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.

Considering all the available treatment options, above anything else, I always recommend:

• load management, in combination with
• a strengthening program.  

​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:

• 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 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 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).  

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)  

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.

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.

​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.  

​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?..

​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?

​Some conditions are self limiting and will just get better by themselves.  Did the injection work, or was it about to get better anyway?

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.

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.

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.

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:

• Number of sessions per week
• Length of session
• Intensity of session
• Novel activity
• Bio-mechanical or environmental variables (eg, footwear, hills, ground surface)

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:

• Time between sessions
• Nutrition
• Hydration
• Stress
• Sleep

Recent research found that getting less than 8 hours sleep a day almost doubles the injury rate in athletes.

The two most common over-loading, or over-use type injuries are:

• Tendon pain
• Stress fractures

Tendon pain is a failure of soft tissues to cope with muscular loading.

Stress fractures are a failure of the boney architecture to adapt to impact loading.

Our bodies like a consistent workload, i.e., doing the same things every day.  If we need to do more, we have to make gradual changes to avoid overloading.  Increases in total load need to be slow and steady.  Increasing load by not more than 10% a week is commonly recommended.

We get in trouble when we have spikes of excessive load.  

We may rapidly increase training levels in preparation for an event.  This is a common cause of injury during pre-season training.

Or it could be a resumption of “normal” training after a period of rest.  Unfortunately, the body quickly adapts to the lower levels, so what was normal is now excessive.  This is a common mechanism of a new injury, having spent some time rehabbing a previous injury.

An otherwise normal load may become excessive if we are not eating, drinking, or sleeping well, or are stressed.  It’s very common to see regular runners breaking down in December when they’ve been going to Christmas parties.
​

Load management is an essential component of injury management.  

Of the total volume of work, I get patients to dial down the load by about a quarter, and stop the most aggravating activities – most likely the more demanding / explosive activities: hopping, skipping, jumping, sprinting, hills, plyometrics.  So usually total rest isn’t required.  

Patients can keep going with their cardio, but possibly trial a lower impact, cross-training option.


​

Sever’s is most common in 9 - 12 year olds.  It’s sore to squeeze the bone at the base of the Achilles where it attaches onto the heel.  It’s not something that can be seen - it never seems to look red or swollen.  It’s worse after sprinting, jumping, and hopping.  It settles with rest.  It is an overuse injury so it’s common in pre-season, or anytime training loads increase too quickly.  My kids get it when they do extra sessions in running spikes or footy boots, without the normal heel support of their running shoes.  It’s an overuse injury from excessive loads.
​

When we talk about excessive loads it can be “external” load such as:

• number of sessions
• length of sessions
• pace of running
• hills
• novel activity
• footware
• ground surface

I think the running pace is the more powerful multiplier in this list.  Extra sprint sessions will do it.  My kids got sore once when we did a boot-camp session with a novel plyometric exercise - split jumps.

There are also “internal” variables that determine our ability to cope with the training load:

• nutrition
• stress
• sleep
• growth spurts

My kids definitely are more prone to Sever’s if they’ve had a couple of late nights that week.  And, if they’re having a growth spurt, their bodies are busy spending resources on growing rather than recovering from the stress of a training session.
​

Text books say that Sever’s disease is self-limiting because the growth plate eventually fuses by the age of 15 or 16.  But I don’t think there’s anyone who would be happy to just let it run its course until then.  It is usually sore enough to stop you participating in sport, so it needs treatment.
​

I used to put kids with heel pain in orthotics, until I read this research which confirms that a simple heel wedge is more effective than orthotics for Sever’s disease.  Cheaper and easier.

I get them to do an isometric Achilles strengthening program which also helps with pain control.

But ultimately recovery comes down to load management.

Load management means reducing the excessive loads. So this could be:

• less sessions/week
• shorter sessions
• less sprint work
• run in joggers rather than spikes or footy boots
• less hills
• heel wedges in shoes
• stay in shoes - no bare feet / thongs / flats. I really like them to stay in some sort of shoe with a heel all the time. Even if they’re getting up to use the bathroom I want them to slip their joggers on.

