon tissue within them. We usually with the island formations than a normal tendon, but they also have more functional tendon tissue kind of on a mass by mass basis than a normal tendon. Think about that. So can we safely apply load to the degenerative tendons? Yes, we can. Remember that degenerative tendons are packed full of healthy tendon tissue and are fully capable of, of, of tolerating load, regardless of the amount of tender, uh, pain the person's having. So the takeaway I think we should have is that we should safely be able to load a degenerative tendon without actually chancing, uh, or having high risk of damaging the tendon. Although we need to be, uh, careful of the people who actually have predisposed conditions like your, uh, and this is me, we just, I didn't read this in here, but I think we consider the people who have some type of diabetes or some type of, um, uh, connective tissue disorder. Degenerative tendons can tolerate load, uh, and they're, they're, they just happen to be more painful. Okay. Or not always painful as I mentioned earlier. So I guess that'd be more of a disrepair stage. Let's say, let's call them tendinopathies at this point moving forward. Okay. I apologize if I'm back and forth on the wrong stages of things, because again, this is, I like to generalize it with my patients and say issues, you know, and just tell them what to do just mainly for compliance. So how should we be treating a degenerative tendon? Well, Jill Cook painted a really good picture, uh, as reassurance that we can and should be loading tendons that are having these issues, uh, as treatment, since we know that rest is a terrible idea. So funny, that's what, that's what people usually do. They rest it too. And so we need to actually, this is just me, me talking, not in the article anymore. We need to get on people's ass on this. Okay. Because, um, they'll jump in and out of care because they're chasing pain versus chasing function and restoration. Okay. Restoration of function in creating the adaptation.

And so long, the long story of it is, I think they, they will not end up caring. I guess, I don't, I guess we just got to get them to care and understand, I guess. So, um, Jill Cook had mentioned that you treat the donut, not the donut hole. Remember I said, there's islands of a tissue that's really not working too well in there. So don't worry about the hole in the tendon that surrounding donut has enough, uh, uh, the surrounding donut has enough mass and trend can transfer enough load safely to load the tendon. So degenerative tendons come with adaptations of increased of good tendon area. Like I mentioned earlier, the hole in the tendon can be visualized oftentimes through imaging as islands of degenerative tissue that are unable to bear load. They're mechanically dead. No worries though. It doesn't really matter. It's surrounded by a massive area of healthy tissue, which is fully capable of transferring load. So I think the body's wonderful and it can adapt and you can, I mean, you can feel good again is anyways, this is what I tell my patients. Uh, I think is we should be very aware of how we communicate these tendon findings to our patients because they might think they're broken and that they need all these other things to, uh, improve their tendons via passive care. And so there's a psychosocial aspect in here based upon how you communicate the findings that you have about their tendon. So yeah, there's the whole, they'll focus on the whole because it's something that they've lost. You know, like I focus on like my wallet when I lose it, right. Versus the things that you've gained. And so make sure that they're aware that they can feel good again, if they just do what you say. Okay. There's no reason to really tell our patients that they're broken in dealing with degenerative when dealing with a degenerative tendon. I think we have the responsibility to tell them what they have, but I think we can rephrase it in a different way. So back to the donut analogy, um, do we need to treat the, the hole or the tear?

No, I know we don't. So here's the issue is as many treatments have been targeted the hole over the years, which do not have proven results like shockwave ultrasound, PRP stem cell. Um, by the way, these are all referenced in her art and in her, um, in her work, or in this case, it was in a YouTube video. I'm probably going to be digging way more into her work as time goes on here and make it sure that I'm well-versed in this as well. Cause I always want to get better too. So, um, people with holes within their tendon don't always have pain, uh, and the relationship between tendon tears found on images and pain is really not that strong. So tearing the 10 pre, uh, tends to treating the terror in the tendon or treating the hole tends to be very passive. Okay. Loading the tendon tends to be put off way too long in my opinion. So I don't think really the danger is treating the hole itself or treating the tear or treating the area that doesn't really function well.

