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Achilles tendinopathy: A prospective study on the effect of active rehabilitation and steroid inject

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Nov 5, 2014.

  1. NewsBot

    NewsBot The Admin that posts the news.


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    Achilles tendinopathy: A prospective study on the effect of active rehabilitation and steroid injections in a clinical setting
    E. Wetke, F. Johannsen and H. Langberg
    Scandinavian Journal of Medicine & Science in Sports; onine first
  2. Admin2

    Admin2 Administrator Staff Member

  3. Mart

    Mart Well-Known Member

    This is really interesting paper. It talks in detail regarding selection for corticosteroid injection, rigorous first line and then injection methodology.

    "GCS injections were considered indicated for patients who
    were unable to commence or progress training because of intolerable
    pain. Also, patients with crepitus or ultrasonographic bursitis
    or peritendinitis so severe that they were judged unable to perform
    exercises were offered GCS injection. As the study was not a
    randomized controlled intervention study, patients were allowed to
    decline injections and were given the same offer at following visits
    if the indication for injection persisted. Patients were offered up to
    three steroid injections with an interval of at least 4 weeks. The
    injections contained 1 mL of lidocaine 10 mg/mL, and 1 mL of
    40 mg/mL Depo-Medrol® (methylprednisolonacetate). The injections
    were placed guided by ultrasound peritendineously anterior
    to the tendon in Kagers triangle as close to the thickest part of the
    tendon, or in case of neovascularization, as close to the
    intratendinous vessel(s) as possible. Active rehabilitation was continued
    48 h after the injection. Patients were informed of possible
    side effects and at the following visit asked whether they had
    experienced any.
    Ultrasonography (US) was performed at all visits by the two
    experienced investigators. A Siemens Sonoline G-50 with a linear
    transducer VF 13-5 (5–13 Hz) was used (Siemens, Bavaria,
    Germany). US diagnostics were performed with the patient lying
    prone with the feet hanging free over the edge and the ankle at
    approximately 80 degrees relaxed dorsiflexion without tension to the
    tendon. The tendon was scanned longitudinally and transversally.
    The two investigators had beforehand agreed upon how to evaluate
    tenosynovitis on gray scale (thickening of hyper/hypo echoic
    paratenon with poorly defined boarders), tendinosis (hyper/hypo
    echoic areas within the tendon), bursitis (clearly visible bursa over
    2 mmin size), insertional tendinopathy (echo changes at the insertion
    and up to 10 mm above), color Doppler was used to measure the
    presence of flowwithin the tendon or peritendon.We used the factory
    setting with pulse repetition frequency on 780 Hz. At an asymptomatic
    area of the gastrocnemius part of the tendon the Doppler was
    calibrated to zero pixels. Peritendinous and intratendinous flows
    were registered as clearly visible color Doppler signal just as visible
    arteries with pulsation within the paratenon and tendon were registered.
    Tenosynovitis could therefore be diagnosed either on gray
    scale and/or with color Doppler. Despite the term “itis”, this is not
    necessarily inflammation, just as increased flow within the tendon is
    not necessarily inflammation. As mentioned, AT covers several different
    pathologies including tenosynovitis and bursitis, conditions
    very common in all patients with AT, as we have described in a
    previous study (Johannsen & Gam, 2010)."

    anyone else doing this clinically and if so what anecdotal outcomes - any ruptures?



    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
  4. Corticosteroid injections around the Achilles tendon, in my opinion, are simply too risky to warrant recommending them. In addition, if the patient did develop an Achilles tendon rupture after your corticosteroid injection, here in Northern California at least, you could probably not successfully defend any malpractice case that was brought against you.

    I've attached a little more reading for all those interested.
  5. Mart

    Mart Well-Known Member

    Hi Kevin

    I understand your medico-legal concerns and why you may not want to consider tendocalcaneus corticosteroid injection within your jurisdiction .......... but

    The paper you cited stated

    "What sort of studies are necessary for a better
    comprehension of the subject? First, the difference
    between a peritendinous and an intratendinous
    corticosteroid injection should be precisely defined".

    That is a big problem with the type of evidence which has caused the concerns regarding unintended rupture.

    It is clear within Mahler's paper that most of the evidence for risk is low quality, and on that basis the assumption which dictates your medico-legal concerns is largely speculative and therefore remains questionable.

