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Author: chad reilly

  • Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy

    Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. Sayana MK, Maffulli N. J Sci Med Sport. 2007 Feb;10(1):52-8. Epub 2006 Jul 7.

    Abstract
    OBJECTIVE: Achilles tendinopathy is prevalent in athletes, but can also affect sedentary patients. We studied the effects of eccentric exercises in sedentary non-athletic patients with Achilles tendinopathy.
    METHODS: Thirty-four sedentary patients (18 males, average age 44 years, range 23-67; 16 females, average age 51 years, range 20-76; average BMI: 28.6+/-4.7, range 22.1-35.4) with a clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance (39+/-S.D. 22.8) and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks.
    RESULTS: Fifteen patients (44%) did not improve with eccentric exercise regimen. Three patients improved after perintendinous injections aprotinin and local anaesthetic. Surgery was performed in seven patients as 6 months of conservative management failed to produce improvements. The overall average VISA-A scores at latest follow up was 50 (S.D. 26.5).
    CONCLUSIONS: Eccentric exercises, though effective in nearly 60% of our patients, may not benefit sedentary patients to the same extent reported in athletes.

    Diagnosis: Mid portion Achilles tendinitis (2-6 cm above insertion)

    Outcome: VISA-A 56% improved VISA-A score at least 10 points and did not have pain that interfered with activity, 44% didn’t respond

    When Assessed: 12 weeks

    Subjects: 34 sedentary adults, ave age 44

    Protocol: 1x 10 to 3 sets of 15, 2x per day, 7 days per week, for 12 weeks, rep speed varied from slow to fast

    Other Activity: Sedentary

    Chad’s Comments: Bodyweight calf raises might be of higher relative intensity for sedentary people as compared with athletes and might explain why the results are not as good.  As such it is probably prudent for less active sufferers of Achilles tendinitis to do their calf training on an exercise machine where they can start with lighter than bodyweight exercise and progress upwards from there.  Anecdotally I have had great results doing this in my physical therapy office.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Surgical Treatment vs. Eccentric Training for Jumper’s Knee

    Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper’s Knee). A randomized, controlled trial. Bahr R, Fossan B, Løken S, Engebretsen L. J Bone Joint Surg Am. 2006 Aug;88(8):1689-98.

    Abstract
    BACKGROUND: Although the surgical treatment of patellar tendinopathy (jumper’s knee) is a common procedure, there have been no randomized, controlled trials comparing this treatment with forms of nonoperative treatment. The purpose of the present study was to compare the outcome of open patellar tenotomy with that of eccentric strength training in patients with patellar tendinopathy.

    METHODS: Thirty-five patients (forty knees) who had been referred for the treatment of grade-IIIB patellar tendinopathy were randomized to surgical treatment (twenty knees) or eccentric strength training (twenty knees). The eccentric training group performed squats on a 25 degrees decline board as a home exercise program (with three sets of fifteen repetitions being performed twice daily) for a twelve-week intervention period. In the surgical treatment group, the abnormal tissue was removed by means of a wedge-shaped full-thickness excision, followed by a structured rehabilitation program with gradual progression to eccentric training. The primary outcome measure was the VISA (Victorian Institute of Sport Assessment) score (possible range, 0 to 100), which was calculated on the basis of answers to a symptom-based questionnaire that was developed specifically for patellar tendinopathy. The patients were evaluated after three, six, and twelve months of follow-up.

    RESULTS: There was no difference between the groups with regard to the VISA score during the twelve-month follow-up period, but both groups had improvement (p < 0.001). The mean combined VISA score for the two groups increased from 30 (95% confidence interval, 25 to 35) before the start of treatment to 49 (95% confidence interval, 42 to 55) at three months, 58 (95% confidence interval, 51 to 65) at six months, and 70 (95% confidence interval, 62 to 78) at twelve months. In the surgical treatment group, five knees had no symptoms, twelve had improvement but were still symptomatic, two were unchanged, and one was worse after twelve months (p = 0.49 compared with the eccentric training group). In the eccentric training group, five knees did not respond to treatment and underwent secondary surgery after three to six months. Of the remaining fifteen knees in the eccentric training group, seven had no symptoms and eight had improvement but were still symptomatic after twelve months.

    CONCLUSIONS: No advantage was demonstrated for surgical treatment compared with eccentric strength training. Eccentric training should be tried for twelve weeks before open tenotomy is considered for the treatment of patellar tendinopathy.

    Diagnosis: Patellar Tendinopathy

    Outcome: VISA-P scores improved similarly in both groups from 30 at baseline to 49 at 3 months, to 58 at 6 months, and 70 at one year. Leg press strength improved statistically at 6 months and more at 12 months. Standing jump and countermovement jump height did not change significantly in either groups, but decreased slightly in the surgery group. 55% of eccentric group returned to prior level of sports with no pain or mild to moderate pain while only 45% of the surgery group did so.

    When Assessed: 3, 6, and 12 months

    Subjects: Average age 30-31 years. Only 14% female. Majority of patients were recreational or sub-elite athletes.

    Protocol: 3 sets of 15 reps of eccentric squats on a 25 degree decline board performed 2x per day for 12 weeks. Pain kept between 3-5/10 VAS, with resistance (5 kg) added when pain dropped below 3/10. Surgery group performed similar exercises protocol, though delayed 6 weeks after procedure, and they were instructed not to train with pain. 66% compliance with exercise in eccentric group and 72% in surgery group.

    Other Activity: “During the first 8 weeks of treatment, the patients were not allowed to take part in sports-specific training. After four weeks, they were allowed to cycle, to jog on a flat surface, or to exercise in water if these activities could be done without pain. After 8 weeks, the patients were allowed to gradually return to their sport if there was no or minimal pain.”

    Chad’s Comments:  If anything the exercise group outperformed the surgery group.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Tennis Elbow: Ice Has Zero Effect

    A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy. Manias P, Stasinopoulos D. Br J Sports Med. 2006 Jan;40(1):81-5.

    Abstract
    BACKGROUND: The use of ice as a supplement to an exercise programme has been recommended for the management of lateral elbow tendinopathy (LET). No studies have examined its effectiveness.

    OBJECTIVES: To investigate whether an exercise programme supplemented with ice is more successful than the exercise programme alone in treating patients with LET.

    METHODS: Patients with unilateral LET for at least four weeks were included in this pilot study. They were sequentially allocated to receive five times a week for four weeks either an exercise programme with ice or the exercise programme alone. The exercise programme consisted of slow progressive eccentric exercises of wrist extensors and static stretching of the extensor carpi radialis brevis tendon. In the exercise programme/ice group, the ice was applied after the exercise programme for 10 minutes in the form of an ice bag to the facet of the lateral epicondyle. Patients were evaluated at baseline, at the end of treatment, and three months after the end of treatment. Outcome measures used were the pain visual analogue scale and the dropout rate.

    RESULTS: Forty patients met the inclusion criteria. At the end of treatment there was a decline in visual analogue scale of about 7 units in both groups compared with baseline (p<0.0005, paired t test). There were no significant differences in the magnitude of reduction between the groups at the end of treatment and at the three month follow up (p<0.0005, independent t test). There were no dropouts.

    CONCLUSIONS: An exercise programme consisting of eccentric and static stretching exercises had reduced the pain in patients with LET at the end of the treatment and at the follow up whether or not ice was included. Further research to establish the relative, absolute, and cost effectiveness as well as the mechanism of action of the exercise programme is needed.

