Repetitive Strain Injuries- A New Approach
Current research discovers an advanced treatment for repetitive strain injuries.
By: Jonathan Hartman DR, DACRB
Do these scenarios describe you? You have been thinking about what new outdoor activity you want to dive into. Seeing all the excitement from your friends running 5k’s or obstacle courses, you decide you want to join in on the fun. Or maybe you are a well-established runner and you have increased your goals to marathons or other longer distance events. You have learned how to properly warm up and you have what you think is a good handle on your training schedule. Your training has been very diligent and you have been making steady gains in your time elapses as it gets closer to race day. Then the unexpected happens; your Achilles Tendons and calf muscles are starting to get sore. The past few runs you have noticed that those first couple of miles are becoming a little harder, yet you manage to “push” through and it’s fine. The next day, it is noticeably sore in the morning upon waking but better as the day goes on. Reluctant to cut back your training, you get into the cycle of suffering Achilles pain and trying to figure out why it’s not getting better because you ice, rest, and take anti-inflammatory medication on good faith it will help you. In spite of all these measures you have taken to correct your problem, your pain still increases. We now know that these treatment modalities will not rid you of your pain, nor will it fix your actual problem. For the past several decades, it was assumed that inflammation was responsible for the pain endured by runners. However, this assumption has now been proven wrong. New research is evolving in the medical profession that is discovering more advanced methods in the treatment of these chronic overuse injuries that are so greatly affecting our health, and therefore our performance.
History on Repetitive Strain Injuries
What has been hiding under the radar all these years is a recently coined term: Repetitive Stress/Strain Injuries (RSI’s). According to federal statistics, the incidents of RSI’s have surpassed back pain, worsening by 670% in the past ten years.1 RSI’s are the result of what is referred to as microtrauma. Microtrauma is an accumulation of small injuries to our tissue that occur under a constant load or tension over a prolonged period of time. Muscles, tendons, bones, blood vessels, fascia, and nerves are all subject to microtrauma and can result in pain and injury. An example of a Repetitive Strain Injury is an Achilles tendinopathy. In this case, chronic running without adequate recovery puts strain on the muscles, tendons, and ligaments in the foot, ankle, leg, and thigh. This is extremely common in runners regardless of their status. It is this constant application of pressure and tension that over time results in microtrauma and injury. This is often times worsened by our inability to rest and/or find the proper treatment strategies specifically designed to alleviate the stress placed on the body. This gradual onset of symptoms can manifest slowly as an ache or fatigue, progressing into more painful and debilitating incapacities that can limit an athlete’s career. It’s not Tendinitis Tendons are tough yet flexible structures that connect muscles to bones and therefore allow for the production of movement. They transmit the forces generated by the muscles onto the bone, allowing us to run, jump, and move in various ways. We almost all know someone who has been told they suffer from an Achilles tendinitis or shoulder rotator cuff tendinitis. Unfortunately, this diagnosis is accurate for only a handful of cases. Tendinitis is the name given to the tendon when it becomes injured, inflamed, and irritated. And in order for the problem to be accurately diagnosed as a tendinitis, inflammation must be present. Inflammation is the body’s natural response to injury. When we have an injury, the body sends out specific cells to the damaged region to set up a local environment to destroy the damaged tissue and provide the essential tools for healing. However, tendons are already at a disadvantage because of the lack of blood supply often associated with them, contributing to their white appearance. Therefore, the body has a hard time delivering oxygen and nutrients necessary for healing. This is why we often see many people with similar problems in common parts of the body. The standard conventional modalities consist of icing, resting, and anti-inflammatory medication, all of which are aimed to combat the body’s excessive inflammatory reaction. However, inflammation is rarely seen in the presence of chronic tendon cases. Research conducted by prominent orthopedic surgeons have developed a new understanding of chronic repetitive injuries.8
Tendinitis vs Tendonosis
This well-established confusion on the misdiagnosis of tendinitis versus tendonosis has lead to several researchers conducting studies on the histology of these injuries. “Tennis elbow”, for example, is commonly thought of as tendinitis of the extensor carpi radialis brevis. However, “signs of either acute or chronic inflammation have not been found in any surgical pathologic specimens in patients with clinically diagnosed lateral tennis elbow syndrome,” proving that tennis elbow is not a tendinitis.2 Dr. Barry Kraushaar, local Emerson, New Jersey orthopedic surgeon, and neurosurgeon Dr. Robert Hirschl have demonstrated with histology, the study of the microscopic structure of tissues, that it is actually tendonosis3. Researchers discovered that the tendons no longer had a “white, glistening and firm” appearance; they instead were degenerated, “dull-appearing, slightly brown and soft.”4,5 This is actually tendonosis, which has been consistently mislabeled as tendinitis. Tendonosis is the chronic degeneration and breakdown of the tendon’s collagen due to chronic overuse. When the tendon is not given enough time to heal, and under constant load- as seen with running- it causes a decrease in blood flow to the associated muscles and tendons. This reduction of blood flow causes an accumulation of waste products very similar to that produced when a muscle tears. However, in the case of overuse injuries, the body is ‘tricked’ into repairing tissue that is not actually damaged. This causes an accumulation of scar tissue restrictions in the otherwise healthy tissues. As a result of this, increased stress in placed on the tendons, furthering their chronic degeneration.8 Pain with use is also a symptom; yet pain is often the last, and therefore worst, indication of a muscle and tendon’s integrity and health. To provide an excellent analogy, imagine injecting a muscle or tendon with a tube of glue. The glue prevents its ability to fully stretch or contract; therefore, the tendon or muscle becomes weakened, unable to provide sufficient strength and stability, and is now easily fatigued. Because of this, your body must recruit the help of other muscles and tendons to accomplish a given task or goal. As a result, the neighboring muscles and tendons become overworked, and with time, they themselves begin to develop scar tissue. This continued cycled of increased stress, scar tissue accumulation and degeneration progresses until you can no longer compensate, at which point, the system has failed with chronic pain as a consequence.8
