How To Recover From Any Injury

Image credit: Marcus Needham

Pain is a complex, emergent experience.

Tissue injuries are not.

Tissue injuries occur when the loading on the tissue exceeds its capacity.

This can be an acute issue – think of a sprinter suddenly straining their hamstring mid race – or a chronic issue – think of a builder developing elbow pain over time.

In both circumstances, the principle is the same.

The formula for managing an injury is fairly simple on a macro level:

  1. Decrease the volume, intensity and/or frequency of aggravating activities to manageable levels
  2. Improve biomechanical efficiency
  3. Increase capacity with progressive overload


What is challenging is how to achieve these objectives in living, breathing humans who have needs, wants and annoying things like emotions that make us behave irrationally.

This is where a clinician needs to have excellent listening and communication skills, be a master of persuasion and thoroughly understand the physiological and biomechanical aspects of movement, stress and adaptation.

This post is going to outline a few of the methods I use to achieve the above outcomes.

Decrease Volume/Intensity/Frequency of Load

The most obvious thing to do when we are injured is often the hardest.

Why?

  • Necessity. We all need to continue working, caring for family or performing our activities of daily living (ADL). It can be hard to offload your injured body part when there is a baby crying or a load of laundry that needs doing. Let alone when you have a work deadline to meet.
  • Desire. This is an emotional issue. Many of us desire to continue doing something as it brings us pleasure, status, or allays a negative emotion like guilt or fear. For example, it is common for people to want to continue to push themselves exercising whilst they are injured because of body image issues.

However, in most cases, an all or nothing approach is not required.

You don’t have to stop something completely to reduce the loading effect.

Here are two examples from a patient who has lateral hip pain that I’ve diagnosed as a gluteal tendinopathy. In these cases we are reducing the volume of the load primarily:

  • Use the fitness tracker in her phone to estimate her daily activity level. Work out at what activity level her symptoms flare up. Stay below that activity level while gradually building up during recovery.
  • Track her walks accurately (pace/duration) and work out at what level her symptoms flare up. Stay below that activity level while gradually building up during recovery.

Here is another example of how I reduced the intensity of the load in a builder with elbow pain. He couldn’t stop working, and a lot of what he did (using tools) aggravated his injury.

  • Use tennis grip tape to wrap around the handle of his hammer. This increases the circumference of the handle, which reduces the mechanical leverage of the forearm muscles, taking the load off the tendons at the elbow.

In most cases, there are ways to continue doing what you need or want to do, with some modifications. And in most cases, this is actually better than complete rest.

Improve Movement Efficiency

Everybody knows Roger Federer. You don’t have to be a tennis fan to appreciate his skill and technique. He makes things look easy.

As we improve our skill at a task, we become more efficient as well. It takes less effort and as a result we tend to load our body less.

Roger Federer demonstrates this – his supreme technique has helped him accumulate very few injuries in his career, despite a demanding schedule and advancing age.

However, we don’t need to look to elite sport for examples of movement efficiency.

Think of your local pizza parlour. If it has been around for a while, watching the chefs put a pizza together is a picture of movement beauty (okay, I really love pizza). Every time I try and replicate this at home I just end up tired with a very messy kitchen bench.

Or let’s keep it closer to home. When I was younger, I didn’t know how to iron a shirt well. My mum could iron all of my dad’s and my brothers’ shirts in the time it took me to do one. All that effort, all that time under load. It’s easy to see how my inferior ironing skills could lead to more load on my body. Even though my mum was doing more total work, her body was adapted to it, and she did it in a way that was smooth and effortless. Contrast that to me, not adapted to ironing (still not) and very tense and inefficient.

When it comes to rehab for an injury, it’s not just the capacity of the tissue that we have to worry about, but the efficiency of movement, which affects the loading on that tissue for each movement/activity.

Improving movement efficiency is a topic in and of itself.

My approach is based on the following formula: 

The input is related to sensory information from the nervous system. The better the quality of sensory information, the better the output. This is why rehab should begin on the sensory side. Sensory input can be improved with manual therapy, which is likely one of it’s biggest roles in modern practice.