    Diagnosis:  Lateral elbow tendinopathy

    Outcome:  VAS over the previous 24 hours. VAS dropped 6.9 points at 4 weeks and 7.1 points (out of a 10 point scale) at 16 weeks in both groups.

    When Assessed:  0, 4 and 16 weeks

    Subjects:  40 subjects, mean age 40 years

    Protocol:  Exercise group did 3 sets of 10 repetitions of slow (30 seconds) progressive eccentric reverse wrist curls with a 30 second rest interval between each repetition, increasing weight with free weights when they could do sets without pain. Performed static stretching in wrist flexion and ulnar deviation 3 times 30-45 seconds before and after eccentric exercise. Exercise performed 5 times per week for 4 weeks. The ICE group did the same exercise program above but applied a bag of ice to the lateral epicondyle for 10 minutes afterwards.

    Other Activity:  “All patients were instructed to use their arm during the course of the study but to avoid activities that irritated the elbow such as shaking hands, grasping, lifting, knitting, handwriting, driving a car and using a screwdriver.” No mention of exercise or sporting activity before, during or after the study.

    Chad’s Comments:  Interesting in that this is the only study that has used ice as a variable (in tennis elbow or any form of tendinitis / tendinopathy) and found it had zero effect, good or bad on outcomes. Pain dropped a lot in a short time period which could be due to effectiveness of the exercise protocol, which was novel (taking 30 seconds to lower the weight) or due to the avoidance of aggravating activities. The outcome measure (VAS over prior 24 hours) perhaps does not take into account pain during activity and there were no functional measures.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Jumper’s Knee, Eccentric Better than Concentric Exercise?

    Superior results with eccentric compared to concentric quadriceps training in patients with jumper’s knee: a prospective randomized study. Jonsson P, Alfredson H. Br J Sports Med. 2005;39(11):847-850.

    Abstract
    BACKGROUND: A recent study reported promising clinical results using eccentric quadriceps training on a decline board to treat jumper’s knee (patellar tendinosis).

    METHODS: In this prospective study, athletes (mean age 25 years) with jumper’s knee were randomised to treatment with either painful eccentric or painful concentric quadriceps training on a decline board. Fifteen exercises were repeated three times, twice daily, 7 days/week, for 12 weeks. All patients ceased sporting activities for the first 6 weeks. Age, height, weight, and duration of symptoms were similar between groups. Visual analogue scales (VAS; patient estimation of pain during exercise) and Victorian Institute of Sport Assessment (VISA) scores, before and after treatment, and patient satisfaction, were used for evaluation.

    RESULTS: In the eccentric group, for 9/10 tendons patients were satisfied with treatment, VAS decreased from 73 to 23 (p<0.005), and VISA score increased from 41 to 83 (p<0.005). In the concentric group, for 9/9 tendons patients were not satisfied, and there were no significant differences in VAS (from 74 to 68, p<0.34) and VISA score (from 41 to 37, p<0.34). At follow up (mean 32.6 months), patients in the eccentric group were still satisfied and sports active, but all patients in the concentric group had been treated surgically or by sclerosing injections.

    CONCLUSIONS: In conclusion, eccentric, but not concentric, quadriceps training on a decline board, seems to reduce pain in jumper’s knee. The study aimed to include 20 patients in each group, but was stopped at the half time control because of poor results achieved in the concentric group.

    Diagnosis:  Patellar Tendinitis

    Outcome:  VAS during sporting activity (72.7 to 22.5) for eccentric group, concentric (74.3 to 68 but 3 patients dropped out) 9/10 eccentric patients satisfied, while 0/9 concentric patients were satisfied

    When Assessed:  12 weeks

    Subjects:  15 men, 2 women, athletes, ave age 25

    Protocol:  Single leg squats on decline board to 70 degrees knee flexion, 3 sets of 15 reps, 2x per day 7 days per week

    Other Activity:  Sport specific training allowed after 6 weeks if there was no “severe pain.”

    Chad’s Comments:   The need to avoid concentric exercise for tendinopathy is starting to be refuted in more recent studies, which are finding the concentric contraction is nearly, though not as, effective at decreasing pain as the eccentric component.  It will be interesting to see which way this discrepancy shakes out in the research.  However, in my physical therapy clinic I’ve noticed tendinopathy outcomes are as good or better (and the treatments are certainly easier to teach and perform) since I started adding the concentric component back into my treatment protocols.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Getting the Most out of Your Total Knee, Strength Matters

    So I read ALL of Dr. Tarlow’s blog, who first suggested I start a blog on my own. It took me a few weeks but I read every post, and learned A LOT about knee surgery from the surgeon’s perspective.  One topic he wrote about that sticks in my memory showed the more you like your doctor the more you will pay for medical expenses, and the more likely you are to die young. So maybe  a good bedside manner isn’t everything,  and maybe it’s better if your health care professional doesn’t just tell you what you want to hear.  However,  reading back to 2010 I came across this one…

    “Outpatient Physical Therapy Does Not Improve Functional Outcome After Total Knee Replacement”.

    …and I wanted to talk about it as I have seen a couple others like it.  The study cited was done in the United Kingdom and they found exactly what was noted. Six weeks of standard outpatient physiotherapy did not improve knee range of motion after total knee arthroplasty when measured one year later. However I think my profession is getting a little short changed as in those 6 weeks the mean number of treatments attended was only 7.3 with no description of the duration of each visit and what was being done during the visit. If you do 7 sessions of exercise and stretch over 6 weeks I wouldn’t expect much difference one year later. Still it makes you think…. There are a number of other studies which found a similar lack of result, and physical therapists should think about what they are doing and whether it is getting patients back where they need to be, or if they are just humoring the patient while they get better on their own. However, a recent study looked at this very thing where researchers found “Early High-Intensity Rehabilitation Following Total Knee Arthroplasty Improves Outcomes” that patients who had 25 visits over 12 weeks (including relatively intense progressive resistance exercise) improved more in strength and function than those who had 10 visits over 6 weeks following a standardized protocol with no external resistance greater than 10 lb. Follow up measurements were also performed up to one year post-op. There were substantial differences between groups at the one year follow up, all in favor of the high intensity (HI) treatment group:

         Time/VariableHI GroupControl Group
          Stair Climbing Test   10.4s   17.3s
          Timed up-and-go test   6.4s   8.8s
          6 minute walk test   552m   470m
          Knee Flexion   122deg   117deg
          Max Voluntary Contraction   1.7Nm/Kg   1.4Nm/Kg
          Quadriceps Activation   89.1%   79.7%

    Researchers conclusions: “The high-intensity rehabilitation program described in this study demonstrated significantly greater short-term and long-term strength and functional performance increases compared to a lower intensity rehabilitation program. The high-intensity rehabilitation program was initiated immediately following hospital discharge and did not compromise knee ROM outcomes, cause musculoskeletal injury, or increase pain in the small group of patients. Key differences between the 2 programs were a greater number of treatment sessions over a longer period and the use of machine-based resistive strengthening and higher level functional exercises.”
    I think it’s worth noting that both the HI group and the control group in this study had greater knee flexion at one year post-op (122 and 117 deg) than both therapy and no therapy groups in the UK study (109.9 and 109.3 deg). Much depends upon the fitness of the patient prior to surgery and how active they want to be afterwards. If the patient is younger, already active and will continue to exercise independently, less therapy is needed once they know what to do. If the patient is badly deconditioned from years of inactivity (often due to the knee arthritis itself) it takes longer to build back strength levels that were well below normal pre-op and likely years before the surgery as well. As noted in the high intensity study, I think post-op TKA is where weight machines shine. They can be progressed from light to heavy all while maintaining and pushing the patient into ever-increasing ROM. A number of bodyweight and even free weight exercises are at a disadvantage early on; while they can provide overload in functional patterns the resistance levels are too great to allow working the muscle and joint through a full range of motion. Later as strength levels and ROM increase, the bodyweight, free weight, and cable exercises become more efficient for fitness and integrating core strength and endurance with that of the knee.