The danger is actually putting off loading the rest of the donut or the tendon itself. It's just a bunch of lost time. And then people will have reoccurring issues that happen over that time. And they're going to slip down into, you know, your, your stage three. So passive care, all good. But a lot of times patients are told to rest as the tear heals itself, creating a larger problem. And so tendons will only be as strong as the chronic demand that you place upon it. This is a timeline of deloading that further degrades the tendons structure. So prolonged rest, here's what it creates, um, at least in tendons. So tendon loses structure and become physically path, pathological. The musculat tendon disjunction, uh, uh, mechanical strength drops within just two weeks that connects change starts to degrade. And also our brain function tends to degrade a little bit with it. So how should we, um, how does a tendon become painful?

Now, this is the section I think I need a little bit about, definitely be a lot better about because recognizing the mechanism of how these things create themselves is actually how we can further help someone rehabilitate, um, kind of doing things on a fly, knowing what's going on with the body without having to, um, think about too much about like a standard format because, um, as it appears rehabilitating tendons, it's, uh, it's an artistry. Okay. So it's the, the clinician is you're an artist. Okay. You have all this hard information to work with, or you have the best, uh, best evidence-based stuff to work with, but also time you're an artist because based upon the person, their age and what they want to do as well as what stages that are stage that they're in. So typically tendons require some type of, um, requires some type of mechanical injury to become painful. Tendons are subjected to three types of forces, which, uh, I guess we can take direct trauma out of the picture in this one. So there's energy storage, compression, and friction energy storage. Uh, let's just say, we'll talk about the Achilles tendon in this. Typically we find that this type of mechanism is present in the middle of the tendon, um, and creates a mid tendon injury. The Achilles is the only tendon. Uh, I hope that's right. Uh, it's the only tendon that tends to have mid tendon pathology guys. I want you to correct me if I'm wrong in that, because I'm still willing to learn this. The, uh, the patellar tendon tends to get in, uh, get a tendinous issues at the insertion into the kneecap, kind of like your jumper's knee, not the mid tendon area, such as the Achilles would compression mechanics, uh, tend to go along or they're, they're present as the tendon inserts into the bone. The Achilles tendon will have compression at full dorsiflexion as it gets compressed against the heel or the calcaneus.

The patellar tendon doesn't experience compressive loads. It's interesting. Um, I think I missed that because, uh, that's going to be insertional. So I'm going to highlight that for myself to rework with. Thanks for working with the guys on this. So, uh, friction peritendinitis tends to happen with friction types of mechanics on the, on the, uh, as the injury, uh, as the tissue around it tends to produce friction. Uh, think about the muscles and tissues that move around the Achilles tendon as we rapidly move it through cycling. The patellar tendon doesn't experience any friction type of loads.

I can tell I was probably wrong in that compressive load section. So I'll move back and probably change that out later. Um, is the tendon, uh, is the treatment for tendon problems all the same? Short answer is no. Each tendon in the body itself is different. We have different shapes and capacities. Uh, our tendons are lobe bearing tent, or we have some lobe bearing tendons such as patellar and the Achilles and other positional tendons, such as the tibialis interior, uh, in, uh, lobe bearing tendons need to be real rehabilitated to function like tendons again. Uh, uh, I think I meant springs again, tension is springs again, and they need to be able to store and release energy as we ambulate.

Uh, rehab of the calf is really important in both Achilles and patellar tendon pathology as well. Um, as the calf absorbs 60% of landing energy. So it's all about sharing load in this scenario. The soleus muscle is important in patellar 10 or patellar, excuse me, tendinopathy as it breaks in, as it break, as it provides a break in change of direction. Perhaps this indicates we do some more, some more CD calf raises. Are MRIs and ultrasounds helpful in the rehabilitation of a tendon? This is the section where I'm sure I'm going to get crap on because I feel like every time I talk about imaging, someone's like, you really hate images, don't you? I don't hate images. It's just, they're overly used. So images are mostly in health, unhelpful in decision-making as pain is not linked to pathology as found on images. Images also cannot see pain as pain is an experience or a feeling.

Similarly, an image cannot see depression and happiness. Images are at, are not the best starting point when gathering information for a tendon injury, but it can be useful to evaluate patients who have not been, who have not, or who have experienced an overstretch injury as they would be more probable to have a large tear detachment. Also though, probably on that same note, within an exam, you'd probably see bruising and swelling that would lead us to that suggested image anyways. However, most people with tendon pain do not need an MRI or ultrasound to start care. This is a, those not responding to load may merit a image later to gather more information as an advanced examination. This is something that actually, uh, I feel like is, um, a big problem.