Processing is based on cues and context. We can change both, but we have no idea how it will affect the processing. I’m not a big fan of the word processing, as it sounds to much like a computer, and we are not a computer or machine.

I discuss this in more detail here, and also here.

Increase Capacity

Remember at the start of this post when I said:

Tissue injuries occur when the loading on the tissue exceeds its capacity.

Well it makes sense that as well as reducing the load on the affected tissue(s), we increase the capacity as well. This has two benefits. No, actually, it has three benefits:

  1. Loading tissues helps with repair.
  2. Loading tissues that are painful helps (re)build confidence in the injured tissue.
  3. Increasing tissue capacity protects against future injury.

I like to use a two pronged approach here:

  • A targeted exercise approach
  • A graded return to activity approach

This isn’t revolutionary. It doesn’t have to be. It just has to be done well.

In the targeted exercise approach, I use a simple progression. I like someone to be able to (where possible) perceive the tissues properly (sensory awareness) before we work on the following:

  • Isometric to dynamic
  • More stable to less stable
  • Simple to complex
  • Less task specific to more task specific

There is some evidence to suggest local loading, particularly with isometrics has a pain relieving effect, which is why I start there.

More stable positions allow people to focus on the movement or activation required, without the extra motor and sensory demands of stabilising their body in space.

Starting simple allows more mental energy to be directed to recruitment patterns, while progressing to complex reinforces these patterns in different contexts.

Finally, starting less specific to the task allows for the load to gradually be progressed as tissue capacity increases.

Graded Return to Activity

This is an expansion of the first topic, reducing the load.

Put simply, we simply reverse the process, gradually increasing the load until the tasks can be performed normally again.

A good rule of thumb is to progress no more than 10% per week, to allow the person and the tissues to adapt. You cannot go too slowly, but you can absolutely go too quickly.

Conclusions

This is my current approach to treating tissue injuries.

You have to remember that not all tissue injuries present with pain, and not all painful presentations are related to tissue injuries.

When pain is the primary problem, we can use a similar approach if localised tissue sensitivity is deemed to be the main contributing factor.

Finally, we know that past injury is a big predictor of future injury. So while the pain from an injury subsides as the tissue heals (the tissue will heal if you give it a chance, regardless if you rehabilitate function or not), if you want to minimise your chance of re-injury in the future, it pays to be thorough.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

Achilles Tendinopathy? Treat The Whole For Better Results

Statue of the Achilles, wounded by an arrow through his heel – Achillion Palace, Corfu island, Greece

The Achilles tendon is one of the coolest tendons in the body.

While many body parts are named in Latin or Ancient Greek, the Achilles tendon draws its name directly from Greek mythology.

For those who don’t know the story:

Achilles was a hero in Greek mythology and one of the main characters that participated in the Trojan War. He was also the protagonist of Homer’s epic, the Iliad. 

When Achilles was born, his mother wanted to make him immortal and thus, dipped him in the river Styx. However, she did not realise that his heel, by which she held him, was not touched by the waters, and so that was the only part of his body that remained mortal. (1)

Achilles was then struck down in battle by an arrow through his heel, or more accurately, his tendon, hence we name it the Achilles tendon.

The Achilles Tendon Is Strong

The job of a tendon is to transmit the force developed by a muscle to the bone to which it attaches. The Achilles tendon is one of the thickest and strongest in the body, and allows us to walk, run and jump efficiently. It’s almost like having our own springs in our legs. In fact, when we run, the Achilles tendon deals with forces up to 12.5 times our body weight – for me, currently weighing around 87 kg, that is 1087.5 kg!

But It Still Gets Injured

One of the most common forms of injury to the Achilles tendon is to develop an “overuse tendinopathy”.

An overuse tendinopathy, or more accurately, an overload tendinopathy, occurs when the loading on the tendon causes an increased rate of tissue breakdown, beyond which the body can keep up with. This results in inflammation, swelling and pain localised to the tendon.

Side note: all tissues in the body are in a constant state of breakdown and building, it’s when the rate of breakdown is increased beyond the body’s repair capacity, or the body’s repair capacity is impaired, that we see problems.