    Not mentioned in the above studies, electric muscle stimulation (when used properly) has been shown to go a long way towards preventing post-op muscle atrophy and restoring strength, even when pain and swelling are otherwise inhibiting a quality muscle contraction, but that’s the subject of my next blog. So much for words, here’s an example of how I treated a patient who had bilateral TKAs 5 weeks post-op to the day:

    [contact-form to=’chadmreilly@gmail.com’ subject=’New Blog Comment(s)’][contact-field label=’Name’ type=’name’ required=’1’/][contact-field label=’Email’ type=’email’ required=’1’/][contact-field label=’Website’ type=’url’/][contact-field label=’Comment’ type=’textarea’ required=’1’/][/contact-form]

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Standard PRE as Good as Eccentric Exercise for Jumper’s Knee in Season Volleyball

    No effect of eccentric training on jumper’s knee in volleyball players during the competitive season: a randomized clinical trial. Visnes H, Hoksrud A, Cook J, Bahr R. Clin J Sport Med. 2005 Jul;15(4):227-34.

    Abstract
    BACKGROUND: The effect of surgery on patellar tendinopathy (jumper’s knee) is questionable, and conservative treatment protocols have not been properly documented.

    PURPOSE: The aim of this study was to investigate the effect of a newly developed eccentric training program for patellar tendinopathy in volleyball players during the competitive season.

    STUDY DESIGN: Randomized clinical trial.

    METHODS: Patients were recruited from male and female elite volleyball teams in Norway, and the diagnosis was based on clinical examination alone. Of 51 players diagnosed with patellar tendinopathy, 29 could be included in the study. The training group (n = 13) performed squats on a 25 degrees decline board as a home exercise program (3 x 15 repetitions twice daily) for a 12-week intervention period during the final half of the competitive season. The eccentric (downward) component was done on the affected leg. The control group (n = 16) trained as usual. The primary outcome was a symptom-based questionnaire developed specifically for patellar tendinopathy (Victorian Institute of Sport Assessment score), and patients were followed up before and after the intervention period, as well as after 6 and 30 weeks. All subjects self-recorded training to document their activity level (eccentric training, volleyball training, matches, other training).

    RESULTS: There was no change in Victorian Institute of Sport Assessment score during the intervention period in the training (pre, 71.1 +/- 11.3; post, 70.2 +/- 15.4) or control group (pre, 76.4 +/- 12.1; post, 75.4 +/- 16.7), nor was there any change during the follow-up period at 6 weeks or 6 months. The training group completed 8.2 +/- 4.6 weekly sessions of eccentric training during the intervention period (59% of the recommended volume), and there was no difference between groups in training or competition load.

    CONCLUSION: There was no effect on knee function from a 12-week program with eccentric training among a group of volleyball players with patellar tendinopathy who continued to train and compete during the treatment period. Whether the training would be effective if the patients did not participate in sports activity is not known.

    Diagnosis:  Patellar Tendinopathy

    Outcome:  VISA-P, static vertical jump, countermovement jump. No difference in pain level between eccentric group and controls. Small 1.2 cm change in countermovement jump for eccentric group, but no difference in control group and no difference in either group for static jump. No trend in either group towards increasing VISA-P in eccentric vs. control group. Both groups however had average VISA-P scores increase from low 60s during pretest to mid to low 70s on graph at week 12 and week 40.

    When Assessed:  3 months and 6 months

    Subjects:  13 in eccentric group and 16 in control group, ~ half male half female. Subjects from clubs in elite and 1st divisions for men and women in Norway. Had to have initial VISA-P score less than 80 points. Initial VISA-P score averaged 61 in eccentric group and 65 in control.

    Protocol:  25 degree decline squats, 3 sets of 15 reps, intended 2x per day for 12 weeks, subjects with continued pain after 12 weeks were encouraged to continue with exercise, starting with bodyweight taking 2 seconds to lower to 90 degrees of knee flexion. Pain recommended to be at 5/10 and increased 5 kg increments when pain at 3-4/10. Both experimental and control group did PRE with rest of team 1.6 hours per week for eccentric group and 2.0 hours for control group. Volleyball training was 5.1 hours in eccentric group and 6.1 hours in control group. Only 6/13 of the eccentric group increased their load with final load averaging 4.2 kg. Eccentric group completed 59% of recommended volume.

    Other Activity:  In season elite competitive volleyball players. Eccentric 1.4 and control 1.9 hours of weight training per week. Eccentric 5.8 hours per week of volleyball training and control 6.4 hours per week.

    Chad’s Comments:  Cited 3 studies indicating patellar tendinopathy is present in 40-50% of high level volleyball players. This study is particularly interesting in that both groups did a little better over time even in the course of a competition season with VISA-P scores increasing from ~low 60s to 70s. There was certainly no increase in pain, nor a decline in function over time. These researchers interpreted the results as eccentric exercise not being effective for tendinopathy in season.  Also both groups strength trained during the course of treatment, the control group more so, which while not detailed I would assume to include weight training to the lower extremities. With the 2009 Kongsgaard study indicating that more conventional PRE as good or better than eccentric exercise for jumpers knee/patellar tendinopathy, one might also explain the results of this study as mild success in both groups while training in season, rather than a failure of response of the eccentric group.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Decline Squats for Volleyball Players with Patellar Tendinopathy

    Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. Young MA, Cook JL, Purdam CR, Kiss ZS, Alfredson H. Br J Sports Med. 2005 Feb;39(2):102-5. Erratum in: Br J Sports Med. 2005 Apr;39(4):246.

    Abstract
    BACKGROUND:

    Conservative treatment of patellar tendinopathy has been minimally investigated. Effective validated treatment protocols are required.
    OBJECTIVES:

    To investigate the immediate (12 weeks) and long term (12 months) efficacy of two eccentric exercise programmes for the treatment of patellar tendinopathy.
    METHODS:

    This was a prospective randomised controlled trial of 17 elite volleyball players with clinically diagnosed and imaging confirmed patellar tendinopathy. Participants were randomly assigned to one of two treatment groups: a decline group and a step group. The decline group were required to perform single leg squats on a 25 degrees decline board, exercising into tendon pain and progressing their exercises with load. The step group performed single leg squats on a 10 cm step, exercising without tendon pain and progressing their exercises with speed then load. All participants completed a 12 week intervention programme during their preseason. Outcome measures used were the Victorian Institute of Sport Assessment (VISA) score for knee function and 100 mm visual analogue scale (VAS) for tendon pain with activity. Measures were taken throughout the intervention period and at 12 months.
    RESULTS:

    Both groups had improved significantly from baseline at 12 weeks and 12 months. Analysis of the likelihood of a 20 point improvement in VISA score at 12 months revealed a greater likelihood of clinical improvements in the decline group than the step group. VAS scores at 12 months did not differ between the groups.
    CONCLUSIONS:

    Both exercise protocols improved pain and sporting function in volleyball players over 12 months. This study indicates that the decline squat protocol offers greater clinical gains during a rehabilitation programme for patellar tendinopathy in athletes who continue to train and play with pain.