    E. Wetke et al reported no ruptures in their study group which comprised 113 consecutive patients. The methodology both for selection based on sound, well defined sonographic criteria, rigor of using eccentric loading to eliminate unnecessary injection and precision of guided injection within targeting zones within Kager fat I believe is unprecedented.

    Hence my enthusiasm for this paper.

    I believe that it may become an important landmark in opinion on this subject - which as we know within podiatry is a very difficult and important one.



    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
  6. Mart

    Mart Well-Known Member

    Just wanted to flesh my last post out a bit.

    Kevin cited Mahler's paper which I believe has been extremely influential because as clinicians we should rightly be cautious not to harm our patients.

    I believe that if if the study which E. Wetke et al have just published had been done Mahler would have been very influenced by it - he hinted at this many times in his paper

    here's where

    The comparison of two groups, one receiving an intratendinous injection of corticosteroid, the other a peritendinous injection, showed that 100% of the group with the intratendinous injection had localized tendon necrosis at the site of the injection. On the other hand, the peritendinous injection group showed an intact structure in 95% of cases

    Phelps, in his study on the tensile strength of the patellar tendon of rabbits after multiple injections of methylprednisolone, found no alterations in the mechanical properties of the tendons injected with corticosteroids". He concluded that tendon rupture in athletes could stem from some underlying pathological process and not to a destructive process initiated by the steroid injection.

    The results showed that a single intraligament injection substantially decreased the tensile strength (between 27 and 39%) up to 52 weeks after the injection. Histological examination showed death and absence of fibrocytes. In the group which received an intra-articular injection, there were no significant changes in tensile strength or histology.

    In the light of these studies tending to show the absence of any deleterious effect of peritendinous injections, how can one explain the reigning controversy as to whether or not peritendinous injections enfeeble the tendon.

    In the light of these studies, it does not seem reasonable to condemn peritendinous injections by invoking a direct deleterious effect on the tendon itself.

    Concerning the possible influence of local injections of corticosteroids on the incidence of ruptures, there is to date no longitudinal study.

    Animal research has shown that intratendinous corticosteroid injections result in collagen necrosis, followed by a decrease in tensile strength. On the other hand, the majority of studies dealing with peritendinous corticosteroid injections are unable to show any direct deleterious effect to the tendon.

    Despite this difference, all the retrospective clinical studies in humans dealing with corticosteroid injections and TA ruptures never attempt to differentiate between these two fundamentally different types of injections.

    This having been said, one might ask if it is really so easy to distinguish between an intratendinous and a peritendinous injection. Theoretically, the resistance to the injection of the product in an intratendinous injection is said to be much greater than in a purely peritendinous injection. Practically, the distinction might not be that obvious. Furthermore, in the presence of a tendinosis or a partial rupture, it is most probable that the resistance to the injection is altered, thereby giving a false impression as to the exact location of the injection.

    It is rare that any distinction is made between the different categories of TA pathology.

    Another important fact that has led to the controversy on corticosteroid injections and TA ruptures is improper diagnosis. As cited before, it is astounding to note that in Shields' study on complete ruptures of the TA, 25% of the patients were given corticosteroid injections after the acute rupture

    It is only through the selection of rigorously homogeneous groups that one will be able to accomplish the prospective studies necessary to elucidate the fundamental questions remaining unanswered.

    What sort of studies are necessary for a better comprehension of the subject? First, the difference between a peritendinous and an intratendinous corticosteroid injection should be precisely defined.

    This is why one is generally obliged to conduct retrospective studies on non-homogenous groups, which unfortunately makes a precise analysis difficult.

    that is why I find this new study by E. Wetke et al a ground breaker.



    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
  7. I asked this question to the orthopedic surgeon I have now been practicing with for the past 28 years. He said he might consider giving a cortisone injection around the Achilles tendon, but also said if a patient had an Achilles tendon rupture within a year of his injection, and the patient sued him for malpractice, he would likely lose the case.

    In other words, we both agreed that it simply isn't worth it here in Northern California where the standard of care is to not inject cortisone in or directly around the Achilles tendon.
  8. Mart

    Mart Well-Known Member

    thanks Kevin

    I am curious how standard of care is regulated by your licencing board and how they evaluate then re-evaluate standards such as this as evidence changes with time. Any insight into that?