Uh, I'll tangent off. It's a big problem is that people wait so darn long to get care because they want to see an exact image. They want to see the image, you know, like the image has some type of smoking gun associated with it. I think we can all agree that as you go to the bottom of the image, it says must be clinically correlated and there's normal stuff all over the place. And so, um, I remember there was someone I was working with. It was a girl runner, uh, and she didn't have, uh, any pain around her ankle. She had it around her foot. I was looking for a metatarsal stress fracture, um, or, uh, some type of reaction because she was supposed to be running and, uh, that ended up being negative. We did an MRI, but we found, um, uh, tendon issues everywhere. And I was like, yeah, pain there. She's like, Nope. And that was my first realization that it had nothing to do with the image, you know, funny amount of a month later, she had ankle pain. So is that chicken or like just maybe no one about it, you know? So we need to remember that physical structure is, is not important, is not as important as we once thought as people who people with structural change can present as early as 16 or before 16 years old and do not have associated pain. People with degenerative tendon findings do not always have pain and degenerative tendons are safe to load. So why are we looking at the image? You know, people tend to have increased fear about loading the tendon if they see the donut hole and it might not be induced. It might not be wise to induce that psychological resistance to an evidence-based loading program in the first place. And so you might just be kicking yourself, shooting yourself in the foot when you're, when you're doing care, if you're, if you're, um, if you do the image too quickly. So now I moved on, I'm going to move on to the section that I referenced more from Ebony Rios. It was the isometric exercise and rehabilitation. So there's not a lot of, uh, uh, tendonopathy, tendonopathy research out there, but we can use what we know and what we've seen clinically to explore good tendon rehabilitation programs and what they could be. To be honest, tendon rehabilitation should be specific, keeping in mind the person's age tendon of the tendon of pathology, as well as the return to their activity. If a person wants to sprint or jump again, they will require more rehabilitation as it builds more attributes to the tendon muscle structure or unit. Um, someone who wants to be able to return to walking will not need to go through such a complex and long rehabilitation program as they will only lose the adaptation once they leave the program completely. As a general rule, the person will only retain what they can chronically, what they use chronically. I know chronically sounds bad, but chronically is, is, is, is what are they being exposed to over time? You know, over and over again, if their sport or life does not require such a demand on the tendon, the tendon will regress to the highest level of physical needs to, that it needs to, uh, that needs to be at on the demands placed upon it chronically. So what we do know is loading the tendon is king. Okay. I learned this years ago when I went to, uh, one of the ACBSP court, ACBSP, uh, chiropractic, uh, work, um, symposiums, but obviously as you can tell, it didn't come up. So I just kind of went on the back burner. Prolonged rest seems to result in disastrous effects and really doesn't give them a chance of full recovery at all. And so that is the first thing we need to make sure our patients know that it needs to be loaded in some way, shape, or fashion, even if it's just bare bones and not being super specific. I think having some load on it is better than nothing. Okay. Um, I have a good friend who presented on, uh, tendon, uh, issues and loading somebody. And, and he said that if you don't like, we won't really know what load sometimes what to do with these people. And so you, what we do know is you don't do anything. They're going to get worse. If you do too much, they'll get tight. They'll get sore and maybe scared of the program. If you do too little, um, you need to work your way up.

And so at least we're looking for that Goldilocks sweet spot a little bit, you know, and, and, and proof would be in the pudding, but maybe that's not what we need for the analgesic effect, or at least in my case, I'm looking for a first aid for the person. Cause I want to get some real good buy-in, which is what I think I found eventually later in this. So, uh, we do know prolonged activity results in disastrous effects without really having a full chance of recovery. As the person rests, the tendon only gets worse and the pain will continue and the function won't be restored either. So all negatives. And so the question is, is how can we convince people with tendon pain to actually load the tendon and comply with treatment plans that include loading?