    Diagnosis:  Patellar Tendinopathy

    Outcome:  VISA-P and VAS scores comparing eccentric single leg squat stepping down a block, vs. single leg squat on a 25 degree decline board to increase quadriceps recruitment. Scores on graph so approximate but step group VISA-P was 56 at baseline, 66 at 12 weeks and 68 at 12 months. Decline group was 62 at baseline, 78 at 12 weeks, and 84 at 12 months. VAS score improved over time in both groups but was not significantly different.

    When Assessed:  12 weeks and 12 months.

    Subjects:  17 elite volleyball players 18-35 years old

    Protocol:  3 sets of 15 reps of eccentric single leg squats performed twice per day in both groups starting with body weight. The step group (10 cm height) was instructed to train with “minimal pain” while the decline (25 degree) group were instructed to train into “moderate” pain. The decline group increased resistance when pain decreased, while the step group was instructed to progress speed from slow to fast before increasing resistance as per Stanish protocol.

    Other Activity:  Sounds like exercise protocol was initiated and completed in the preseason and then the athletes were tracked for the full competitive season with no additional intervention.

    Chad’s Comments:  Interesting for several reasons. First it is impossible to say if decline board is better than the step down because the exercise protocol was different (more pain allowed in decline group, increasing speed in step down group). I think perhaps a leg extension machine might be best still as you know for sure you are getting 100% quadriceps involvement as both above interventions allow for at least some degree of substitution from other muscles. Both groups improved but not as well as Achilles tendinopathy studies, that Alfredson was also a part of. Noted that most competitive athletes training with pain and patellar tendinopathy have a VISA-P of 50-80 which perhaps indicates that if you are below 50 it might be wise to take a break from sports.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Eccentric Training and Neovascularisation in Achilles Tendinosis

    Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis? Ohberg L, Alfredson H. Knee Surg Sports Traumatol Arthrosc. 2004 Sep;12(5):465-70. Epub 2004 Apr 2.

    Abstract

    The background to the good clinical results reported using painful eccentric calf-muscle training as treatment for chronic painful mid-portion Achilles tendinosis is not known. Recently, using ultrasound and colour Doppler technique, we showed that painful tendinosis was associated with a local neovascularisation. Furthermore, in a pilot study, destroying these neovessels by sclerosing therapy cured the pain in most patients. Dynamic ultrasound and colour Doppler examination has shown that the flow in the neovessels stops during dorsiflexion in the ankle joint. Therefore, it was of interest to study the occurrence of neovascularisation before and after eccentric training. Forty-one tendons in 30 patients (22 men and 8 women, mean age 48 years) with chronic painful mid-portion Achilles tendinosis were examined with ultrasonography and colour Doppler, before and after 12 weeks of eccentric calf-muscle training. Before treatment, there was a local neovascularisation in the area with tendon changes (hypo-echoic areas, irregular fibre structure) in all tendons. At follow-up after treatment (mean 28 months), there was a good clinical result (no tendon pain during activity) in 36/41 tendons, and a poor result in 5/41 tendons. In 34/36 tendons with a good clinical result of treatment there was a more normal tendon structure, and in 32/36 tendons there was no remaining neovascularisation. In 5/5 tendons with a poor clinical result there was a remaining neovascularisation in the tendon, and in 2/5 tendons there were remaining structural abnormalities. In conclusion, in patients with chronic painful mid-portion Achilles tendinosis, a good clinical result after eccentric training seems to be associated with a more normal tendon structure and no remaining neovascularisation. Action on the area with neovessels during the eccentric training regimen might possibly be responsible for the good clinical results.

    Diagnosis:  Mid portion Achilles tendinitis (2-6 cm above insertion)

    Outcome:  “At follow-up after treatment (mean 28 months), there was a good clinical result (no tendon pain during activity) in 36/41 tendons, and a poor result in 5/41 tendons. In 34/36 tendons with a good clinical result of treatment there was a more normal tendon structure, and in 32/36 tendons there was no remaining neovascularisation. In 5/5 tendons with a poor clinical result there was a remaining neovascularisation in the tendon, and in 2/5 tendons there were remaining structural abnormalities.”

    When Assessed:  28 months

    Subjects:  41 tendons, 22 men 8 women, mean age 48 years

    Protocol:  2 exercises (one with knee straight and one with knee bent) 3×15 each, 2 x per day, 7 days per week for 12 weeks, starting with full body weight on one leg, train with pain unless “disabling”, no indication of varied speed. After 12 weeks they were encouraged to keep up the exercises 1-2 times per week.

    Other Activity:  “The patients were allowed to gradually go back to their previous (before injury) tendon loading activity during the last 4 weeks of the 12 week training regimen.”

    Chad’s Comments:  None

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Low Back Pain. Free Weights Good, Weight Machines and Stretching Bad — It’s Science.

    Are flexibility and muscle-strengthening activities associated with a higher risk of developing low back pain? J Sci Med Sport. 2013 Aug 8

    The researchers followed 4610 adults and compared their exercise program and incidence of low back pain over an average of 4.9 years.

    Quotes from the study:
    “CONCLUSIONS: In this sample, stretching or use of weight training machines is associated with increased risk of developing low back pain compared to use of free weights, calisthenics or exercise classes.”

    “Our data show that participants, who report regular stretching were at a greater risk of developing low back pain than those who did not.”

    “We found participants who regularly used weight training machines were at a higher risk of developing LBP, but this association was not found in people who used free weights”

    “One argument often given in favor of free weights over machines is that it allows not only for the development of the main target muscle group, but also surrounding stabilizing muscles, such as those in the back and abdomen. However, when using machines, the ROM is defined by the machine, providing isolation of the movement in one plane, meaning the deep paraspinal stabilizing muscles may not be engaged as much as they are with free weights, and subsequently underdevelop.”

    Chad’s comments:

    For the most part this study agrees with my observations. I put it under the category of vindication that I was right, and a lot of others wrong, when I was a physical therapy student in the 90’s. The researchers cite muscle cytoskeleton damage as why they think the stretching leads to increased low back pain, but my feeling is that modern society puts people in repeated and prolonged spine flexion, which over time leads to degenerative disc disease. Most stretching programs either purposely or accidentally put people into further spine flexion, repeatedly, worsening the condition. So I don’t doubt that stretching programs increase the risk of low back pain, particularly if they are stretching the spine itself. I just don’t see many patients complaining of low back pain that I would diagnose with cytoskeletal muscle damage. The general theme of flexibility of the spine causing more harm is in accordance with lumbar spine researcher Stuart McGill’s recommendations, which I am also largely in agreement with.

    As for their rationale as to why machine training led to increased incidence of low back pain while free weights did not, I think the researchers are pretty close to the mark. I would add that unlike most machines, free weights generally require you to coordinate many joints together using the body as a single unit, such as in a squat or deadlift. With good technique, this imparts not just strength and endurance, but better motor control of the spine, all of which are protective. Also, most abdominal weight machines require repeated spine flexion or twisting, both of which have been shown to be pathologic stresses to the spine. These muscles are better strengthened isometrically which happens both explicitly and implicitly with a lot of free weight exercises. Certain weight machines in my opinion are often very useful and can play a role in everyone’s fitness program but the advantages and disadvantages of their use should be kept in mind and they are probably best worked into a program combined with free weight exercises for optimal function.