Our nervous system is a complex and intricate collection of nerves and specialized cells that transmit signals between different parts of the body. It is the body’s control system for communication between all other bodily systems. It allows our brain to communicate with the environment and the rest of the body. Another common problem seen with scar tissue formation is the development of nerve entrapments. This is what occurs when scar tissue adheres a nerve to a neighboring muscle, tendon, ligament, or fascia. Symptoms that accompany nerve entrapment include radiating pain, numbness, tingling, pins and needles, burning, and deep aching. A nerve fiber is very similar in size and feel to spaghetti. With over 600 miles of neurons running through our body, our nerves course throughout, traveling next to muscles, tendons, bones, and ligaments. If a nearby structure (muscles, tendons, and ligaments) develops scar tissue that is close to a nerve, the two can become fused. Therefore, it can no longer glide and must now stretch, becoming injured and unable to function optimally. Symptoms can begin to occur from as little as 15% compression and therefore increase tension on the nerve.8 This damages the nerves and results in the classic burning down the back of the leg, or tingling down the arm and into the hand. There are approximately 45 common locations in the body where nerves can become trapped. Nerve entrapment is the cause of many cases of sciatica, however, it is not the only cause or tissue involved. It is important to have an accurate understanding of sciatica. Its causes can vary widely, and often, there is scar tissue accumulation in the hip that restricts the gliding movement of the nerve. The sciatic nerve (almost as wide as your thumb) lies deep to the hip muscles and hamstrings, traveling down the back of the leg to the foot, and must glide several centimeters when the hip is flexed. Symptoms can include sharp pain with movement, loss of sensation or numbness/tingling, weakness when bending the knee, difficulty standing on your toes, difficulty bending forward or backward, aching, and burning down the back of the leg into the foot. If you experience pain and symptoms in the entire foot, not only do you have sciatica; other nerves may be involved. If the pain and symptoms are also in the front of the thigh and front of the leg, it is likely that you are suffering from more than sciatica. Healthcare providers commonly misdiagnosis and categorize pain in any part of the leg as sciatica. This is a crucial mistake because effective treatment strategies are based upon a specific, accurate diagnosis.
Tendonosis and Its Treatment:
We now know that scar tissue formation is the only mechanism a muscle has for healing. With such a universal response to repetitive stress and injury, it is very likely that you are suffering from chronic degeneration and scar tissue accumulation when you experience pain from overuse injuries. This scar tissue accumulation does not go away on its own. In the same manner, interest accumulates and compounds on a loan or mortgage, the results become greater and lead to worsened performance. A common scenario occurs when someone takes time off from exercise; they start to feel better, and once they resume running, the pain returns again. This is highly indicative of scar tissue accumulation. If this were strictly a tendinitis, and therefore an issue of inflammation, rest would have resolved it and it would not have returned. In summary, we know that there are clear distinctions between inflammatory problems and chronic, overuse/degenerative scar tissue accumulation. As stated earlier, effective treatment strategies are based upon a specific, accurate diagnosis and must change appropriately. There are more accurate treatments than the standard-issued over-prescription of rest, ice, and anti-inflammatory medication. Manual Adhesion Release (MAR) is a revolutionary procedure for the reduction of scar tissue and reversing chronic degeneration. Every MAR session is a combination of examination and treatment based upon specific findings from the clinician. Doctors trained in Manual Adhesion Release are able to locate scar tissue by touch. With Manual Adhesion Release, there are no harsh side effects seen with medication or surgical complications. The doctor first identifies a region of scar tissue accumulation by using his hands. Once found, that muscle/tendon/ligament is shortened by having the patient move their body. The doctor places his thumb or fingers directly on the scar and with specific pressure, generating tension. Lastly, the doctor instructs the patient on how to move that body part back to its normal length, all the while having tension generated on the scar tissue. This breaks down the scar tissue, restoring the proper length, tension, texture, and function. Reduced pain and better performance are also the result of treatment. Prevention of repetitive use/strain injuries are very difficult. Continuing to run can easily cause chronic degeneration and overuse injuries. There are some strategies you can do to avoid or delay the effects of repetitive use injuries. They include the following:
- Load Management- Overtraining is one way athletes can easily burn out and ruin months of diligent training. When an athlete continues to run without having proper management of the repetitive strain injuries that have accumulated over time, their symptoms worsen, prolonging their progress and potentially ending their career. The more you run, the more likely you are to accumulate scar tissue unless they are properly managed by a certified provider.