We Don’t Know Exactly Why

Researchers haven’t been able to isolate a single variable that causes Achilles tendinopathy (surprising eh?), but the following are implicated:

  • Running (recreationally and competitively)
  • Participation in other sports like track and field, racquet sports, volleyball and soccer
  • Use of certain antibiotics (fluoriquines)
  • Biomechanical issues at the feet
  • Age, gender, height and weight
  • Injury history, like previous ankle sprains

What we don’t know, is exactly what happens that makes the tendon painful.

We Don’t Even Know Why They Get Better

With Achilles tendinopathy, we will often see symptoms that correlate with structural changes early on in the clinical history, but as the condition progresses and goes on for longer, this correlation becomes weaker and weaker.

In fact, in many cases, it has been shown that diminished or even absent pain is accompanied by little to no structural change to the tendon!

We Do Know What NOT To Do

You’d think that simple rest would therefore be best for an Achilles tendinopathy, however, that’s not the case. Too much rest and we lose conditioning of the tissues, and thus our capacity is reduced, leading to recurrence, only this time it takes less and less loading to aggravate.

We also know that taking anti-inflammatory drugs is not the best approach either. Firstly, there isn’t strong evidence to suggest inflammation is the primary cause of pain. Secondly, anti-inflammatory drugs have side effects. Thirdly, anti-inflammatory drugs can impair healing.

Stretching tendons also gets a bad rap, though I’m not sure why this is a blanket no. Some tendon injuries respond to being stretched (it’s simply a form of load), while others do not. You’ll see why below.

We Also Know What Works

In the physiotherapy world, where much of the research on tendinopathies is done, load management strategies combined with targeted exercises are currently the treatment with the best supporting evidence.

The actual type and dosing of the exercises has not been fully established, though we do know that you can push the loading higher than you would expect, even if it is painful.

You can use different types of exercises:

  • Eccentric where you load the lengthening portion of movement
  • Isometric: where you load the tendon without lengthening or shortening it
  • Concentric/Eccentric: where you load the tendon in a full range of motion (lengthening and shortening)

To my knowledge, the best approach has not been established in research, and in my experience, different people respond better to different approaches.

This might have something to do with some recent research that suggests there are different types of tendinopathy: compressive, shear and friction, and tensile.

As the names suggest, these imply that the tendinopathy occurs as a result of different types of tendon loading, which makes sense to me. It also makes sense that if there are different aggravating loads, the exercises which have the most benefit will also differ.

The evidence suggests avoid those loading mechanisms which are aggravating (load management), whilst stimulating the tendon with loads that don’t aggravate it.

For most people, isometrics are a good, neutral, place to start.

You can do these in a variety of ways, but one of the most accessible is to sit with your thighs under a table and feet on a block, then press your thighs into the table by raising your heels. You want to be about 70% of your maximum contraction, at least to begin with. Hold that contraction for up to 45 seconds (though I will often break it down to 3×15 second holds per set). Over time you can increase the intensity of the contraction and then progress to dynamic loading.

Sometimes exercises will hurt while you do them. That’s okay. As long as your pain doesn’t spike, or get really bad afterwards, you are stressing the tissues in a positive way.

Hands On Treatment?

This is something I learnt from my colleague, osteopath Cameron Kealy who runs Recharge Osteopathy in Melbourne, along with teaching at Victoria University.

There aren’t any studies (to my knowledge on this), just clinical observations.

Cameron will treat Achilles tendinopathy with a localised technique. He will grasp the tendon and find a position where tension is relieved and hold it – often for 5-10 mins – waiting for a tissue texture change. He will then check and treat the pelvis and upper neck. Another osteopath, Walter McKone, has also suggested the key to relieving Achilles tendinopathy is optimising blood flow by treating the pelvis.

Success leaves clues, even when there aren’t studies.

Now, we know that manual therapy doesn’t change the structure of tissues.

What is happening is likely an effect of working with the sensory nerves around the tendon.

But if a person’s pain decreases, allowing them to load again and return to activity, I’m all for it.

This Makes It Work Even Better!


At the moment, one thing that all this focus on localised exercise for tendinopathy is doing, is forgetting that the injured and painful tendon is part of the body, which is considered a whole.

After all, the blood that supplies our tendons also supplies everything else.

The nervous system that perceives the tendon also perceives everything else.