And so if you've ever had tendon pain, I haven't really. Uh, but the thought is that, or the thought of loading the tendon makes really no sense at all. Okay. It's against all what you believe. And so rest, ice, heat, compress, all the passive care sounds a lot better to me if I'm a patient. So how can we convince someone who has pain increased when loading their tendon that loading is the exact thing that will improve their situation? By the way, I think we need to remember that we're going to cool it down before we actually build it up. Perhaps having a discussion that not all loads are created equal might be helpful just as veggies are not all created equal either. The kind of load that we're going to put, um, that, or the kind of load that often brings the tent to the state of pain in the first place is one where we, um, where the tenant is required to store energy. And so when the tenant moves up and down like a spring, that's when we're talking about jumping, sprinting, burpees, even walking are examples where the tenant has to do some type of energy storage in some manner. Funny, these are all, um, body weight things. And so a lot of times people will say, well, that's okay. We'll do that, you know, because hits training never hurt anybody, you know, that's a joke. And so let's not forget that there's other mechanics of the tendon, uh, such as compression and friction, you know, where we were, we need to make sure that's not a problem as well. And so can we load the tenant without pissing the tenant off? Uh, yes, we can. And so we think the answer is isometrics, which is the safest type of loading and perhaps explaining the isometric exercise is something that's been used, uh, post-op as entry-level rehabilitation for many years. And so on second, uh, uh, maybe further down that line is, is that after explaining these things to the patient, I think we can give them a choice because really people like the ability to choose. No one likes to be forced into anything. I think we just give them the choice and see what they want to do. So they can, can a, they can continue to rest, which result in absolute disastrous effects for them, or they can choose to keep resting it for weeks before they test it because everyone likes to test it, you know, uh, in the same activity to create the problem, i.e. loading the tendon as a spring for energy storage. Typically I'm going to go run again. I'll just rest for a week and run again. That's you could do that too. Uh, or you can choose a lower risk choice such as loading the tendon, not as a spring, more as a static non-movement contraction, like isometric holds holds, given the choice. Isometrics have been found to reduce pain nearly immediately as well. I, so I need to, I need to investigate this a little bit further in our clinic, but, um, I have had a lot of people tell me that. And so that gives me a lot of hope in using this as a first aid in isometrics. We found a safe middle ground where we are not destroying the tendon with rest nor provoking it with the activity that pisses it off. And we can actually get a good reduction of pain as a bonus. Isometric exercise can be used to immediately reduce the pain.

70% of, of, uh, perceived effort in five sets of 40 second reps with two minute break between was a generic prescription given, uh, while obviously keeping each person's unique situation in mind. Ebony reels presented a good question of, can we use isometrics before activity to give their clients, um, to reduce pain so they can actually move and do their activity. Challenging the muscle 10 complex before the activity may be a good way to reduce pain yet fatigue of the general region might degrade, um, performance or worse yet give fatigue to the reason so much that we set the stage for another injury. Obviously we don't want to hurt anybody. Cook presented the research indicating that after I isometric exercise, the patients had a 19% increase in strength immediately after the exercise as a, uh, as the brain is no longer putting the quote unquote breaks on the movement. Yet we still need to consider that we, it might not be wise to crush somebody with isometric exercise before sending them out to play without ample recovery. Uh, we need to tippy toe this line a little bit as clinicians. So how much load should we start putting on with these people? As much load, as much isometric load as they can mentally and physically tolerate. Okay. As long as they're not challenged so much that they're shaking, you shouldn't be okay. You want to look for the Goldilocks zone, which is the just right zone. In what position should we place them in? Whatever position they can physically be in without pain, ideally linking up more kinetics chain when possible. For the Achilles tendon, we can see, we can consider a calf raise position, a single leg, a single leg calf raise position.