    Likewise I do think some stretching has it’s place, but it should not be a foundation of one’s exercise program. People fall and break hips because they are not strong enough to prevent the fall. Generally nothing bad happens if you can’t bend over and touch your toes; plus, the posterior direction of herniation in peoples’ discs indicates that they bend forward too much as is and don’t need any special stretches in the same direction. Unfortunately many physical therapy clinics base their lumbar rehabilitation programs on traditional wisdom and start their patients with supine knees to the chest stretches (which is only more spine flexion) and posterior pelvic tilts (which are also more spine flexion), which is probably not the best thing to do. As they say, traditional wisdom is often long on tradition and short on wisdom.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Eccentric Calf Muscle Training for Achilles Tendinitis

    Chronic Achilles tendon pain treated with eccentric calf-muscle training. Fahlström M, Jonsson P, Lorentzon R, Alfredson H. Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):327-33. Epub 2003 Aug 26.

    Abstract

    Injuries involving the Achilles tendon and manifested as chronic tendon pain are common, especially among recreational athletes. In a pilot study on a small group of patients with chronic painful mid-portion Achilles tendinosis, eccentric calf-muscle training was shown to give good clinical results. The aim of this prospective study was to investigate if the previously achieved good clinical results could be reproduced in a larger group of patients, and also to investigate the effects of eccentric calf-muscle training in patients with chronic insertional Achilles tendon pain. Seventy-eight consecutive patients, having chronic painful Achilles tendinosis at the mid-portion (2-6 cm level) in a total of 101 tendons (55 unilateral and 23 bilateral), and thirty consecutive patients with chronic insertional Achilles tendon pain in 31 tendons (29 unilateral and one bilateral) were treated with eccentric calf-muscle training for 12 weeks. Most patients were recreational athletes. Evaluation of the amount of tendon pain during activity was recorded on a visual analogue scale (VAS), before and after treatment. In 90 of the 101 Achilles tendons (89%) with chronic painful mid-portion Achilles tendinosis, treatment was satisfactory and the patients were back on their pre-injury activity level after the 12-week training regimen. In these patients, the amount of pain during activity, registered on the VAS-scale (mean+/-SD), decreased significantly from 66.8+/-19.4 to 10.2+/-13.7. On the contrary, in only ten of the tendons (32%) with chronic insertional Achilles tendon pain was treatment satisfactory, with a significant decrease on the VAS-scale (mean+/-SD), from 68.3+/-7.0 to 13.3+/-13.2. Our conclusion is that treatment with eccentric calf-muscle training produced good clinical results in patients with chronic painful mid-portion Achilles tendinosis, but not in patients with chronic insertional Achilles tendon pain.

    Diagnosis:  Mid portion Achilles tendinitis (2-6 cm above insertion) & patients with insertional tendinitis.

    Outcome:  VAS during activity. 90/101 good vs. poor result for mid-portion tendinitis, while 10/31 of insertional tendinitis had good vs. poor result. Good groups were able to return to preinjury activity level and had VAS drop from ~66 to 13 while poor groups only dropped 5-10/100 points on VAS.

    When Assessed:  0 and 12 weeks

    Subjects:  101 mid portion tendons, 31 tendons with insertional pain. Average age in 40s.

    Protocol:  2 exercises (one with knee straight and one with knee bent) 3×15 each, 2 x per day, 7 days per week for 12 weeks, starting with full body weight on one leg, train with pain unless “disabling”, no indication of varied speed

    Other Activity:  “During the 12-week training regimen, walking and bicycling was allowed if it could be performed with only mild discomfort or pain. Light jogging on flat ground and a slow pace was allowed after four to six weeks, if it could be done without pain. Thereafter their activities could be gradually increased if not severe pain in the tendon was felt.”

    Chad’s Comments:   They found significantly more women and those with high BMI in the poor result group. In the poor result insertion group all were treated surgically and there were signs of retrocalcaneal and subcutaneous bursitis in all subjects and signs of impingement between the postero-superior part of the calcaneus and the Achilles tendon.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Decline Squats for Patellar Tendinopathy

    A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. Purdam CR, Jonsson P, Alfredson H, Lorentzon R, Cook JL, Khan KM. Br J Sports Med. 2004 Aug;38(4):395-7.

    Abstract
    OBJECTIVES:

    This non-randomised pilot study investigated the effect of eccentric quadriceps training on 17 patients (22 tendons) with painful chronic patellar tendinopathy.
    METHODS:

    Two different eccentric exercise regimens were used by subjects with a long duration of pain with activity (more than six months). (a) Nine consecutive patients (10 tendons; eight men, one woman; mean age 22 years) performed eccentric exercise with the ankle joint in a standard (foot flat) position. (b) Eight patients (12 tendons; five men, three women; mean age 28 years) performed eccentric training standing on a 25 degrees decline board, designed to increase load on the knee extensor mechanism. The eccentric training was performed twice daily, with three sets of 15 repetitions, for 12 weeks. Primary outcome measures were (a) 100 mm visual analogue scale (VAS), where the subject recorded the amount of pain during activity, and (b) return to previous activity. Follow up was at 12 weeks, with a further limited follow up at 15 months.
    RESULTS:

    Good clinical results were obtained in the group who trained on the decline board, with six patients (nine tendons) returning to sport and showing a significantly reduced amount of pain over the 12 week period. Mean VAS scores fell from 74.2 to 28.5 (p = 0.004). At 15 months, four patients (five tendons) reported satisfactory results (mean VAS 26.2). In the standard squat group the results were poor, with only one athlete returning to previous activity. Mean VAS scores in this group were 79.0 at baseline and 72.3 at 12 weeks (p = 0.144).
    CONCLUSION:

    In a small group of patients with patellar tendinopathy, eccentric squats on a decline board produced encouraging results in terms of pain reduction and return to function in the short term. Eccentric exercise using standard single leg squats in a similar sized group appeared to be a less effective form of rehabilitation in reducing pain and returning subjects to previous levels of activity.

    Diagnosis:  Patellar tendinopathy

    Outcome:  VAS score in eccentric decline squat group decreased from 74.2 to 28.5 at 12 weeks with pain scale at 26.2 in 15 months. In standard squat group VAS score decreased from 79 to 72.3 at 12 weeks with no follow up shown at 15 months. 6/8 subjects in decline group returned to preinjury levels of sports, while only 1/9 in standard group returned to preinjury level of pain.

    When Assessed:  12 weeks for both groups, 15 months for decline squat group only.

    Subjects:  8 men 1 woman, average age 22, in standard eccentric squat group, and 5 men 3 women, average age 28, in decline eccentric squat group.

    Protocol:  Both groups did eccentric squats 3 sets of 15 reps twice per day, flexing the knee to 90 degrees. Standard squat group did their eccentric squats with foot flat on the ground while declined group had foot on 25 degree decline board intending to increase quadriceps activity and to lessen calf, glute and hamstring activity.

    Other Activity:  Most subjects appeared to be athletic, participating in a variety of sports but study did not detail time off of protocol for return to activity in either group.