    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
  9. The standard of care of medical practice is not regulated by licensing boards, but, rather, is determined by what the standard, accepted medical practices are within any medical community. These vary from one medical profession to another medical profession (i.e. podiatry vs orthopedic surgery) and from community to community. That is why I am only speaking for Northern California when I state that it is standard medical practice to not inject cortisone around the Achilles tendon here, in our medical community, due to risk of Achilles tendon rupture.
  10. Mart

    Mart Well-Known Member

    Thanks Kevin

    The reason I am interested in this is because I am involved in developing standards of care and curious about how his is done elsewhere.

    When you talk about accepted standards within local communities how are they established and how and where are they defined? I am interested to here from others reading this thread too. What I am beginning to belelive is that it is possible that standards of care may be largely a function of legal precident in malpractice suits. That seems possible but unlikely. If it is true then that is problematic because it implies that standards might have difficulty changinging in step with the prevailing scientific evidence.

    Thoughts on that appreciated

    cheers Martin
    Send from my Iphone
  11. musmed

    musmed Active Member

    Dear Team
    Finally sunny weather and beautiful down the south coast.
    in the hills of Tasmania last week minus 7C and snow.

    Steroids are not used out load but I have heard of it being used in cases of Achilles problems.

    has anyone tried The antibiotic vibramycin?
    it stops the production of VEFG= vessel endothelial growth factor

    Vibramycin plays a major role in rapid rehab of this condition. I use it along with cross fibre friction using an eraser with a 45 degree slope so then can get at the specific tender points.

    In combination, year long plus problems can be gone in 6-8 weeks with full time resumption of training.

    to all from sunny south coast of New south Wales

    Paul Conneely.
  12. Mart

    Mart Well-Known Member

    Hi Paul

    Can you point us to information which you feel substantiates your belief?

    cheers Martin Send from my Iphone
  13. musmed

    musmed Active Member

    Dear Martin
    I was in NZ in 2006 for a conference and the local achilles guru who was mad keen on prolotherapy said when he could not get his recalcitrant people to get better this is what he did. I have used it since.
    I cannot remember his name but I am sure you will find him on Dr. Google
    He lived in Christchurch then ? moved

    The name Rycroft, rylcroft, Lycroft or similar is ringing a few distant cranial bells!

    the other thing is to put them on 5000IU Vit D3 a day.

    currently i have 3 people on this and on monday there will be another

    Paul conneely
  14. Craig Payne

    Craig Payne Moderator

    Charlie Baycroft ?
  15. Mart

    Mart Well-Known Member

    Hi Paul

    How do you approach the idea of noise and probability when you evaluate your perception of reality ?

    Just curious about how you perceive the effect you believe your actions have?
  16. musmed

    musmed Active Member

    Dear Mart
    I don't have perception of reality
    I just ask the athletes what it is like to be back running after an absence that cost them a trip to the Olympics etc.
    After 43 years looking at sporting injuries of all kinds and i mean all kinds I don't have any worries unlike others.
    The only noise I hear is noise of silence about their problem.

    I am not going into noise and probability. I have a degree that dealt with all these great calculations. Basically academia and reality often miss

    paul conneely
    beautiful sunset. Do I need reality or perception here?
    (i have only experienced 365X66 plus a few) rough idea...........
  17. Mart

    Mart Well-Known Member

    Interesting any interest in creating a thread on those ideas?

    cheers Martin Send from my Iphone
  18. Ian Drakard

    Ian Drakard Active Member

    I think vibramycin is the same as doxacycline? I am always wary of this as one of the worst case of bilateral tendinopathy I've seen was in someone on long term doxacycline. There is some evidence in rats for effect on MMPS- see attached

    This may of course been completely coincidental, or there may be a difference in short and long term use.

    Attached Files:

  19. Mart

    Mart Well-Known Member

    Hi Ian

    Agreed adverse effect of tetracyclines seem well documented ::good:

    This correspondence speaks to that

    Letter to the Editor

    Tendinopathy and drugs—Potential implications for beneficial and detrimental effects on painful tendons
    Karsten Knobloch

    Dear editor,

    I read with great interest the recent opinion piece by Dr. Fallon and coworkers.1 I would appreciate to comment on some of the issues raised by the authors.

