"What is your approach to painful achilles tendinopathy (or any body region)? What I'm really asking is you do you pay special attention to the tissue (more than you would in a nonspecific body pain)? Is Håkan Alfredson
way off base with his prescription of painful eccentrics? 12 weeks is an awfully long time to do a painful exercise. Curiously, I am yet to see a tendinopathy since I've gotten back into orthopedics 6 months ago.
Thanks in advance!"
Great question! I am a fan of the Alfredson study, the madness that got him there in the first place, and it has been validated by other studies in the long term. However, in The Eclectic Approach, we assume several things for most conditions
- up to 80% will be rapid responders
- screen the spine first with repeated motions as they are powerful modulators for conditions that seem like extremity dysfunction
- the 20% may respond slowly, or not at all
- true persistent pain states i.e. central sensitization, chronic whiplash - very slow or non responders
- you may improve function but not pain levels significantly
- true "issues in the tissues" like achilles tendinosis
- you will slowly improve motion/function, but may still modulate pain rapidly
The last bullet point is the most important for the Slow Responders. Eccentric loading is proven to remodel tissues in the long term, improve function and decrease pain. However, we still have our manual therapies to modulate this discomfort, and perhaps speed up the process due to decreasing perceived threat and stretch perception of the involved area. I have not come across studies that look at eccentric loading only, vs eccentric loading plus manual therapy, vs control group, but like many multimodal studies, it seems the more favorable inputs you combine, the better the outcome. That would be my hunch.
Remember, manual therapy is a cheat to get the patient moving and feeling better so they may self treat, whether that process is rapid or slow and steady, we can help the patient and reassure them along the way.
Keeping it Eclectic....