Chiropractic Paradigm Shift: Reducing Compression in Tendinopathy

The pathogenesis of tendinopathy is well-defined.  Regardless of location, the progression of tendinitis to tendinopathy (and eventually tearing) is fairly uniform in all tendons.  As evidence-based chiropractors, we are uniquely positioned to help these patients regardless of their point along this continuum. Tendinopathies require a multimodal approach - heavy in rehabilitation and patient education. This blog will discuss why treatment timing and preventing re-injury are so crucial in this patient population.

Watch Dr. Steele describe how he initially treats tendinopathy patients.

Chiropractors typically become very proficient at specific techniques and treatments.  These treatments are often the PASSIVE tools responsible for restoring motion, relieving pain, and calming down inflamed tissue.  Most evidence-based chiropractors also incorporate ACTIVE procedures (rehabilitation and ADL modification) into their protocols since most musculoskeletal conditions require a multimodal approach.

However, the timing of when to apply each mode of care can be confusing for both the patient and practitioner. Tendinopathies need both active and passive treatment for full recovery.  Patient healing and long-term satisfaction are dependent on our understanding of the etiology of tendinopathies and rely on current chiropractic research to navigate the best rehabilitation for these patients.

First, let’s examine the etiology

The pathomechanics underlying the development of tendinopathy are similar throughout the body. The combination of increased overload, decreased load shielding, and tendon compression (mostly at or near the bony insertion) lead to injury. However, recent literature suggests that the combination of tensile and compressive overload appears to be particularly damaging.  Without intervention, repetitively stressed tissue will continue to degenerate with reduced tensile load–bearing capacity. As this process continues to progress; the tendon is predisposed to tearing at relatively lower and lower tensile loads. (2)

Proper treatment of a tendinopathy requires two phases:

• Remove irritants and calm down pain (and inflammation, if present).

• Stimulate regeneration and enhance capacity.

The FIRST step in the treatment of a patient with acute tendinopathy is to reduce pain, inflammation, and undesired stress.

Often, inflammatory pain is due to a repetitive activity that directly overloads a specific tissue.  For example, the gluteus medius is a commonly injured tissue - resulting in lateral hip pain.  The tendon of the gluteus medius is subject to tensile and compressive forces that may exceed its capacity.  As activity continues without proper rest or recovery, the tissue can be injured. Muscles may become hypertonic as a protective mechanism, and compensatory movement patterns may develop secondary to pain.  The result is that muscles overlying the damage protectively contract, but hinder recovery - since added compression impedes blood flow and lymphatic drainage.

In the hip example, increased compression of the distal portion of the gluteus medius and minimus tendons occurs against the bone into which they insert—the greater trochanter. Compression is further amplified by the overlying iliotibial band, particularly during sustained hip adduction (2).  Here’s one common way this happens for 6-8 hours each night:

The same scenario happens in the shoulder with rotator cuff impingement.  Impingement occurs not only through repetitive movement stress but also due to static sleeping positions or workstation postures.

Calming down irritated tissue

The first step of successfully treating tendinopathy is to provide pain relief.  Clinicians must employ a variety of best practice treatments to successfully reduce pain and inflammation.

“As with other pain conditions, effective treatment of any tendinopathy relies on the clinician making the correct diagnosis; understanding the etiology and pathology; recognizing, understanding, and addressing the modifiable risk factors and comorbidities; identifying and evaluating the contribution of biomechanical deficiencies and likewise pain; and then prescribing, modifying, and progressing the most appropriate interventions, based on clinical reasoning and changes in the condition over time.” (3)

One crucial step in the reduction of pain is to identify and modify activities, postures, or positions that generate tensile or compressive forces and delay recovery.  Clinicians and patients must seek to minimize compression of injured tissue through ADL modification. In the case of greater trochanteric pain syndrome, counseling on sleep positions is essential.

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• References

  1. Almekinders LC, Weinhold PS, Maffulli N. Compression etiology in tendinopathy. Clin Sports Med. 2003;22:703-710. http://dx.doi. org/10.1016/S0278-5919(03)00067-X

  2. Birnbaum K, Pandorf T. Finite element model of the proximal femur under consideration of the hip centralizing forces of the iliotibial tract. Clin Biomech (Bristol, Avon). 2011;26:58-64. http:// dx.doi.org/10.1016/j.clinbiomech.2010.09.005

  3. Grimaldi A, Fearon A. Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management J Orthop Sports Phys Ther 2015;45(11):910-922. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5829