    The authors proposed to use ibuprofen (400 mg tds) and doxycycline (100 mg daily) over 14–28 days. Taken into account the very slow tendon metabolism with tendon division by week 8, one is tempted to speculate that a 4-week medication does not necessarily effect the tendon metabolism at all. In my personal view a longer and sustained medication might influence the matrix metalloproteinases such as doxycycline over a period of 3–6 months.

    Taking into account the beneficial effects of topical transdermal nitric oxide (NO) the randomised-controlled trials found a beneficial effect against placebo as early as 8 weeks after the start of the study. The recent three 3-year follow-up found encouraging results with treatment over 6 months daily.2

    Currently, the use of non-steroidal anti-inflammatory drugs (NSAID) is not unquestionable. The recommended ibuprofen has been found to inhibit Achilles tendon cell migration both ex vivo and in vitro.3 Similar inhibition was also observed on the spreading of tendon cells. Suppression of mRNA expression and protein level of paxillin was revealed by RT-PCR and Western blot analyses.

    Regarding the proposed doxycycline application in Achilles tendinopathy, a recent study in rat with doxycycline-coated sutures found an improved suture-holding capacity as measured by higher energy uptake than in untreated tendons.4 Force at failure showed a trend towards improvement. However, currently prospective randomised-controlled trials in humans are needed to show whether doxycycline has a place in acute tendon therapy.

    In addition to the opinion piece presented, I would further strengthen the awareness among sportsmen and trainers of both, potential beneficial drugs as the aforementioned ones, as well as potentials deteriorating drugs in the athlete. Quinolone antibiotics have to be avoided in athletes suffering tendon pain. Furthermore, low molecular weight heparin has been reported recently to impair Achilles tendon repair in rats.5 Caution should be applied amongst athletes following organ transplantation, such as kidney transplantation. Cyclosporine, cortisone and rapamycine might have a detrimental effect on the tendon of the transplanted athlete.

    In conclusion, I would like to thank the authors for their stimulating work.

    K. Fallon, C. Purdam, J. Cook, G. Lovell
    A “polypill” for acute tendon pain in athletes with tendinopathy?
    J Sci Med Sport, 11 (2008), pp. 235–238

    Article | PDF (92 K) | View Record in Scopus | Citing articles (7)
    J.A. Paoloni, G.A. Murrell
    Three-year follow-up study of topical glycerly trinitrate treatment of chronic noninsertional Achilles tendinopathy
    Foot Ankle Int, 28 (2007), pp. 1064–1068

    View Record in Scopus | Full Text via CrossRef | Citing articles (48)
    W.C. Tsai, C.C. Hsu, C.P. Chen, M.J. Chen, M.S. Lin, J.H. Pang
    Ibuprofen inhibition of tendon cell migration and down-regulation of paxillin expression
    J Orthop Res, 24 (2006), pp. 551–558

    View Record in Scopus | Full Text via CrossRef | Citing articles (16)
    B. Pasternak, A. Missios, A. Askendal, P. Tengvall, P. Aspenberg
    Doxycycline-coated sutures improve the suture-holding capacity of the rat Achilles tendon
    Acta Orthop, 7 (2007), pp. 680–686

    View Record in Scopus | Full Text via CrossRef | Citing articles (10)
    O. Virchenko, P. Aspenberg, T.L. Lindahl
    Low molecular weight heparin impairs tendon repair
    J Bone Joint Surg Br, 90 (2008), pp. 388–392

    View Record in Scopus | Full Text via CrossRef | Citing articles (4)
    Copyright © 2008 Sports Medicine Australia. Published by Elsevier Ltd All rights reserved.


