Is Trigger Point Therapy.. well.. bollocks?

I am firmly of the opinion that anyone who ever treats anyone with plantar heel pain, or, the ubiquitous "plantar fasciitis", should be required to suffer same said condition for at least 4 weeks.

I have, and let me tell you, it is very, VERY unpleasant.

Actually having experienced the problem.. living it, being frustrated by it and being limited by it is a very valuable lesson indeed. Does it give one more insight into your limping patient's problem? Well.. that depends on how empathetic you are, but it certainly did for me. Of course, I am a very caring, sharing person!

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My take aways from the 21st Biomechanics Summer School 10th and 11th June 2016. Part 1.

 

 

 

This was the 8th of 21 BSS’s I have attended, and an absolutely stellar faculty ensured it was the best, by a considerable margin.

In this report, I will not cover every lecture and every workshop, but pick some of the key points that resonated with me.

The term “expert” is much overused, and one I usually treat with deep suspicion. However, Dr. Peter Malliaras, a sports physiotherapist from Melbourne, Australia is a fully paid up, card carrying member of the expert club, especially when it comes to all things tendon.

The first of Peter’s 2 lectures was entitled “Rehabilitation of foot and ankle tendinopathy: applying current research in the clinical setting.

Well, of course, this was right up my alley, so I sat up straight and paid attention!

Peter segmented his lecture very nicely, covering:

·         Current evidence

·         Mechanisms to consider: pain, function, tendon

·         Criteria based rehabilitation for the individual

·         Subjective, load testing, strength, and pain score outcomes

·         Education, load management, and compliance

First up, I was delighted Peter covered the crusty issue of eccentric exercises for Achilles tendinopathy. Now, the eccentric exercise protocol devised by Haken Alfredson some time ago now has been considered the gold standard and has been applied with vigor in almost every case of Achilles tendon pain. But recently, this practice has been brought into question. Of interest to podiatrist particularly, similar programs have been used in the management of plantar fasciitis, with reportedly very good outcomes.

The question is though, are eccentrics better than concentric exercises, or should we be using a combination of both?

So, what is the evidence? Well basically, there is no difference in terms of pain scores and patient satisfaction at 12 months between eccentric and concentric rehab protocols (in the Achilles tendon).

Peter’s take on this was really interesting and put a big spotlight on pain monitoring. He made the critical observation that pain improves with very different loading patterns, in other words..

There is no gold standard, nor is there one size fits all

Furthermore, loading does not need to be eccentric to improve pain, and the loading side of rehab needs to be specific for the outcome, for example, tendon adaption and improved function.

Great! I have been waiting to hear this for quite some time!

Next Peter took a look at load tolerance and tried to define what might be an acceptable load tolerance for tendon.

On this topic, he cited his own recent research which proposes a model whereby load titrated according to a less than 1/3rd (3/10 VAS) pain score during the activity. This may be too high for some athletes, and there is again no one size fits all rule. This protocol also monitors after exercise pain and expects an increase in pain post exercise for no more than 24 hours.

The tests are simple and easily reproduced functionally (always go for functional vs passive testing) in a clinical setting. Look for

·         calf raise and step with knee bent

·         submaximal hop

·         faster hop/hop on toes

·         maximal forward hop.

By Peter’s definition, the injured tissue is load tolerant when the pain resulting from the perturbation exercise settles within 24 hours.

I really like this model. Most of us are afraid of pain and have not thought about how it might help us to monitor tissue healing.

The evidence behind tendon adaption to exercise is overwhelming, with multiple recent studies now showing heavy isometric and isotonic exercises lead to increased tendon stiffness (in normal tendon it must be said). The evidence of such change in tendinopathic tendon is conflicting and somewhat equivocal.

It also needs to be said that the continuum model proposed by both Jill Cook and in a septate study, Peter Malliaras suggests that severe tendon pathology cannot be reversed. However, a very recent study by Docking asserts that the remaining normal tendon may adapt.

 

 

Ultrasound tissue characterization of the Achilles tendon mid-substance. (A) Normal Achilles tendon characterized by a high proportion of echo type I (green pixels), representing aligned tendon bundles. (B) Reactive tendinopathy due to tendon thickening and the presence of diffuse speckling of echo type II (blue pixels) and echo type III (red pixels). (C) Degenerative tendinopathy indicated by significant focal area of echo type III (red pixels).

