Isometrics and Tendinopathy editorial

[Eric Magrum]

Have a read – discuss newer evidence, and clinical decision making.

When to apply based on critical review of the reserach as recent evidence gets published.

Happy Monday

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[jeffpeckins]

Interesting article. In my experience, I have had a lot of success with using isometrics for acute pain relief, especially within session. I have seen this in a variety of muscles and joints. My typical implementation is using them in the painful region of AROM – so for instance if someone has pain with shoulder ABD at 70 deg, I will have them hold the isometric either right before or at the painful ROM. This way I am targeting the muscle where it is most aggravated for acute pain relief. Then I re-check and see if the pain in the painful ROM has decreased, if so I progress to AROM exercise.

In addition, I am more apt to use an isometric if AROM in painful, and the pain increases with increased reps of the movement. In previous tendinopathy articles, they tend to use a “no more than 3/10” approach, so if a patient’s pain is above this or increases quickly, I stick to the isometric. This commentary mentions how acute pain response is not the ideal indicator for response to treatment, and rather pain-rating the next day is a better indicator. I agree with this, however in the real-world setting, I find it difficult to properly educate patients on this, and to have this be reliable. In a low-irritable patient who is not fearful of pain and has a good understanding of the management of a tendinopathy, I think having the patient work through some pain and having them tell you their response is a good choice. But if the patient has high irritability and does not quite understand the concept of “hurt does not always equal harm”, then an isometric is going to be my treatment of choice (with further education to help them understand these concepts).

The commentary helps me remember that pain during exercise is okay, and that it is oftentimes essential to proper healing of a tendinopathy. It reminds me to ask my athletes or individuals on how they felt the day after treatment. I think HEP flexibility with these patients is really important, and educating them on which exercises to perform based on their response to treatment is really important. For instance, if the patient had minimal pain after a treatment, it would be just fine for them to continue their exercises. But if the patient had 6/10 pain the day after a treatment session, then it would be a good idea to regress the exercises to a less-painful version while they are at home. Helping patients understand progressions and regressions would be really helpful in their own management of their symptoms, and I believe makes them feel like they have more understanding and control over their rehab.

[Cameron Holshouser]

– The Tendinopathy continuum is so broad. Because of this, we have make sure we identify where the individual falls within the continuum. For example, is this a 1) young individual with a reactive tendinopathy, 2) an older individual with a degenerative tendinopathy, or 3) someone with a degenerative tendon that is currently in the reactive phase? Based on where the individual falls within the continuum, the treatment plan will be very different.

– One of their questions was, it is beneficial to achieve acute pain relief in individuals with long standing tendinopathy? Typically with someone with chronic tendinopathy, typically I try to stimulate an inflammatory type response to promote with healing, and working through some pain (i.e. eccentrics). This is what the authors where eluding to in their article. However, I would be more inclined to perform isometrics if this is an acute-subacute tendinopathy (tendonitis). I personally have seen good results with pain in the short term with a reactive Achilles tendinopathy/tendonitis and gluteal tendinopathy. It doesn’t make sense to use isometrics for chronic tendinopathy if the goal is to stimulate an inflammatory response.

– My take on isometrics would be that they are great for cuing certain muscles (i.e. post-op or an inhibited muscle) and they are great for decreasing pain during an acute inflammatory phase. It also doesn’t make sense to make specific treatment recommendations (isometrics) for a broad pathology (tendinopathy).

[Erik Kreil]

Cam, to add to your point, that portion of their discussion also makes the point that maybe making pain reduction the primary goal for long-standing pathology isn’t even the best idea — the chronic nature isn’t going to be healed within-treatment just from doing isometrics so it’s probably not even worthwhile to measure success this way.

My moral of the story is to be an active consumer of information — one of their counterpoints very simply looked at the research that the isometric-is-the-gospel claim came from, and they found that the results couldn’t be replicated upon attempt. As newer information comes out, need to be thinking about it. (Like the all-in-one value of thoracic thrusts).

[Jon Lester]

Jeff, I like your point of using isometrics to provide a window of opportunity to improve ROM and tolerance to more functional exercises/movements. I think this is where isometrics in even a chronic tendinopathic scenario can be useful. I don’t think this will help in the healing process necessarily (unless you’re trying to encourage activation like Cam said), but I believe that using the pain modulation qualities of isometrics can allow for more specific treatment in those with higher pain levels. Even chronic tendinopathies can have higher levels of pain and any method that can encourage pain reduction and increased tolerance to loading/movement can be beneficial for the right patient. I realize I’m playing a little bit of devil’s advocate with this viewpoint – I agree with everything that everyone has said.

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