Better options for tendon problems – Hint; the tendon is a symptom, not the problem

The NY Times recently reported in their article on Traditional Tendon Pain, Think Beyond The Needle http://www.nytimes.com/2011/03/01/health/01brody.html?_r=1&scp=1&sq=tendon%20pain&st=cse), that:
1. “Corticosteroid injections into the injured tendon, has been shown to provide only short-term relief, sometimes with poorer long-term results than doing nothing at all.”
2. “Resting the injured joint, is supposed to prevent matters from getting worse. But it may also fail to make them any better.”

The author references his problems with tendinopathy (fancy medical way of saying something is wrong in the tendon) of the shoulder.  
He mentions his experience with therapies and gives opinions from a professor in the physical therapy department at a well-known school. 
This authors in the box experience is typical, but frustrating for me to read, since he is doing what is usually done, treating the symptom with exercise and rest, rather than understanding the problem.

Most sports chiropractors, like myself, may handle it similarly, but use manipulation as well as myofascial techniques as well as exercises to resolve the problem.  This yields consistent results but the problem often returns with the activity which is why a better level of thinking, with tendon problems, is essential.

Understanding Tendonopathy 

The problem is rarely the tendon.  The result of the problem usually is a painful tendon.  You may ask yourself, what does that mean?  Usually, tendons become involved when fascial restrictions exist surrounding the muscles they connect to.  When muscles contract and relax poorly, with fascial adhesion, the force is placed on the tendon, creating micro scars.  These scars are not flexible and when you have enough of them, the tendon becomes brittle and we get constant micro failures which is the inflammation and pain after activity.  Releasing the adhesions in the surrounding fascia improves mobility, lessens pain and unloads the tendon, giving the ability of better movement and tolerance, and when the tendon is in poor shape itself, techniques like instrument assisted fascial treatment (Graston is a great example), can break up adhesion, and get the tendon to become more flexible again.

What about the shoulder?

In the case of this writer, the shoulder is unique because there are four muscles and four tendons in the rotator cuff.  If you change the correct firing position or increase the load on the shoulder while pulling the joint forward, these tendons can get quite sore. Also, the supraspinatus muscle, which sits at the top of the scapular spine, has its tendon slide between the attachment of the scapula and the clavical.  If this is pulled forward, the tendon can grind in the groove, and bony outgrowth from years of poor mechanical function will impinge and even tear the tendon and muscle, a very painful problem called impingement.

Solving this involves solving postural issues which is another long-winded subject altogether, but for the purposes of this blog, you cannot solve these problems unless you first look at the pelvis and how that functions.  I tight hip capsule can cause recruitment into the oblique and abdominal muscles, pulling the shoulder forward, creating the impingement.  Using out of the box thinking, any practitioner evaluating the shoulder should look for restrictions in the hip, pelvis, and abs first.  Not doing so results in expensive rehab and assuming stuff just happens. The reality is that most shoulder problems I see start in the hips, and then alter the firing angle of the shoulder, causing it to be pulled forward and impinging the shoulder tendons, most commonly the supraspinatus.  

Bottom line
To solve shoulder tendinopathy, you need to look at the person, not just the symptom at the point of pain.  As a patient, be suspicious when the doctor obsesses at the point of pain, wants to medicate or simply inject, or just exercise the painful part.  Musculoskeletal diagnosis is a thinking man’s game and is not found on a diagnostic flow chart.  Resolving problems of the tendons require understanding the mechanisms of pain first, then applying that knowledge and then using tools like myofascial release or Graston or other methods to resolve them.


What do you think? As always, I value your opinion.  Any questions can be directed to [email protected]