Uh, I need to get some water, single leg calf raise position, barbell loaded or hand loaded for patellar tendon. We might want to use a Spanish squat or a Smith machine. Uh, I was actually playing around the other day with the, um, like kind of like a self-induced Spanish squat without having to do any of the bands and stuff like that. I was actually sitting on a stairwell and I used my, um, I kept my torso upright by using my hands to kind of position myself. And I, and I kept the load on the, on the, the knee in that fashion. It was pretty challenging. I was shaken. I'm pretty sure I would have spilled my water. So I needed to find a little bit of higher position. I'm sure with like a TRX or something like that, you could probably do it a little bit too. So all of these isometric holds should be 45 seconds with a weight, if needed to attain 70% RPE. This isometric load is safe and reduces pain. And we can use isometrics to perform a movement audit to see if we're on the right track on rehabilitation. And so we have three basic clinical, um, possibilities here. And so we have case one, case two, case three. I wrote these down in here. Okay. In case one, you have someone pain with running, you do isometric exercise to reduce pain. Now we have first aid, first aid that is established by the way, I guess I should digress to test out, to see if it works. You should do the activity that bothers them, do the exercise and do the activity again, and see if there's a reduction of pain. It's because we call it a movement audit. We do that with all the other stuff too, for first aids. And so someone has pain with running isometric exercise helped. We have a first aid that's been established. Now we need to discuss provoking activity and how to make sure that we keep, uh, the provoking activity at bay for at least a week or so. And we need to do supportive exercise that link up more of the connects chain and brain patterns. Case number two, pain with running isometrics do not reduce pain. Consider adding more load or adjusting time under tension.

And so say we did, uh, and so let's just say the Achilles area, um, we might have a peritendinitis or calcaneal bursitis that won't respond immediately, but removing repeated mechanical mechanism of injury and sustaining load as an isometric should help, um, maybe not immediately, but very soon. And so in this case, we have a little bit more of a less magic trick first aid that has been established. We should still discuss provoking activity and we should still give more supportive exercises. Okay. Case number three, uh, pain with running isometrics don't reduce pain and actually gets worse. In this case, we should consider the diagnosis again. Maybe we should go back and see if there's a post post your ankle impingement, which way, which may actually get worse as you start to pinch that thing out with isometric positions, um, established, maybe new, uh, first working diagnosis, a first aid triggers, and then supportive exercises at that point.

Uh, general, uh, rules that I kind of wrote down this, I'm into my bullet point sections here. Uh, and let's see how far we've gone here. We've gone 40 minutes. So we wanted to stop with these bullet point sections. I'm actually only at page 15 of 23 that I actually wrote on this. So you can see how detailed I tried to get. Um, I, so I'm going to go down these bullet points. Cause I think this, this will probably be a good enough information to at least get you guys going and you should read all the, read all the stuff that, that is, uh, suggested on this. Okay. So rehabilitation of the leg section, more specifically, um, starting loads, if they had a boot starting with body weight, if they can do double leg standing, start them, uh, start there because it's 50% of body weight.

Okay. If they can do a single leg cat, a single leg calf raise and hold it, then use that. If they could do multiple calf raises, single leg, then you might consider using external loads. And if they shake or bounce and you've done too much. Okay. Uh, Guido mentioned the other day that, uh, if you can't eat soup, uh, while you're doing the activity and it shakes out of the spoon, then you've done too much. Okay. Positions, uh, uh, the, for the Achilles insertion or a plantarist issue, you want to have a high raise or full plantar flexion, which reduces compressive loads, uh, compressive forces.

I would be wrong on this one, but I know that the mid Achilles, uh, mid Achilles area, you want to do mid range. And this is how this whole conversation started when I was texting DMACC and he's like mid range, uh, loading, at least in this case for a middle tendon, it wasn't insertional for patellar tendon. We consider the wall squats, Spanish squats, or knee extension machine. And most people won't have a sort of leg extension. Um, most people won't have that. So I think, uh, getting more creative for home activity is going to be important because they're expected to do this quite a bit. Uh, and then they mentioned the glute tendon too, with a hip hitch type of exercise.

Uh, I didn't take a lot of notes on, on the glute tendon because quite honestly with you, I feel like people who are on the, um, the back or outside part of the hip, I find that most of it's referrals and maybe, maybe it's not referrals and maybe we just plug in a referral exercise or something. And then we end up loading the area. It's in slow methodical fashion and it tends to help. Um, and actually we start with a lot of isometrics too, with glutes too. So it's, it's, uh, maybe we're just haphazardly getting it. I have no idea. Um, let me mention other sections I put down in here, which I won't really go into too much. We have progressive tendon loading guidelines and there's stage one, two, and three. That was from Joe or one through four, which was Joe Cook's work.