The nutrients delivered to the tendon are, you guessed it, also the nutrients delivered to everything else.

Once we have labelled the tendinopathy, the more important thing to do is to look at the health of the person.

In fact, this is the premise of osteopathy: find the health within the person, and remove the barriers to that health being expressed.

After all, it isn’t lack of exercises that cause a tendinopathy, it is lack of capacity. Exercise can increase physical capacity, no doubt about it.

However, lack of capacity can be cause by sub-optimal physiological function, and not just poor load tolerance. For example, impaired blood flow.

And, as I have discussed before, it is often easier and more efficient to “remove the handbrakes” to performance/health, than it is trying to force adaptations.

Enter The ANS

The autonomic nervous system (ANS) regulates physiological function in our bodies.

It is controlled by lower brain centres – that means we don’t have direct conscious control over it. This is a good thing, as regulating all the systems in our body is a lot of work.

Having a balanced ANS is important for health. When the ANS is over or understimulated, so that it skews towards one state too much, health is affected.

This is where it gets really interesting.

The School Of Physiotherapy at The University of Otago has been doing some interesting research (and research that should be done by osteopathic schools, but that’s another issue altogether) on the effects of manual therapy and the ANS.

Recently, one of their PhD students looked at whether spinal manipulation, delivered to the thoracic spine (which is where many important ANS centres are located) would have any effect on recovery from Achilles tendinopathy.

First, they did a review on the effects of manipulation and the ANS. That is, they looked at all the research on the topic to see if manipulation affected ANS function in any way. They found a positive relationship.

Then, to look at whether this would affect recovery from Achilles tendinopathy, the researchers created two groups: a control, which received usual care for Achilles tendinopathy (read: exercises) and the intervention group, which received usual care plus spinal manipulation.

The group receiving the spinal manipulation made better improvements in both pain and function compared to the usual care group.

Whilst only a pilot study, this is promising. It suggests that improving whole body, or rather whole person, health and function, is the most optimal way to treat Achilles tendinopathy.

Future studies will need to look at whether this was a specific effect of spinal manipulation, or a general effect of manual therapy, however, my gut feeling is that the researchers are onto something.

Don’t Forget The One Percenters

Finally, when we are really seeking above average results, we can add the extras, which can help take things from good to great.

These extras wouldn’t be classed as treatment on their own, but they enhance what you are doing already.

In my opinion, these extras are what should define private healthcare. This is what you are paying for. Not just “usual care”, which is offered by the public health system, but exceptional care, with exceptional results to match.

Some of these “one percenters” can include:

  • A tailored, not generic exercise plan
  • Specific nutritional strategies, including supplementation advice
  • Behavioural and mindset coaching (we know that mindset is an important factor in recovery from injury)

These are not specific to Achilles tendinopathy, but they can definitely play a role in addition to the treatments mentioned above.

Conclusions

If you are suffering from Achilles tendinopathy, the two most important things you can do to manage/treat it are:

  1. Load management: avoiding/reducing aggravating movements initially
  2. Build capacity: use loading/exercise strategies to build capacity in the tissue and inhibit pain

However, while these strategies would give you the majority of benefits, if you are looking to optimise your recovery, then there are more options available.

I’ve outlined some of these options, which you give you a clue as to how you can really enhance your recovery from an Achilles tendinopathy injury.

As with everything, it comes down to you.

The two big questions any osteopath worth their salt should ask are: what do you want, and what can you do to achieve it?

Some interventions are not realistic because of cost, availability or other reasons. Whatever your situation, your treatment approach should be optimised for you.

That means treatment for Achilles tendinopathy should have a whole person focus, and not just a tendon focus.

Nick Efthimiou Osteopath

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

 

References

(1) Achilles

(2) Throw Away The Anti-Inflammatories & Start Loading Your Damaged Tendons

(3) Infographic – Tendinopathy – Thou shalt load. But how? With Dr Ebonie Rio

(4) Exploring the changes in pain, function and sympathetic activity when a thoracic spine manipulation is used as an adjunct to the treatemnt of Achilles tendinopathy

Further Reading

Why Achilles Tendon Problems Don’t Heal

Recharge Osteopathic Clinic