- Proper Technique- Having a coach or someone knowledgable in the field can be a great asset to improving your form, and therefore your potential risk of injury. Attending running clubs, classes, reading magazines and books, or watching movies on running are other ways you can learn to improve your technique.
- Sleep- Sleep quality and quantity are extremely important in every aspect of health. When it comes to running, it’s even more important to make sure your body has enough time to recovery. Sleep deprivation causes the body to metabolize glucose less efficiently. Cortisol, a stress hormone, also rises, which has been linked to impaired recovery in athletes.6 Lack of sleep also causes a reduction in human growth hormone, which is vital during tissue repair.
- Stretching- The benefits of stretching are thought to decrease your risk of injury. When the muscles, nerves, and surrounding structures can freely glide and move around one another, it prevents scar tissue formation. This also improves blood circulation and therefore your athletic performance as well as your recovery from running. The proper way to stretch is to hold each stretch for about 30 seconds, avoiding bouncing and maintaining a pain-free range of motion. If you feel pain, you might be over-stretching; therefore, back off until you do not feel pain, and then hold the stretch. Stretching intermittently throughout the day, especially when at work, has great benefits to maintaining a healthy body.
- Nutrition- This cannot be overemphasized enough. Ann Wigmore, holistic health practitioner and nutritionist said, “The food you eat can be either the safest and most powerful form of
medicine or the slowest form of poison.” You should strive to consume whole foods that are nutritionally dense, devoid of trans fat, sugar, and refinement. For more information look into the Paleo Physicians Network, a database of compassionate, evidence-based paleo-oriented healthcare practitioners. A simple summary of a healthy Paleo Diet is the following chart: There are numerous scientific studies that have shown that a paleo diet goes far beyond the benefits of athleticism and performance. Studies have shown it can “dramatically reduce the instances of obesity, cancer, diabetes, heart disease and cognitive decline.”7 Having proper nutrition will eliminate the amount of toxins and waste products that accumulate in our bodies during exercise. With sleep, nutrition is a key source of optimum recovery, performance enhancement, and preventing or recovering from repetitive strain injuries.
New research has discovered more effective treatment strategies for the reduction and presentation of repetitive strain injuries. I specialize in these new treatment modalities and have the wonderful pleasure of getting to change people’s lives without medication and surgery. Active Release Technique and Manual Adhesion Release are two advanced treatment approaches with astounding results in reversing repetitive strain injuries, restoring health, and helping runners get back to reaching their goals and doing the things they love. At Third Space Medical, we are a multi-disciplinary, ethical and evidence-based chiropractic and rehabilitation center focused on achieving the highest standards of patient satisfaction and functional restoration.
1. United States Department of Labor. Occupational Safety and Health Administration. Preventing Repetitive Stress Injuries.
2. Boyer MI, and Hastings H., Lateral tennis elbow: Is there any science out there? Journal of Shoulder and Elbow Surgery. 8(5):481–491. 1999.
3. Kraushaar B, and Hirschl R., Current concepts review – tendinosis of the elbow (Tennis Elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. Journal of Bone and Joint Surgery. 81(2):259–278. 1999.
4. Heber, M., Tendinosis vs. Tendinitis. Elite Sports Therapy. http://www.elitesportstherapy.com/tendinosis-vs–tendonitis. Accessed November 21, 2013.
5. Khan KM, Cook JL, and Taunton Je, et al. Overuse tendinosis, not tendinitis—Part 1: A new paradigm for a difficult clinical problem. Physician Sportsmed. 2000;28(5). http:// www.massagebyjoel.com/downloads/overuseTendinosis- Physsptsmed.pdf.
6. Spiegel, Leproult and Van Cauter. Impact of sleep debt on metabolic and endocrine function. The Lancet (1999;354:1435-1439).
8. Brady, William. A New Understanding of Overuse Injuries. Berklee Today. http://www.berklee.edu/bt/142/overuse_injuries.html.