And aid recovery with:

• plenty of sleep
• massage calf muscles
• ice and Ibuprofen for pain relief when sore

​I’d guess that most people feel guilty about not stretching enough.

Interestingly, health professionals have changed our tune about the importance of stretching.  Research over the last 15 years has suggested static stretching is not as beneficial as was once thought.  I’ve been having conversations about the reasons to stretch (or not) for at least the last 10 years, but the current science on stretching just isn’t catching on.  

So, what do we know?…
​

No.  There is a lot of evidence that stretching does not reduce the risk of injury.  This systematic review and meta-analysis of randomised controlled trials found stretching does not prevent injuries, whether done before or after training.  This randomised controlled trial, and this systematic review concluded stretching before exercising only reduces the risk of injury by less than 1%.  

​Therefore, in practical terms the average athlete would need to stretch for 23 years to prevent one injury.  Definitely not worth it.
​

No.  A systematic review concluded that stretching before or after exercising does not confer protection from muscle soreness (ref).  Stretching was found to reduce muscle soreness by a trivially small amount - less than 2%.

“Most athletes will consider effects of this magnitude too small to make stretching to prevent later muscle soreness worthwhile.”

​No.  Stretching for the amount of time that most people would hold their stretches, does not make any actual difference to flexibility.  The mechanisms of stretching have been extensively studied.  There is moderate evidence from a systematic review that stretching can increase flexibility (ref). However, to achieve an actual improvement in muscle compliance we know the total duration of stretching needs to be at least five minutes per muscle group (ref).  Therefore to stretch hamstrings, quads, and calves, both left and right, as part of a warm up before sport, it should take at least 30 minutes - which is practically impossible as part of a warm up.  We know the one or two, thirty second stretches the majority of athletes would perform during their warm up are just not enough to actually improve their flexibility (ref).
​

What people find most surprising about static stretching is it impairs subsequent performance (ref).

A substantial body of research has shown that sustained static stretching acutely decreases muscle strength and power (ref).  Stretching before an endurance event lowers endurance performance and increases the energy cost of running (ref).  Cycling efficiency and time to exhaustion are reduced after static stretching (ref).

Pretty much any measure of performance is made worse by stretching.  Static stretching impairs: 

• strength
  
• maximal  voluntary contraction
  
• isometric force
  
• isokinetic torque
  
• one repetition maximum lifts
  
• power
  
• vertical jump
  
• sprint times
  
• running economy
  
• agility
  
• balance

A comprehensive review (ref) from 2011 concludes:

“Based on the majority of the literature, it would seem logical to recommend that prolonged static stretching not be performed prior to a high level or competitive athletic or training performance.”

​Obviously, I’ve been talking about sustained, static stretching.  It has been shown that there is no stretch-induced strength loss with dynamic stretching (ref).  However, the efficacy of dynamic stretching for increasing flexibility is yet to be determined (ref).
​

I do get people to stretch if there’s a specific pathology that needs treating.  And you do need to stretch if you need flexibility to achieve certain positions in your sporting performance (hurdlers / gymnasts / divers, etc).
​

If you’re happy with your stretching routine, keep doing it.  If you think it feels good to stretch after exercise then there’s no harm.  But I definitely wouldn’t recommend stretching at the expense of other techniques that are proven to aid recovery.

ACL Rehabilitation Guide (available here)
​
A criteria driven ACL rehabilitation protocol and guide for both clinicians and people who have undergone a surgical reconstruction of the Anterior Cruciate Ligament (ACL).

Author: Randall Cooper

I was thinking about what frustrates me about physiotherapy.  What are the things that physios do that confuse me?  If I was a patient, what would stop me coming back?  

What I don't like is physios that make things super complicated.  I'm not sure if that helps position them as an "expert", meaning you've got to pay them because you absolutely can't help yourself. Or it may be that they don't completely understand what they're talking about so can't explain it well.  But I don't like smoke and mirrors.  I think physio can be pretty simple.

This leads me to ask - if I boil it down, what are the most important things I do to help you recover from your injury?