Generally speaking, we can say deload to reload. I also wrote a whole section on patellar tendon pathology. Uh, like, uh, let's see, let me give you the setting headings, set the headings. And so we have, um, uh, should you jump with, with jumper's knee? We also have Achilles tendon pathology and hamstring tendon pathology, which is from a whole nother section, a whole nother presenter who gets in at hamstring tendon pathology, uh, location of pain, presentations, uh, rehabilitation. Uh, I think something that, that I would only like to say about the hamster high hamstring tendon pathology is that, uh, me and DMACC did a whole section on all things hamstring. We didn't really talk about this part too much, but I think they're like, if you do differentiating test, uh, to see if there's neural tension or a spinal flexion has an association with it, you might be surprised how many of these might not actually be high hamstring tendinopathies. And it was mentioning the mechanics of compression with the high hamstring is really more so with torso or trunk forward lean associated with hip flexion too, which is kind of like your slumps test. Right. Um, and I guess it'd be torso forward lean, not flexion to be lean. And so I'm sure we can get creative on our, on our examination process to figure out if we're actually looking at a patella or a hamstring tendon, high hamstring tendon or not, but obviously things like your, your SI joint clusters, your, um, hip joint lumbar referral, um, of some type need to be ruled out before you actually treated as such. And I had a gentleman come in just a few months ago who was treated very much like a hamstring, you know, and there, he was also doing things that were actually detrimental to his, um, actually he was a spinal referred, um, important to note too, uh, within all the stuff that I mentioned that you should go back and listen to or watch, uh, they talk about the whole eccentric model of loading too. And so isometrics apparently is way superior. And so when I last looked at, uh, uh, tendon or at least hamstring tendon, it was a lot of eccentrics associated with it. However, it looks like isometrics are the way.

And so I think I was wrong. And so, uh, if you're still kind of on that eccentric model, I suggest you at least look at all this stuff to consider, um, where you want to place your treatment plan based upon the current stuff that we know. Uh, and like I mentioned before, I'm, I don't pretend to know everything on this. This is just broken down information that I'm going to use in my clinic. And I'm going to learn even more and plug in the holes as we go. And you heard me correcting the paper as I was actually reading this too. And so I hope this one was helpful to you guys. Uh, I won't, um, I might do a part two coming up, or I might brainstorm it with one of the other, uh, doctors in the office too. Um, or maybe I'm just fortunate enough to have somebody, uh, like I get Jill cook who comes on and maybe somebody wants to refer the, does anyone know, or you should just, uh, hook me up, you know, I'll have her come on and we'll just talk about tenants and so on. Um, but yeah, um, good times. And so if you guys like the show, please subscribe and share it with other clinicians who you think would benefit from the show as well. Um, I'm always looking for show referrals. Okay. Uh, I don't tend to market the show really at all. And, uh, I'm just, I, as you can see, I'm trying to work on my skills as we go through this and this actually helps me doing this actually helps me remember it. So you're part of my memorization process. Uh, if we didn't cover it already, I don't think we did is, uh, I do have a premium version of the podcast and I do have stuff that you can, you guys can learn from me as well, if you want to.

So if you like the information I put out and you think, huh, I wonder what else he has. I wonder if he does any workshops. We do. I do. But, um, I have put a lot of information, a little bit more organized that actually doesn't include these, the tendinopathy stuff within, um, uh, workshops that I have on my web website. There'll be a link in the show description at the very bottom and just click on it. It's very much worth your time and money. Uh, and if you want to hear more stories and, um, uh, clinical case studies, I do have a premium version of the podcast that are released this year, which is released once a week. It's about 15 minutes or so. It's a little bit less like this, but I'm sure I'm, I'm sure I'm going to do. I mean, I do whatever is pertinent on that day. If there's a good case, I'll share it. If we find out that we were just completely screwing up these tenants, cause we were doing 30 seconds instead of 45 or the load was too much, I'll share it. And so, uh, we continually retest things in our clinic to see if we can improve ourselves as well as our patients without hurting them. So I continually share on that. That one does cost just a little bit, but if you want to follow all things that I have, those would be the two things that probably worth your most time as a clinician. So thanks for being part of the movement. I'll see you guys next week.