    Chad’s Comments:   Results would indicate that you do want to isolate the quadriceps to ensure other muscles are not doing all the work.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Drop Squats vs. Leg Extension/ Curl for Jumper’s Knee

    A randomised clinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper’s knee in athletes: pilot study. Cannell LJ, Taunton JE, Clement DB, Smith C, Khan KM. Br J Sports Med. 2001 Feb;35(1):60-4.

    Abstract
    OBJECTIVES:

    To compare the therapeutic effect of two different exercise protocols in athletes with jumper’s knee.
    METHODS:

    Randomised clinical trial comparing a 12 week programme of either drop squat exercises or leg extension/leg curl exercises. Measurement was performed at baseline and after six and 12 weeks. Primary outcome measures were pain (visual analogue scale 1-10) and return to sport. Secondary outcome measures included quadriceps and hamstring moment of force using a Cybex II isokinetic dynamometer at 30 degrees/second. Differences in pain response between the drop squat and leg extension/curl treatment groups were assessed by 2 (group) x 3 (time) analysis of variance. Two by two contingency tables were used to test differences in rates of return to sport. Analysis of variance (2 (injured versus non-injured leg) x 2 (group) x 3 (time)) was also used to determine differences for secondary outcome measures.
    RESULTS:

    Over the 12 week intervention, pain diminished by 2.3 points (36%) in the leg extension/curl group and 3.2 points (57%) in the squat group. There was a significant main effect of both exercise protocols on pain (p<0.01) with no interaction effect. Nine of 10 subjects in the drop squat group returned to sporting activity by 12 weeks, but five of those subjects still had low level pain. Six of nine of the leg extension/curl group returned to sporting activity by 12 weeks and four patients had low level pain. There was no significant difference between groups in numbers returning to sporting activity. There were no differences in the change in quadriceps or hamstring muscle moment of force between groups.
    CONCLUSIONS:

    Progressive drop squats and leg extension/curl exercises can reduce the pain of jumper’s knee in a 12 week period and permit a high proportion of patients to return to sport. Not all patients, however, return to sport by that time.

    Diagnosis:  Patellar tendinopathy

    Outcome:  VAS. Over 12 weeks pain dropped 2.3 points (36%) in the leg extension/curl group and 3.2 points (57%) in the squat group. 9/10 in the drop squat group returned to sports but 5 still had low level pain. 6/9 of the leg extension/curl group returned to sports 4 of which still had low level pain.

    When Assessed:  6 and 12 weeks

    Subjects:  7 males and 3 females in the drop squat group, average age 26. 6 males and 3 females in the leg extension/curl group, average age 26.

    Protocol:  Squat group did 3 sets of 20 bilateral drop squats once a day 5 days per week for 12 weeks. Starting from a standing position they unlocked their knees and dropped rapidly until thighs were just short of parallel to the ground, starting with body weight and adding resistance when easy, appears they rose back to standing with concentric leg activity so not a pure eccentric program. Leg extension/curl group did 3 sets of 10 reps, once a day 5 days per week, instructed to lift slowly, hold weight 2 seconds at top, with entire rep to take 5 seconds. They started with 5 kg and increased resistance when they could do 3 sets of 10 with that weight.

    Other Activity:  “Once the subject’s knee pain was completely absent, he/she began an alternate day running program beginning with 1 km in running athletes and increasing by 1 km every third run…”

    Chad’s Comments:  Both groups had improved function and decreased pain. The drop squats were intended to increase eccentric activity but both groups included concentric and eccentric action.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Eccentric Training for Lateral Epicondylitis

    Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia. Svernlov B, Adolfsson L. Scand J Med Sci Sports. Dec 2001;11(6):328-334.

    Abstract

    In a pilot study 38 patients with lateral humeral epicondylalgia were randomly allocated to two treatment groups. Group S (stretching) was treated with a contract-relax-stretching program while group E (eccentric exercise) underwent an eccentric exercise program. Both groups also received forearm bands and wrist support nightly. The programs were carried out daily at home during 12 weeks. Evaluation before and 3, 6 and 12 months after treatment, included subjective assessment of symptoms using visual analogue scales and grip strength measurements. Thirty-five patients were available for follow-up. Five patients, three in group S and two in group E, did not complete the programs due to increased pain while 30 (86%) reported complete recovery or improvement. Reduced pain and increased grip strength were seen in both treatment groups but 12 out of 17 patients (71%) in group E rated themselves as completely recovered as compared to 7 out of 18 (39%) in group S (P=0.09), and in group E the increase in grip strength after 6 months was statistically significantly larger than in group S. In a second study the eccentric training regime was used in a consecutive series of 129 patients with lateral epicondylalgia. The patients were divided into two groups with one group consisting of patients with less than one year duration of symptoms and the other comprised patients with a duration of symptoms for more than one year. The results of treatment were evaluated in the same way as in the pilot study, and also after 3.4 years using the scoring system by Verhaar et al. At the end of the treatment period statistically significant improvements were seen in all VAS recordings and in grip strength. After 3.4 years 38% had excellent, 28% good, 25% fair and 9% poor results according to the score. In the self-rated outcome 54% regarded themselves as completely recovered, 43% improved, 2% unchanged and 2% worse. No significant differences were seen between patients with a duration of symptoms for more than one year compared to patients with symptoms for less than one year. The eccentric training regime can considerably reduce symptoms in a majority of patients with lateral humeral epicondylalgia, regardless of duration, and is possibly superior to conventional stretching.

    Diagnosis:  Lateral Epicondylitis

    Outcome:  VAS at rest, palpation, resistance, middle finger, grip but data not given between groups. Slight edge given to eccentric group over stretching but results poorly reported and follow up so far out that difficult to determine if either group better off than if no treatment. Also eccentric protocol so low in resistance, reps, and slow of progression as to be of doubtful efficacy.

    When Assessed:  3 months, 6 months, 1 year

    Subjects:  Eccentric group 13 men & 2 women, ave age 42. Stretch group 9 women 6 men, ave age 43.

    Protocol:  Eccentric group did warm up, static stretches, 3 sets of 5 reps of eccentric reverse wrist curls starting with 1kg for men and 0.5kg women adding 10% per week, exercise performed once daily

    Other Activity:  “No change in usual working or training activities was prescribed; instead all patients were encouraged to use the affected arm as much as pain allowed.”

    Chad’s Comments:   “Previous steroid injections associated with inferior results.”

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Eccentric vs. Concentric Training in Achilles Tendinitis

    Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Mafi N, Lorentzon R, Alfredson H. Knee Surg Sports Traumatol Arthrosc. 2001;9(1):42-47.

    Abstract

    In a previous uncontrolled pilot study we demonstrated very good clinical results with eccentric calf muscle training on patients with painful chronic Achilles tendinosis located at the 2-6 cm level in the tendon. In the present prospective multicenter study (Sundsvall and Umeå) patients with painful chronic Achilles tendinosis at the 2-6 cm level in the tendon were randomized to treatment with either an eccentric or a concentric training regimen for the calf muscles. The study included 44 patients, with 22 patients (12 men, 10 women; mean age 48 years) in each treatment group. The amount of pain during activity (jogging or walking) was recorded by the patients on a visual analogue scale, and patient satisfaction was assessed before and after treatment. The patients were instructed to perform their eccentric or concentric training regimen on a daily basis for 12 weeks. In both types of treatment regimen the patients were told to do their exercises despite experiencing pain or discomfort in the tendon during exercise. The results showed that after the eccentric training regimen 82% of the patients (18/22) were satisfied and had resumed their previous activity level (before injury), compared to 36% of the patients (8/22) who were treated with the concentric training regimen. The results after treatment with eccentric training was significantly better (P<0.002) than after concentric training. The good clinical results previously demonstrated in the pilot study with eccentric calf muscle training on patients with chronic Achilles tendinosis, were thus reproduced in this multicenter, showing superior results to treatment with concentric training.