    Some limitations of this study include the use and
    translation of our findings from a rat model to clinical
    human situation. In this study, administration of doxy
    began one day prior to tendon transection to ensure
    that serum levels of doxy would be clinically relevant at
    the time of surgery. While prophylactic doxy administration
    for tendon injury prevention is an unlikely
    mode of administration, patients may potentially receive
    the medication after sustaining a tear injury, but
    prior to surgical repair. The current study also surgically
    created a “clean cut” tendon transection using a
    scalpel, whereas clinical Achilles tendon ruptures are
    typically traumatic with shredding or “mop ends”
    morphology, and does not yield the same clean tear
    that was used in this study. It is unknown if a more
    severe clinical injury would benefit from doxy administration
    to the same level as in our induced injury model.
    In addition, the current study demonstrates observable
    benefits of doxy treatment on the biomechanics of
    Achilles tendon at a single early time point during the
    healing response. Future studies will investigate the
    effects of MMP inhibition at longer time points to
    ascertain if the observed benefits are sustained.
    In summary, our findings indicate that treatment
    with oral doxy can provide a therapeutically relevant
    serum concentration and inhibits the increases in
    MMP-8 activity associated with Achilles tendon transection.
    Extended delivery of doxy resulted in improved
    tendon structure and biomechanical properties
    when compared to no doxy or limited duration treatment.
    These findings suggest that MMP inhibitors
    may be optimized for ameliorating development of
    fibrosis and improve the quality of repair after Achilles
    tendon ruptures

    Enhancement of Achilles tendon repair mediated by matrix metalloproteinase inhibition via systemic administration of doxycycline.
    Kessler MW, Barr J, Greenwald R, Lane LB, Dines JS, Dines DM, Drakos MC, Grande DA, Chahine NO.
    J Orthop Res. 2014 Apr;32(4):500-6. doi: 10.1002/jor.22564. Epub 2013 Dec 18.
    PMID: 24346815 [PubMed - indexed for MEDLINE]
    Related citations



    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
  20. Finn Johannsen

    Finn Johannsen Welcome New Poster

    Thank you for your interest in our study on achilles tendinopati. In Denmark Glucocorticoid injections (GC) are included as an optional treatment in the clinical guidelines for the treatment of achilles tendinopati.
    I think it is very important, never to use GC as a monotherapy. The treatment remains reduced activities and slowly progressive training, which has shown significant effect in many efficacy studies. However if this is not possible due to pain, I use GC to be able to continue the planned training. Compliance are important, and I explain very thorough my patients to follow the rehabilitation programme and not to jump to more violent exercises, as the tendon might be weakened for the Next month after the injection. But the catabolic effect of GC is far less than the anabolic effect of the controlled rehabilitation programme.
    I have injected more than thousand achilles tendons ultrasound guided and never induced an achilles tendon rupture.
    kind regards Finn Johannsen, MD
  21. Finn:

    Thanks for coming on here to explain your results with glucocorticoid injections. What would be a typical injection that you do for the Achilles tendon? How much and what type of cortisone do you inject and do you include local anesthetic and what type and what volume into the injection? Also, do you know if your standard of practice in Denmark is being used here in the United States? From my own experience (30 years) there are very few orthopedic surgeons who inject the Achilles tendon with glucocorticoid here in the United States.
  22. Finn Johannsen

    Finn Johannsen Welcome New Poster

    hi Kevin
    I use 1 ml Xylocain 1% and 1 ml Depomedrol (methylprednisolon 40 mg/ml).
    I have no idea in how far glucocorticoid injections are used in achilles tendinopati in USA, but Glucocorticosteroid has been miscredited in many countries due to case stories on tendon ruptures and animal studies showing deleterious effect. I think these ruptures are mainly due to the weaknes of the tendon due to the injury, and not due to the injection. BUT if you inject without controlled activity reduction, the injection will camouflate the pain, giving the patient the false impression that the injury is cured, and thereby propably too vigorous sports activities leading to increased risc of tendon rupture.
    kind regards Finn Johannsen, MD
  23. Finn:

    Thanks for that information. The steroid cocktail you use is very similar to what myself and the orthopedic surgeon I have worked with for the past 30 years use on a daily basis for other tendon/ligament injections. However, here in the USA, we do have lots of attorneys who would very much like to sue any doctor that injected around the Achilles tendon and "caused" and Achilles tendon rupture.

    If you had a patient of yours that did develop an Achilles tendon rupture within a year of your injection, do you think, in Denmark, you would be able to defend yourself adequately from any potential malpractice suit? Whether you know it or not, the public and attorneys in the United States are very "malpractice-happy" and am wondering if things are better for physicians in Denmark than in the United States.

    Thanks again for coming on to Podiatry Arena and enlightening us further about your research. I really like it.:drinks
  24. Mart

    Mart Well-Known Member

    Hi Finn

    Thanks for responding to my email; your emphasis on pain control to permit physical rehab was missing from the thread.