I think it comes down to two key components:

1. You need to understand what's wrong.  I need to explain some complicated stuff to you in a way that my Nanna or my kids could understand.  If you understand what's going on, you'll understand why it's important to do what I ask you to do to get yourself better.
2. What are the one or two most important things you need to do?  If it was just one thing, what would you do?  Best bang for your buck?

Usually the most important thing comes down to you doing a stretch or strengthening exercise at home.  More often than not it's you consistently making small gains with a home program that makes the biggest difference to your recovery.  Not anything miraculous that I can do to you here.

If it's super important, why do some people do their home exercise and others don't?  Life gets in the way.  It's hard to remember.  You've got better things to do.

So, I need to make it as easy as possible for you.  That's my job.  That's why I'm better than just googling it.

​I understand that small stuff gets in the way.  You remember to do the exercise when you're in the car and can't do it.  Before you know it, you get to the end of the day and it's not been done.  There's lots of little things that make a home exercise program hard to do "now" - meaning you leave it for "later".  If you have to get on the floor you'll do it "later".  If there's too many exercises to do, you'll do it "later".  If you have to use equipment - it's not on hand.  Any little barrier to getting it done means it doesn't get done.  It needs to be easy.  

So my practical solution for your recovery comes back to: WHAT WOULD I REALISTICALLY DO MYSELF?.  It's lucky I've had a few injuries and have learnt what's realistic and what's not.  If I had your injury, what is the one thing I would actually, realistically do myself?

I think that is a great question for all healthcare professionals.  Because we know that around 40% of our health budget is wasted on unnecessary tests and treatments.  Unnecessary healthcare expenses add up to $45 billion/year in Australia.  It is amazing how many things healthcare practitioners recommend to patients that they wouldn't do themselves.

I think we could save a lot of time, effort, and money if all health practitioners had a tick box to sign-off on all investigations and treatments  - Would they do it themselves?

So that's what I give you.  Things that I would do.  I understand what is practical and realistic.

Simple Explanations + Practical Solutions = Happy You!

Research Summary: Saw AE, et al. Br J Sports Med 2015;0:1–13. doi:10.1136/bjsports-2015-094758

Monitoring athletes' response to training is crucial for improving performance and avoiding injury.  

Elite level sport utilises an increasing number of ways to measure athlete well-being.  Batteries of tests are packaged into commercial products attracting premium fees.  This is justifiable if you are Sydney Swans or Liverpool FC, but where does that leave the rest of us?  Are we missing out if we're not testing cortisol levels to know if we are over-training?

A recent paper carried out a systematic review where objective measure, such as:

• blood markers - hormonal / inflammatory / immune response
• heart rate
• oxygen consumption
• ​heart rate response

were compared against subjective measures, such as:

• mood
• perceived stress

for their response to acute and chronic training loads.

The researchers concluded that the:

• Subjective measures responded well to training-induced changes in athlete well-being.
• Subjective well-being typically worsened with an acute increase in training load and with a chronic training load; and improved with an acute decrease in training load.
• Subjective measures for routine athlete monitoring are relatively cheap and simple to implement.
• Subjective measures are useful for athlete monitoring, and practitioners may employ them with confidence.

Netball Australia has developed a great program to help prevent knee and other lower limb injuries in netball.

Knee and ankle injuries are common in netball, making up three quarters of all injuries. Devastating ACL injuries are unfortunately common, making up 25% of serious injuries.

The KNEE program offers a range of warm-up exercises that help prevent injury.  There are a range of age and experience appropriate exercises for junior through to elite netballers.  They are easily understood by players and coaches, with a number of options offering variability and progression.

It would be great to see this program widely adopted by Australia's largest participation sport for females.

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.

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”).

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:

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:

[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

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: 

• 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

Hamstring injuries: prevention and treatment — an update (Peter Brukner, 2015)

TLDR Summary:

• The rate of hamstring injuries is as bad as it’s always been, and the recurrence rate remains high.
  
• Central tendon injuries and over-stretch style injuries (proximal semaimembranosous tendon) take longer to return to play than the more common sprinting style injury (long head of biceps femoris).
  
• Strengthening based rehab should be performed in a lengthened position.
  
