Adaptations to Training
When we “use” our bodies, our bodies adapt to the activity we are doing. The more we do, the more we are able to do. The less we do, the less we are able to do. This is essential in eliciting a training response.
When we train we want to cause stress to our body. (This may be our muscles, bones, cardiovascular system, etc.) We want to overload the system, which causes a degree of damage or micro-trauma. The body then responds by growing bigger / stronger / faster / fitter, so it can cope with that load in future. We cause stress to force adaptations.
Stress/load => damage => rest/recovery => adaptation/growth.
Load
A lot of common gradual-onset injuries result from a failure to adapt to load.
There are a number of variables that can be multiplied to determine the total load:
The intensity of the activity is the most powerful multiplier in this list. When we are considering total load, we also need to consider variables that make it harder for our bodies to adapt to load. Variables that can be multiplied to determine how well we adapt to the load:
Recent research found that getting less than 8 hours sleep a day almost doubles the injury rate in athletes. 
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I’ve been frustrated this week by a couple of patients with Achilles problems that I thought should recover well. They’ve disappeared to go and have an injection, against my recommendation. It’s made me think about whether or not I should have made the referral myself? What are our options for injections, and do they work?
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TENDON PAIN
Tendinopathy (tendon pain) is very common. They are the most common type of overuse injury (ref). Achilles tendinopathy affects the majority of runners (ref) and is the reason 16% of athletes have to stop sports participation (ref).
There are a range of commonly prescribed treatment options for tendinopathy, but very few are supported by quality, randomised, prospective, placebo-controlled trials.
There are a range of commonly prescribed treatment options for tendinopathy, but very few are supported by quality, randomised, prospective, placebo-controlled trials.
SO WHAT DO I DO?
Considering all the available treatment options, above anything else, I always recommend:
- load management, in combination with
- a strengthening program.
WHAT ABOUT INJECTIONS?
Having mapped out a management plan, patients will routinely ask my opinion on getting an injection. They may have had a friend for whom an injection worked well, or the GP has suggested it as an option, or they’ve had one before and it worked.
There are a range of drugs to inject into or around a tendon, depending on who you are referred to:
There are a range of drugs to inject into or around a tendon, depending on who you are referred to:
- Corticosteroid (A strong anti-inflammatory)
- Prolotherapy (An irritant to stimulate new tissue growth, e.g. hypertonic dextrose/glucose)
- Sclerotherapy (An irritant to decrease vascularisation, e.g. Polidocanol)
- Traumeel (A homeopathic preparation derived from arnica)
- Actovegin (derived from calf blood)
- Autologous blood (injecting your own blood into the tendon to promote healing)
- Platelet-rich plasma (blood is taken and PRP is extracted and injected to promote healing)
- High-volume injections (to damage the tissue and encourage new growth)
CORTICOSTEROIDS
Corticosteroids are an anti-inflammatory medication injected around the tendon to decrease pain that is caused by inflammation (although it is now thought that inflammation does not play a significant role in tendon pain). Corticosteroid injections have historically been commonly prescribed but more recently their use is controversial. Repeated corticosteroid injections can weaken the tendon and increase the risk of rupture. Corticosteroid injections are good at relieving pain in the short term (2-6 weeks) however, there is strong evidence that long-term outcomes (> 6 months) are worse than other conservative treatments or no treatment at all (ref).
PROLOTHERAPY / SCLEROTHERAPY
Prolotherapy injections act as an irritant causing an inflammatory response then scarring of the nerves that transmit pain. There is no solid support in the medical literature for this procedure for the treatment of tendinopathies. A randomised controlled trial of polidocanol injections showed the potential to reduce tendon pain in patients with chronic painful mid-portion Achilles tendinopathy (ref). However, a systematic review found limited results for use of prolotherapy in sports related soft tissue injuries (ref).
AUTOLOGOUS BLOOD INJECTIONS
The rationale of autologous blood injection consists of enhancing tendon healing through collagen regeneration and the provision of cellular mediators. Good experimental models are lacking, and clinical application is anecdotal. A 2013 randomised controlled trial investigating the efficacy of autologous blood injections as a treatment for mid-portion Achilles tendinopathy concluded they did not reduce pain or improve function any more than a strengthening program. (ref)
HIGH-VOLUME INJECTIONS
The suggested mechanism of high-volume injections is the mechanical disruption of local tissues then stimulates a healing response. One study (ref) has shown that high-volume injection of normal saline solution, corticosteroids or anaesthetics reduces pain and improves short and long-term function in patients with Achilles tendinopathy. However, more research is required.