    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
  25. Finn Johannsen

    Finn Johannsen Welcome New Poster

    In Denmark we have a common Governmental Insurance, where patients can get compensation for side effects. Even if these side effects are known. Per example will an infection after injection could lead to compensation, but if the doctor had followed the aseptic procedure, he has done no malpractice ! The important thing is to inform the patients about the side effects before a procedure. I am not aware of any compensation for tendon rupture after injection. The doctor is not paying the compensation, this is done by the common Insurance, but if he has done malpractice he might come unter supervision by other Experts.
    In Denmark Glucocorticosteroid injection is included in the guidelines for treatment of achilles tendinopati (I wrote the guidelines, which was accepted by a specialist society), and an achilles rupture within a year after an injection is not malpractice. Luckily in Denmark it is the Experts (doctors) that define malpractice, not the attorneys.
    kind regards Finn Johannsen
  26. Sounds very reasonable to me compared to what we have in the USA. Do you need any good podiatrists in Denmark?!;)

    Here in the USA, a patient doesn't need to pay anything to sue a doctor and a patient doesn't even have to have had an injury that was caused by a doctor's negligence. All a patient needs to do to win a malpractice suit against a doctor is to show that the doctor acted out of the "standard of care for the medical community" (which can vary from one community to the next) and get another doctor to testify in court (who is handsomely paid by the plaintiff attorney and will often lie in court to win "their" case) that the doctor being sued was negligent in their treatment or decision-making process.

    Therefore, even though your protocol sounds safe to me, Finn, if I were to have one of my patients develop an Achilles tendon rupture after a corticosteroid injection using your exact same technique here in California, even though I followed your exact same protocol, I could likely be sued and lose a very, very expensive lawsuit just because your technique is not accepted here in California as the "standard of care for the medical community". This threat of malpractice suits is something that drastically changes the way we practice and drives up the cost of healthcare for all individuals.

    Denmark sounds like a much more reasonable place to practice medicine. Thanks again for your contributions, Finn.....maybe, someday, your work will be accepted as the standard of care here in California.:drinks
  27. Mart

    Mart Well-Known Member

    Many thanks Finn. Would you be able to share the guidelines you developed with those reading this thread ? That would be very helpful for me because I am planning to submit a similar document to our regulatory body for consideration.

    I an curious regarding perception within the orthopedic community where you practice regarding importance of sonography generally and tendo-calcaneus injections specifically both in terms of improving specificity within differential diagnosis and needle placement for drug delivery. Is sonography mentioned within guidelines and do orthopedic surgeons use sonography as an extension of their physical exam in daily MSK practice? :drinks



    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
  28. gingerphysio

    gingerphysio Member

    Throughout my career I have dealt with many thousands of those suffering chronic achilles pain. The majority of which responded immediately to manual therapy treatments at L5S1. By which I mean, effort to reduce and eliminate lumbar spinal protective behaviour. The benefits are usually immediate, incremental over one to three treatments and full resolution expected in that time frame. It does occur to me that many seeking answers at the site of pain and swelling may not realise the strong likelihood of referred neuralgic events as the primary factor.
    I prefer to describe achilles pain for this reason as sciatica, unless proven otherwise.
  29. Mart

    Mart Well-Known Member

    Interesting anecdote......... for those you helped, would you expect a peritendinous injection of lidocaine to have any effect on their pain?

    Cheers Martin
  30. gingerphysio

    gingerphysio Member

    Hello Martin, indeed, temporary pain relief by injections of various substances can often relieve the pain and sometimes the swelling associated with events caused by nerve root and other nerve irritations proximaly. Many wasted therapeutic moments have gone into that. By this relief many will erroneously assign cause to the distal element, and negate the proximal, a common error.
  31. Mart