• No evidence to support PRP injections for hamstring injury.
  
• Nordic curls are effective at preventing hamstring injury.
  
• The volume of muscle injured, as measured on MRI, does not predict the prognosis for the time taken to return to play (RTP).
  
• Self-predicted time to RTP is reasonably accurate.
  
• Biceps femoris injuries have a high recurrence rate.
  
• Eccentric hamstring strength is reduced even after RTP.
  

Recommendations:

• Early reduction of pain (to decrease muscle inhibition).
  
• Early muscle activation.
  
• Eccentric exercise at longer muscle lengths.
  
• Early return to running.
  
• Rapid progression to high-speed running.
  

Example Exercises:

• “Extender”
  
• “Diver”
  
• “Glider”
  
• Nordic curls
  

Ankle sprains are the most common sports injury.  

After an initial ankle sprain, athletes are prone to re-injury of the same ankle.  The risk of suffering an ankle sprain is doubled in the year following initial injury.

Common interventions aimed at preventing ankle sprains include taping, bracing, muscle strengthening, and balance training.  

Taping and bracing have shown to be effective prevention for ankle sprains, however disadvantages include hindering performance, loosening with activity, and skin irritation.

A 2015 systematic review and meta-analysis from La Trobe University has concluded that balance training programmes are effective at reducing the rate of ankle sprains in sporting participants, particularly those with a history of ankle sprains.

Approximately 17 sporting participants, or 13 participants with a history of ankle sprain need to undergo balance training in order to prevent one future ankle sprain.

http://www.jsams.org/article/S1440-2440(14)00074-7/fulltext

An essential part of diagnosing and treating sporting injuries is navigating a successful return to play.  If you're a footballer, this means your first game back.  If you're a runner it might mean returning to full training volumes.

It’s theoretically possible to return to play as soon as you’re able to stand up again, but obviously there’s a high chance of injury aggravation &/or recurrence. So, successful return to play isn’t just getting back on the field, but also doing our best to make sure:

• your performance is up to standard
  
• and the injury doesn’t happen again.
  

For a lot of injuries we can agree on a rough timeframe of recovery based on our previous experience with similar injuries, and a known pattern of tissue healing.  However, time alone is only a small component in determining successful return to play.

This article (Creighton, 2010) outlines the extensive range of other considerations for negotiating a successful return to play:

After assessing an injury I like to outline the milestones that are necessary to achieve a successful return to play.

Physical factors may include:

• Pain is tolerable
  
• Swelling / effusion has gone down
  
• Strength is similar to the other side
  
• Range of movement is similar to the other side
  

This guides our treatment & gives us goals to work on with rehab, which may include: 

• Stretches
  
• Strengthening
  
• Tissue healing
  
• Pain modulation
  

Functional milestones need to be achieved sequentially. You need to pass one level to get to the next. 

Roughly, this might look like:

• Walk without limping &/or pain
  
• Hop
  
• Jog
  
• Run
  
• Sprint
  
• Non-contact training
  
• Train with contact
  
• Play
  

Progression through each of these functional stages may include:

• Increasing volume
  
• Increasing intensity
  
• Introducing hills
• Second daily running
  
• Two days on, one day off
  
• Daily running

By the time we return to the playing field we have confidence in the injury because we’ve done the work.  Doing the rehab in a graded, progressive manner serves two purposes:

1). The exercise is conditioning, or “mechanotherapy”, to aid recovery.

2). It serves as a screening program, answering the question “am I OK to return to play?”.  

Doing the rehab gives us confidence that you’re OK to do “Z” because you’ve successfully completed “W”, “X”, & “Y”.

Here is a graded, progressive running program I like you to progress through before returning to training.

Here is a graded, progressive rehab programs for throwing & a similar rehab program for kicking.

Successful return to play isn’t just about getting back on the paddock.  

We know the biggest risk factor for any injury is a previous history of the same injury.  That means once you’ve had an injury, you’re at risk of re-injury.  

So successful return to play must include rehab aimed at preventing the same thing happening again.  This might include specific stretching, strengthening, taping, bracing, proprioception, or skills.  The job is only half done if you’re still at risk.