 

The discussion then moved forward, trying to identify functional deficits that may contribute toward tendon injury. This highlighted something I have talked at length about in my Functional Assessment Workshop: excessive ankle joint dorsiflexion, leading to a stiff ankle strategy with hopping and subsequent loss of hopping power. This has been reported in the literature by Ayra in 2006 and Wang in 2012.

The result of this functional deficit is that tendon behavior is altered. Specifically, there is high tendon load and load rate and a change to the tendon energy storage levels. This further leads to impaired motor control.

The bottom line here is that progressive tendon load is absolutely essential for tendon rehabilitation. There is increasing evidence backing the use of isometric exercise, especially in league with a metronome, which assists in motor cortex excitability and introduces a skill component to rehab.

The heavy load/fast energy storage model, that was such a big part of the Alfredson Eccentric model, has fallen out of favor somewhat. The new paradigm supports the concept of

Just enough to achieve load tolerance

Along with careful monitoring of progress with load testing (something most of us do very poorly!),  and a big focus on something I have been talking about for ages..

Replace traditional activity with cross training

We can finish up by underlining the importance of keeping the athlete going if at all possible. The negative effect of absolute rest in tendon rehabilitation is impossible to overemphasize.

Education is also critically important, especially in relation to pain.

Peter did go on to discuss some basic concepts in relation to Central Pain Processing, but that is a big topic and something I shall discuss in another blog.

The take home message is as follows:

·         Do the simple things well!

·        M = manage sensitization and manage load

·         E = establish contributors including load, motor systems, kinetic chain and any potential systemic component (think metabolic syndrome)

·         N = Nurture a healing environment, which especially underlines education

·         D = develop load tolerance and concentrate on the unloading/reloading of sensitized tissue

So, that is part one, a terrific starter from Pete Malliaras. Next up, Rich Bouche and “The ABC’s of lesser MTPJ instability”

  

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Minimalism is dead, but this paper is VERY interesting!

So much research has now been published on the minimalist fad now that I barely glance at anything related to it. This new paper however, made me stand up and pay attention..

The influence of minimalist footwear and stride length reduction on lower-extremity running mechanics and cumulative loading. Ferminger, C.R., Edwards, W.B., Journal of Science and Medicine in Sport Published Online: March 17, 2016

So, what is new and different about the findings of this study?

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Current thoughts on the use of footwear and insoles to treat medial compartment knee osteoarthritis

There have been great advances in this area over the past few years, with much of the work coming out of my research group at the Centre for Health Exercise and Sports Medicine (CHESM) at the University of Melbourne.

Knee osteoarthritis (OA) is a prevalent musculoskeletal condition worldwide and is a leading cause of knee pain and disability amongst elderly people. It is calculated that 50% of people aged over 50 years will develop osteoarthritis in the western World.

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Houston we have a problem. Retail is just NOT listening to the current thoughts on pronation!

I have just finished my second round of training for technical staff here at my "real job" with Salomon. Once more the discussion revolved around questions like "how come there is no dual density midsole?".. or.. "where are the 'motion control' features?

Those of you who know me would understand there is a real threat that anyone who asks me questions like this will receive a swift backhander and be told to leave the room.. but.. it is a problem.. a BIG problem.

You see.. retail have a version of what they think running shoes should look like and should do, and for the vast majority, this version is outdated, inappropriate and.. WRONG.

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Treadmill vs overground running. This should put this discussion to bed!

I can't tell you how many times I have been asked the question, " is treadmill running a valid way to analyse gait?" The smart money has always said, well, it depends on whether you are talking about a research environment or a clinical environment, coz, the rules are different.

That said, a brand new paper may well have put the debate to bed once and for all, and, the answers almost certainly will not be what you expect!

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How should we run? Will Gait retraining help?

Once all but ignored, running technique is now the topic of countless magazine and Web site articles, is taught by a growing number of running coaches, and is intensively discussed on Internet chat forums and actual training runs.

These days, the way we run is covered by one catch-all phrase.."form". But the major question to be asked and answered is:  can a correct style of running, in fact be effectively taught—or, is there is an identifiably correct way to run that every runner can learn and use to run faster and with fewer injuries? And the even bigger question may well be, "does changing form decrease or increase the risk of injury?

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All the April research goodies for you with my commentary!

There were a couple of ripping papers this month, in what was generally a fruitful period for things that might interest and challenge us. Let's start with

Loading rate increases during barefoot running in habitually shod runners: Individual responses to an unfamiliar condition Tam et al Gait and Postures Published Online: February 21, 2016

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