    Diagnosis:  Mid portion tendinitis (2-6 cm above insertion)

    Outcome:  VAS during running or walking, 82% of eccentric group returned to previous activity level (PAL) with VAS decreasing from 69 to 12, of those that did not return to PAL VAS decrease to 44. 36% of concentric group achieved PAL with VAS decreased from 63 to 9, while non-responders went to 60.

    When Assessed:  12 weeks

    Subjects:  Eccentric group 12 men & 10 women, ave age 48 . Concentric group 12 men 10 women, ave age 48.

    Protocol:  Eccentric: 2 exercises (one with knee straight and one with knee bent) 3×15 each, 2 x per day, 7 days per week for 12 weeks, starting with full body weight on one leg, train with pain unless “disabling”, no indication of varied speed. Concentric: 2 to 3 sets of 15-20 repetitions of concentric calf raises with theraband, seated calf raises without resistance, standing heel raises, step ups on a bench, jump rope and lateral hops. Higher impact/functional exercises added after 4 weeks.

    Other Activity:  Running allowed to continue if “with only mild discomfort and no pain.” “The patients were instructed to start jogging or walking activity at a slow pace, on flat ground, and for a short distance. Thereafter their activity could be gradually increased if there was no severe pain in the tendon.

    Chad’s Comments:  Concentric group did not seem to be as steady or structured as program as the eccentric group. Not so sure about 48 year old patients jumping rope.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Eccentric Overload Training and Chronic Achilles Tendinitis

    Eccentric overload training for patients with chronic Achilles tendon pain–a randomised controlled study with reliability testing of the evaluation methods. Silbernagel KG, Thomeé R, Thomeé P, Karlsson J. Scand J Med Sci Sports. 2001 Aug;11(4):197-206.

    Abstract

    The purpose was to examine the reliability of measurement techniques and evaluate the effect of a treatment protocol including eccentric overload for patients with chronic pain from the Achilles tendon. Thirty-two patients with proximal achillodynia (44 involved Achilles tendons) participated in tests for reliability measures. No significant differences and strong (r=0.56-0.72) or very strong (r=0.90-0.93) correlations were found between pre-tests, except for the documentation of pain at rest (P<0.008, r=0.45). To evaluate the effect of a 12-week treatment protocol for patients with chronic proximal achillodynia (pain longer than three months) 40 patients (57 involved Achilles tendons) with a mean age of 45 years (range 19-77) were randomised into an experiment group (n=22) and a control group (n=18). Evaluations were performed after six weeks of treatment and after three and six months. The evaluations (including the pre-tests), performed by a physical therapist unaware of the group the patients belonged to, consisted of a questionnaire, a range of motion test, a jumping test, a toe-raise test, a pain on palpation test and pain evaluation during jumping, toe-raises and at rest. A follow-up was also performed after one year. There were no significant differences between groups at any of the evaluations, except that the experiment group jumped significantly lower than the control group at the six-week evaluation. There was, however, an overall better result for the experiment group with significant improvements in plantar flexion, and reduction in pain on palpation, number of patients having pain during walking, having periods when asymptomatic and having swollen Achilles tendon. The controls did not show such changes. Furthermore, at the one-year follow-up there were significantly more patients in the experiment group, compared with the control group, that were satisfied with their present physical activity level, considered themselves fully recovered, and had no pain during or after physical activity. The measurement techniques and the treatment protocol with eccentric overload used in the present study can be recommended for patients with chronic pain from the Achilles tendon.

    Diagnosis:  Mid portion tendinitis (2-6 cm above insertion)

    Outcome:  Tested ROM, functional tests, pain, yes or no follow up questions. Both groups improved over time but the experimental results were better. At one year 12/20 felt fully recovered while control group 4/17 were fully recovered.

    When Assessed:  12 week exercise program, assessed at 6 weeks, 3 months, 6 months, and follow up questions at 1 year.

    Subjects:  30 tendons in experimental group, 27 in control group, average age 47 and 41 respectively.

    Protocol:  All groups included some stretch and body weight concentric and eccentric calf raises. Eccentric group was allowed to train though pain of up to 5/10, while control group avoided pain. Eccentric group ramped up repetitions as symptoms would allow but no additional resistance was added beyond body weight. Frequency varied from 3x per day to every other day, progressing to lesser frequency as time progressed. Control group did concentric and eccentric calf raises but only progressed to 3 sets of 5 reps.

    Other Activity:  Largely active group, more than half were joggers, and several others were active in other sports.

    Chad’s Comments:  Both groups improved, but neither did so in a stunning manner. The eccentric group did do better but exercise intensity and duration was also more so one can not determine if changes are due to the eccentric nature of the exercise, or the amount of exercise. Exercising with pain up to 5/10 was clearly not detrimental in comparison to pain free exercise. Even eccentric exercise group intensity was relatively light as they never added external resistance beyond body weight.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Isokinetic Eccentric Exercise for Recurrent Tendinitis

    Treatment of recurrent tendinitis by isokinetic eccentric exercise. Croisier J-L, Forthomme B, Foidart-Dessalle M, Godon B, Crielaard J-M. Isokinetics and Exercise Science. 2001;9:133-141. 

    Diagnosis:  9 Achilles, 10 patellar, and 15 lateral epicondyllar

    Outcome:  15/34 patients had complete relief of symptoms, 10/34 had marked decrease in symptoms, 5/34 had moderate decrease in symptoms, and 4/34 had no change in symptoms.

    When Assessed:  After 20 to 30 sessions, which should be ~7-10 weeks. Follow up for return to sporting activities was “after 3 months of practice”.

    Subjects:  34 patients, 9 Achilles, 10 patellar and 15 epicondyllar. No blinding and no control group.

    Protocol:  Isokinetic eccentric exercise 3x per week, 1-5 sets of 10-30 reps, increasing speed and intensity over time. 20-30 sessions. Comanaged with ice, TENS, ultrasound, massage and stretching.

    Other Activity:  “Subjects were instructed to avoid provoking pain or discomfort in the course of activities between training sessions.”

    Chad’s Comments:   Reported they generally noted a significant decrease in pain by the 10th session. Did exercises just 3x per week to good effect. Found roughly the same effectiveness regardless of tendinitis type.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Hip Abduction Strength More Important to Function than Quadriceps after TKA

    Hip abduction strength more important to function than quadriceps after Total Knee Arthroplasty. Physical Therapy. Feb 2011; 91(2): 225–233.
    From the study:

    Measurements
    Strength of quadriceps muscles and hip abductors was measured using an isokinetic dynamometer. Performance-based physical function was assessed with 4 measures: self-selected walking speed, the Figure-of-8 Walk Test, the Stair Ascend/Descend Test, and the 5-Chair Rise Test. Self-reported physical function was assessed with the Western Ontario and McMaster Universities Osteoarthritis Index Physical Function Subscale.
    Results
    In hierarchical regression models, after accounting for demographic and anthropometric factors, quadriceps muscle strength was associated with performance on the Stair Ascend/Descend Test. After accounting for demographic, anthropometric, and quadriceps strength, hip abductor strength was associated with performance on the Stair Ascend/Descend Test, the Figure-of-8 Walk Test, and the 5-Chair Rise Test.
    Conclusions
    After TKA, hip abductor strength influenced physical function in participants more than did demographic or anthropometric measures or quadriceps strength. Longitudinal studies with larger samples are warranted. If findings are replicated, they will justify targeting the hip abductors during rehabilitation after TKA.