    Mart Well-Known Member

    Thanks please could you point me towards evidence and if possible mechanism to support that idea. Cheers Martin
  32. gingerphysio

    gingerphysio Member

    Sorry Martin, I have a busy clinical schedule, only moments to post from time to time. day off tomorrow however, I'll endeavour to flesh out( sorry ) the neurophysiology . Starting point for any protocol about investigating a painful structure though, must always be, proximal first. Nerves are involved in every event, irritations to large nerves a common contributor to and/or the final arbiter of resolution.
  33. gingerphysio

    gingerphysio Member

    as briefly listed elsewhere the four changes associated with proximal nerve root irritation are
    #altered sensation; hypersensitivity to stretch, touch, pressure etc
    # altered patterns of recruitment ; tight calves, hamstrings, occasions of spasm in muscles ( cramps)
    # pain
    # autonomic change ; fluid build up, redness
    referred events present and feel exactly the same as local events in most cases.
    They also present commonly with no pain felt proximaly. ie in the case of sciatica, no LBP may be described.
    Injections to, treatments of, manual handling of, taping of, electrotherapies to the site of pain etc will often bring about reductions of symptoms in the short term, rarely resolving, often altering the site of pain etc but no satisfactory resolution is gained.
    This is the case for many who attempt local treatments of the achilles, foot, ankle,shin, knee etc, when a more thorough examination and treatment of the lumbar spine will quickly resolve the issue. I spend my clinical life doing just this.
    Conversations with Podiatrists are sometimes very awkward as the situation requires, in most cases, a willingness to relinquish the patient to a properly skilled Physiotherapist for manual therapy to the spine.
    It must be also said that the prospect of appropriate treatment in the hands of medical practitioners is close to nil, as they very rarely use manual therapies.
    Not all Physios are trained in the effective mobilisation of and restoration of normal mobility to spinal joints, wish that were the case. Sometimes you just get lucky.
  34. Mart

    Mart Well-Known Member

    Thanks for your reply. I have no problem understanding radicular pathology manifesting as foot or ankle pain according to nerve root, however I do not understand why you believe that blocking nociception at tendocalcaneus would eliminate radicular mediated retrocalcaneal pain. Am I misunderstanding you? I have never seen isolated retrocalcaneal pain which I could plausibly attribute to radiculopathy. Cheers Martin
  35. Ian Drakard

    Ian Drakard Active Member

    Remember browsing a physio forum a little while back- nearly every thread had a particular poster advocating spinal treatment for every single condition. It wasn't you was it?

    Not saying proximal issues aren't involved and indeed missed......... just always a bit wary of a sweeping statement
  36. gingerphysio

    gingerphysio Member

    blocking noceptive input will temporarily inhibit and/or change the pain image created in the brain, as perceived in any structure As will compression, tape, manual handling etc. Surgery will do this too. It is routine to find those whose symptoms have been altered in this way, to then discover and effectively eliminate spinal cause, thus eliminating the perceived pain and other neural symptoms.
  37. Mart

    Mart Well-Known Member

    What I do not understand is how you think that pain with a radicular origin could cause isolated retrocalcaneal pain which is completely eliminated by blocking tendocalcaneus nociceptors. Thanks for your help. Cheers Martin
  38. gingerphysio

    gingerphysio Member

    Not every local pain /swelling problem is a referred event. ( obvious , but just for the record).
    When a persistent distal pain/swelling event resists local treatment ( plantar, achilles, heel, calf etc) a thorough exam will very likely find proximal factors involved in the cause and/or the effect of the symptoms. Eliminating these spinal proximal events is rather straightforward with appropriate manual therapy. When I do this, the types of problems immediately and permanently resolved include those previously diagnosed as " achilles tendinosis" "paratenonosis" and plantar fasciitis". Very few fail to resolve in this way.
    Referred events are commonly misunderstood and mistreated .
    I haven't the time or inclination to present rheams of documentation to support these claims, as I am not an academic, rather, a busy clinician interested in outcomes. Do with it what you may.
  39. Mart

    Mart Well-Known Member

    Thanks again. Perhaps we see very different population segments, I rarely see radicular pathology manefesting as isolated retrocalcaneal pain it seems you pretty much exclusively see that.

    If anyone else is reading this who has not come across Peter Malliaras blog it is worth checking out, he is a very convincing commentator on tendon issues.

    You can start at good critical look at value of therapeutic value of tendon loading


    Cheers Martin
  40. gingerphysio

    gingerphysio Member

    The only way to be certain wether any presentation is radicular or not is to treat it ( at the spine ) first. If there are immediate symptom changes , the direction for further attention proximaly is set. Continued proximal treatment that incrementaly relieves and ultimately resolves the distal symptoms proves the cause effect question. Thinking ( guessing ) it may or may not be radicular will be wrong most of the time.

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