PLATELET RICH PLASMA (PRP)
Platelets are naturally occurring in your blood, where they play an important role in healing damaged tissue, so superficially it’s inherently appealing to just add more of them to the sore spot. PRP injections are particularly trendy at the moment and it’s easy to find someone who will tell you they work well. Unfortunately, research concludes there is no benefit to PRP injections. This study found PRP injections do not improve plantar fasciopathy pain or function. This study concluded there is insufficient evidence to support the use of PRP for treating musculoskeletal soft tissue injuries. This systematic review found strong evidence against platelet-rich plasma injections for tennis elbow. This study found PRP did not improve tendon structure. This meta-analysis found no greater clinical benefit of PRP over placebo or dry needling for tendinopathy.
SO…
Would I have any of these injections, or would I recommend them to my patients, friends, or family? Well it depends. In my experience some people get some benefit some of the time. HOWEVER, these injectables are not consistently effective and their use is mostly not supported by research. I suggest that patients try the strengthening program and the results will be overall better in the long term.
WHY DO THE INJECTIONS WORK FOR SOME PEOPLE?
I’ve been frustrated with a couple of patients that cancelled their follow-up appointment and, when I phoned and asked what had happened, they’ve had an injection and now feel fine. My conclusion is the injections don’t work, but if you were sore and now you’re not, your conclusion would be they do work. So what is it?..
REGRESSION TO THE MEAN
Most people seek treatment when they are at their worst. By definition the only possible change from being as bad as at can be, is an improvement. Was it the injection working, or was it getting better anyway?
NATURAL HISTORY
Some conditions are self limiting and will just get better by themselves. Did the injection work, or was it about to get better anyway?
PLACEBO
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Injections are a powerful way to administer a placebo effect. You need to see a specialist to receive it. You need to pay more money. There’s some high-tech equipment spinning the blood. Everything is set up for you to expect improvement and, in a decent percentage of cases, that’s all it takes to get better. If you believe the injection will help you then it is much more likely to work. However, the research tells us it doesn’t really matter what substance is injected, it is your belief in whether or not it will help that is the variable more likely to determine the outcome.
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SUMMARY
I understand that getting an injection seems like a much easier option than doing 12-weeks of strengthening exercises, but in the long run, a strengthening program is the thing that actually works.
TL;DR
If treating tendon pain was as easy as getting an injection then that’s what everyone would do first. Unfortunately it’s not as easy as that.
Have you had an injection for your tendon?
Load Management For Injury Prevention
Managing training load is crucial in injury prevention and treatment. A graphic in Tom Goon’s recent blog visualises how training load outweighs all other factors.
Historically we have advised that training loads shouldn’t increase by more than 10% a week. I’m not sure where this figure comes from. I’ve got no problem with it, it seems reasonable, and I’ve quoted it hundreds of times.
There’s a recent BJSM podcast interview with Tim Gabbett on load management for injury prevention. Specifically Tim talks about this paper:
Spikes in acute workload are associated with increased injury risk in elite cricket fast bowlers
- Billy T Hulin, Tim J Gabbett, Peter Blanch, Paul Chapman, David Bailey, John W Orchard, 2013.
- Billy T Hulin, Tim J Gabbett, Peter Blanch, Paul Chapman, David Bailey, John W Orchard, 2013.
It is research into fast bowlers but I think the principles apply just as well to any athlete.
They measured the acute workload of the last 7 days (and call it “fatigue”) and compare that to the chronic workload of the previous 4 weeks (which they call “fitness”).
Measuring Training Load
For runners, if the training is reasonably homogenous, we could most simply measure the workload as the total kms/week.
Or we could be more accurate and account for a mixed training program that may include a variety of hills / sprints / cross training etc, by giving each session a rate of perceived exertion (RPE) out of 10, and multiply that score by the number of training minutes:
Or we could be more accurate and account for a mixed training program that may include a variety of hills / sprints / cross training etc, by giving each session a rate of perceived exertion (RPE) out of 10, and multiply that score by the number of training minutes:
Training load = session RPE x duration (minutes)
This is called a Foster’s Score, and provides a simple method for quantifying training loads from a variety of different training modalities.
The research subtracted the current 1-week average from the previous 4-week average and called this number the “training-stress balance”.
A negative training-stress balance increases the risk of injury 4 times.
So:
The research subtracted the current 1-week average from the previous 4-week average and called this number the “training-stress balance”.
A negative training-stress balance increases the risk of injury 4 times.
So:
[Last 7 days’ session RPE x duration (minutes)] - ([Last 4 weeks’ session RPE x duration (minutes)] / 4) = TRAINING-STRESS BALANCE
Negative balance = 4 times risk of injury
Negative balance = 4 times risk of injury
Essentially this formula means you shouldn’t increase your training load by more than 25% a week.
For people that may be more vulnerable to injury I would change the 4-week average to a 6-week average, therefore, bringing the increase in load each week down from 25% to 16%.
This more cautious group could include:
For people that may be more vulnerable to injury I would change the 4-week average to a 6-week average, therefore, bringing the increase in load each week down from 25% to 16%.
This more cautious group could include:
- Pre-season training
- Kids going through growth spurts
- Athletes returning from injury
- Known history of over training injuries
- People without any training history
- Novel exercise modality
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