Welcome to tendinopathy rehab blog 43 (subscribe here). Sorry for the delay this week, just returned from teaching in europe, visit to FC Barcelona and conference in Monaco. Good to be back with family now.
The Mastering Lower Limb tendinopathy course in Sydney is full, still places for Melbourne, Perth Canberra and Adelaide.
This week is a brief commentary on compression and tendinopathy. Bullock et al. just published this study where they investigate evidence for compression of the Achilles tendon with MRI. Very interesting, and a good opportunity to review current thinking around compression and tendinopathy.
Achilles Impingement Tendinopathy on Magnetic Resonance Imaging
Background: the authors Bullock et al. 2017 focus on Haglund’s syndrome and define it as a ‘bony prominence of the superior aspect of the calcaneal tuberosity’ associated with and bursal / tendon pathology. They suggest it is a common cause of insertional Achilles or posterior heel pain. The term the authors use is Achilles impingement tendinopathy. The main aim was to describe the pathology and demographics of Achilles impingement tendinopathy, to determine whether the Haglund’s bump is also present in controls, to compare the Halglunds deformity position with the site of insertional pathology.
What they did: They reviewed ankle MRI scans between 2008 and 2014 among people 15-99 years old. Impingement tendinopathy was defined as being within 4mm from the superior calcaneum with pathology close to the anterior border of the tendon (otherwise they just called it insertional tendinopathy without impingement). The tendon insertion was divided into 5 equal parts from lateral to medial and in this way the authors determined whether the site of the Haglund deformity corresponded with the site of the pathology. They identified superior projections, as well as posterior protruding eminence or exostosis or posterior calcaneal hyperconvex pathologies, all within the banner of Haglund’s deformity. They included a control group of people having an MRi for suspected tibialis posterior pain.
What they found: 59 MRI scans were included. There were high grade tears/ruptures in 19 and insertional tendinopathy in 40 (67.5% impingement, 12.5% not impingement related, based on their definitions). I am going to focus on the pathological findings rather than demographics. Impingement lesions were less common laterally than medially. It was common to see bone marrow oedema and bursa pathology along with the tendon pathology.
Hypervonvexity or posterior prominence was more associated with pathology than was a superior projection of the calcaneal tuberosity. They report that superior projections were equally common in controls (they had n=32 controls) and people with insertional Achilles pain, but strangely do not report whether this was also true for posterior calcaneal protrusions and hyperconvexities. High grade tears/ruptures were on average 6.48 cm +/- 0.30 above the calcaneum whereas the insertional pathology was on average 4.65 +/- 0.32 cm above the insertion.
Clinical interpretation: On a positive note, the authors show that insertional pathology often involves multiple tissues including tendon but also bone and bursa. This is useful to know. Reassuringly for clinicians, the rehab interventions for these complex mix of pathology is the same. You can argue that other treatments like injections may vary but often you don’t (and you can argue should not) need to go there.
The authors big point of the authors is that you can see a correlation between the bony pathology and tendon pathology that is related to impingement/compression. The issue with this is inherent bias in looking for areas of bony and tendon pathology to ‘match’, and also issues with sensitivity and accuracy of MRI. Not to mention that the authors themselves found similar deformities, at least in terms of superior projections, but no pain in controls. Of course, there are many factors that can explain this (e.g. different loading patterns), but I think everyone would agree that just having a Haglund’s bump does not mean you are doomed and will have pain.
The authors go on to argue that insertional Achilles tendinopathy does not respond well to conservative treatment and their findings support bony resection as a possible treatment. This can be a dangerous view. If a surgeon told a patient that I bet it would have an impact on their outcome.
So I guess the key messages to take away is, as we know, bony pathology does not equate to pain, and we need to be careful not to scare our patients.
Last take home point is now translating this to a rehab context. Should we be pushing people into compression/impingement when we do tendinopathy rehab? And should we be allowing people to stretch? My view on this is pretty relaxed, here is a summary:
1) Re-establishing load tolerance into compression is often important. This is not to say you need to smash them with heavy load into end range, but you may do some loading into a range that is compressive, especially if they are not load tolerant here and need this range for function. Who doesn’t need a bit of dorsiflexion? So, I don’t think it is a matter of avoiding compression, it is a more a matter of introducing when possible with load tolerance. There is also double standards at times with a more acceptance of some loading into flexion (compression) for a hamstring, but absolutely no loading into hip adduction (compression) for a gluteal tendinopathy. Why the difference in standards?
Important point: I am not aware of any evidence linking slow rehab load (whether into compression or not, and regardless of how heavy, I call these SLOW + HEAVY LOADS) with tendon pathology. Pathology most likely relates to repetitive running, jumping, walking (I call these FAST+HEAVY LOADS). This is an important distinction in tendinopathy.
2) A little stretching is ok, as long as, again they are load tolerant. We do not need to tell people to necessarily stop stretching, unless it is really painful or provocative (and this would be for a short amount of time until symptoms settled). Of course, doing no other rehab but just stretching is not advised, and if someone is stretching for hours a day then we should educate them to reduce. Then again I am reminded of my patient the Australian pole dancing champion who stretches her hamstrings 30+ minutes per day and she has a hamstring origin tendon issue – we were able to reintroduce this at the right time without an issue.
3) A good reason to have a relaxed attitude about some compression and stretching is that a) we can afford to me (a little will not matter if bought in at the right time); and b) more important, if we are very strict on messages like…YOU MUST NOT STRETCH…patients develop a very fragile and weak impression of their body. Messages like that, and more importantly the feelings they evoke, are hard to undo.
See you next time
Clinical gems and tendinopathy management model for busy clinicians. Your tendinopathy patients will love you for it!