    Chad’s comments:

    I always like to read a study where I learn something new. While I think restoration of total leg strength is important it does surprise me that hip abduction correlated more so with physical performance tests than did quadriceps. I would imagine if they looked at other muscles, hip extension, adduction and knee flexion would also have considerable correlation with physical performance tests post Total Knee Arthroplasty. This finding along with some additional research on greater trochanteric pain syndrome (formerly known as trochanteric bursitis) has made me more likely to have patients use both my hip abduction machine and perform hip abduction in side lying both in the clinic and in home exercise. One plus with the hip abduction machine is that it puts very minimal stress on the knee and is subsequently very well tolerated very early on post-op.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Heavy Load Eccentric Training for Achilles Tendinosis

    Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Alfredson H, Pietila T, Jonsson P, R. L. Am J Sports Med. 1998;26(3):360-366.

    Abstract

    We prospectively studied the effect of heavy-load eccentric calf muscle training in 15 recreational athletes (12 men and 3 women; mean age, 44.3 +/- 7.0 years) who had the diagnosis of chronic Achilles tendinosis (degenerative changes) with a long duration of symptoms despite conventional nonsurgical treatment. Calf muscle strength and the amount of pain during activity (recorded on a visual analog scale) were measured before onset of training and after 12 weeks of eccentric training. At week 0, all patients had Achilles tendon pain not allowing running activity, and there was significantly lower eccentric and concentric calf muscle strength on the injured compared with the noninjured side. After the 12-week training period, all 15 patients were back at their preinjury levels with full running activity. There was a significant decrease in pain during activity, and the calf muscle strength on the injured side had increased significantly and did not differ significantly from that of the noninjured side. A comparison group of 15 recreational athletes with the same diagnosis and a long duration of symptoms had been treated conventionally, i.e., rest, nonsteroidal antiinflammatory drugs, changes of shoes or orthoses, physical therapy, and in all cases also with ordinary training programs. In no case was the conventional treatment successful, and all patients were ultimately treated surgically. Our treatment model with heavy-load eccentric calf muscle training has a very good short-term effect on athletes in their early forties.

    Diagnosis:  Mid portion tendinitis (2-6 cm above insertion)

    Outcome:  VAS while running (81.2 to 18.0) Worked, 15/15 back to full running program

    When Assessed:  12 weeks

    Subjects:  15 recreational athletes, average age was 44

    Protocol:  2 exercises (one with knee straight and one with knee bent) 3×15 each, 2 x per day, 7 days per week for 12 weeks, starting with full body weight on one leg, train with pain unless “disabling”, no indication of varied speed

    Other Activity:  Running allowed to continue if “with only mild discomfort and no pain.”

    Chad’s Comments:   None

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Evaluation of Eccentric Exercise in Treatment of Patellar Tendinitis

    Evaluation of eccentric exercise in treatment of patellar tendinitis. Jensen K, Di Fabio RP. Physical Therapy. 1989 Mar;69(3):211-6.

    Abstract

    The purpose of this study was to analyze the effects of a quadriceps femoris muscle eccentric training program on strength gain in patients with patellar tendinitis. The effect of an eight-week eccentric exercise program on quadriceps femoris muscle work was evaluated in four groups of subjects–two groups of “normal” (healthy) subjects and two groups of patients with patellar tendinitis. All four groups participated in a home muscle stretching exercise program, but only two groups–one group of normal subjects (N-A) and one group of subjects with tendinitis (T-A)–received additional eccentric training on an eccentric isokinetic dynamometer. The eccentric quadriceps femoris muscle work ratio (involved limb/uninvolved limb x 100) was used to quantify strength in the N-A and T-A Groups. Pain ratings were recorded for subjects with tendinitis before and after the eight-week experiment and were correlated with the dependent variable using a Spearman rank-order correlation coefficient. The N-A Group performed significantly better than all subjects with tendinitis (p less than .05). Subjects in the T-A Group, however, showed a trend toward increasing eccentric quadriceps femoris muscle work capacity over the eight-week training period. As pain ratings in the T-A Group increased, work ratios decreased. We concluded that eccentric exercise may be an effective treatment for patellar tendinitis, but that knee pain may limit optimal gains in strength.

    Diagnosis:  Patellar tendinopathy

    Outcome:  Strength tested with eccentric contractions on KIN/COM dynamometer and VAS scores both resting and during activity. Normal subjects gained more strength (23%) than tendinitis group also increased strength but it was not statistically significant, noting that while strength did increase, the pain may limit work loads, which thereby hinders strength increases. Though they tested pain levels they did not report how pain changed over the course of the treatment in any group.

    When Assessed:  8 weeks

    Subjects:  31 subjects, 15 female, 16 male aged 21-45 years. 15 had patellar tendinopathy and 16 were normal controls.

    Protocol:  Subjects were divided into 4 groups, normal and tendinitis groups with home stretches only and normal and tendinitis groups with the addition of isokinetic eccentric exercises done 3 times per week on KIN/COM dynamometer for 8 weeks progressing from 30 degrees per second to 70 degrees per second. Six sets of 5 reps were done in week one, 8 sets of 5 week 2 and 12 sets of 5 week 3-8.

    Other Activity:  No mention.

    Chad’s Comments:  Noted the Curwin and Stanish theory, suggesting that eccentric exercise would better prepare the patient to withstand the higher forces of eccentric contractions during sports or ADLs with the theory it was these contractions that cause the damage to the tendon, they cited the 1973 Komi study on force velocity curves which is not on Medline. Difficult to determine much from this study as the results were not given in very clear format, the protocol was only 8 weeks long and the exercises were done 3 times per week with sets of only 5 repetitions.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Original Eccentric Exercise/Tendinitis Study

    Eccentric exercise in chronic tendinitis.Stanish WD, Rubinovich RM, Curwin S. Clin Orthop Relat Res. 1986 Jul;(208):65-8.

    Abstract
    Chronic tendinitis, particularly of the Achilles tendon, frequently outwits traditional programs of therapy including surgery and/or prolonged immobilization. A hypothesis proposes that disruption of the tendon, micro or macro, occurs under specific conditions of eccentric loading. In order for the healing tendon to be adequately rehabilitated, the treatment program must include specific eccentric strength rebuilding exercises.

    Diagnosis:  Nonspecific tendinitis

    Outcome:  “44% of patients had complete relief of pain and function impairment, 43% had a marked decrease in symptoms (complaining of mild pain after athletic activities), 9% had virtually no change in their clinical state, and 2% were worse after the exercise program.”

    When Assessed:  16 months

    Subjects:  200 patients with tendinitis lasting 18 months, failed prior physical therapy and had at least 3 corticosteroid injections

    Protocol:  6 week program, 3 sets of 10 reps, 1x per day, slow speed, medium speed, then fast speed, then add resistance.

    Other Activity:  No mention.

    Chad’s Comments:  Oldest of the research. No control, not very well described. 6 week program, but mean follow up was not until 16 months after the initiation of treatment.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.