Saturday, December 23, 2006

Long Slow Recovery

For those of us who weren't attached to the knee in question, it was the ungodly noise of an epic mechanical failure that made us all wince. Our friend Harlan was wincing for entirely different reasons. Mid-'Helen' with only three pull-ups to go and it was the small hop to the pull-up bar that ripped muscle from bone. And yet it wasn't really. The groundwork for this particular injury was built on the road - long slow distances on bike and foot that led to bouts of inflammation in the form of tendinitis and the resultant scar tissue that made his tendons ripe for this kind of injury.

As Coach Rippetoe pointed out when coaching a snatch, it's not instinctual to step under falling weight. The risks are obvious and don't require any explanation. In long slow distance (LSD) events, however, athletes are not only pursued by the competitor behind them but by repeat-motion injuries and cumulative stress that dog their every step. It's just not as obvious a threat as falling weight.

In the LSD culture, 'run through it' is not only the common approach to most injuries it's a 'merit badge' of sorts. It's so ingrained that LSD athletes stop questioning the 'why' of injury and consider it almost as necessary to their training as top of the line running shoes. The exploration of their diagnosis generally stops after the question, "But can I keep running/biking?" is answered.

In tendinitis of the knee, there are four stages:

Stage 1 - Pain only after activity, without functional impairment
Stage 2 - Pain during and after activity, although the patient is still able to perform satisfactorily in his or her sport
Stage 3 - Prolonged pain during and after activity, with increasing difficulty in performing at a satisfactory level
Stage 4 - Complete tendon tear requiring surgical repair

You'll note that the question of 'can I keep running/biking?' is technically 'yes' until stage 4. The fact that the activity can be performed, with 'increased difficulty' of course, up until surgical repair seems to be enough to speed people along through the gruesome completion of all four steps. After stage 4, the answer of 'can I keep running/biking?' is decidedly 'no'.

Tendinitis: Everything is just swell

From "A tendon is the end part of a muscle that attaches the muscle to the bone. The normally very elastic and soft muscle tapers off at the end to form the much more dense and stiff tendon. While this density makes the tendons stronger, the lack of elasticity of the tendon and the constant pulling on its attachment to the bone with movement, makes it much more susceptible to a low level of tearing at a microscopic level. This tearing will produce the inflammation and irritation known as tendinitis."

"With proper care for the area, the pain in the tendon should lessen over three weeks, but it should be noted that the healing of the area continues and doesn't even peak until at least six weeks following the initial injury. This is due to scar tissue formation, which initially acts like the glue to bond the tissue back together. Scar tissue will continue to form past six weeks in some cases and as long as a year in severe cases. After 6 months this condition is considered chronic and much more difficult to treat."

"After the scar tissue has begun to accumulate, it will be important to perform procedures which help break down the scar tissue in the tendon tissue, so as to let the tendon and muscle regain it's normal flexibility and lessen the chance of further injury. While exercise is appropriate for breaking down scar tissue once the area has healed, it may further irritate the area during the initial stages."

Tendinitis, is common to the LSD athlete and can plague a mixed-modal athlete (read CrossFitter) as well. The difference is that a LSD athlete has few tools to rely on and when impaired, loses forward momentum in their sport. A mixed modal athlete can rest afflicted areas and continue to improve adding valuable skills while recuperating.

Fighting inflammation or not?

In my research, conflicting reports existed as to whether or not inflammation is a factor. I read many entries in PubMed that discussed the absence of inflammation but those abstracts weren't as easy to digest and threatened to send you skittering off subject and back to you e-mail queue. I offer the following link to which sums up the issue nicely but may not be the most reliable resource.

"For decades, overuse injuries have been treated with anti-inflammatory methods. These include non-steroidal anti-inflammatory drugs (NSAIDs such as Advil and Motrin), electric stimulation, steroid injections and ice therapy. However, research, including a 2000 study in The Physician and Sportsmedicine and a 2003 study in Clinics in Sports Medicine, indicates that most overuse conditions are not inflammatory in nature and that treating them as such may delay or prevent full recovery.

If inflammation isn't responsible for chronic conditions like tennis elbow and iliotibial band syndrome, what is? There's a good chance it's scar tissue. Repeated or sustained muscular contractions in any athletic endeavor increases tension on soft tissues (muscles, tendons, fascia and nerves), which in turn decreases blood and oxygen supply to the area.
With muscles, nerves and fascia, the result is a build-up of scar tissue. In tendons, decreased oxygen leads to degeneration. Scar tissue and degeneration are the common cause of chronic overuse injuries, whereas inflammation is predominant in acute injuries such as muscle and ligament tears.

Although the understanding of overuse injuries has improved with continued research, most traditional medical paradigms have not yet adapted, partially explaining why some injuries seem resistant to treatment. Karim M. Khan, M.D., Ph.D., a primary researcher on overuse injury, affirms, "Treatment needs to combat (scar tissue) breakdown rather than inflammation."

It's my assertion that inflammation is present at the onset of the injury and flares up when the injury is aggravated but that the long term chronic nature of the problem is due to the scar tissue as stated above. Therefore, it's prudent to treat flare-ups with anti-inflammatory protocols as it will limit additional scar tissue formation.

Couch-Surfing: Neither a sport nor an option

If your tendons are at risk, why stress them in the first place? Glad you asked. The question is, how do you gain the benefits, listed below without the cumulative stress of LSD? Simply reduce the duration, and vary the loads (read CrossFit). I'll spare you the link partly because you'll only find the abstract and because the complete article is not in English.

Metabolic activity and collagen turnover in human tendon in response to physical activity.
Kjaer M, Langberg H, Miller BF, Boushel R, Crameri R, Koskinen S, Heinemeier K, Olesen JL, Dossing S, Hansen M, Pedersen SG, Rennie MJ, Magnusson P.
Institute of Sports Medicine and Copenhagen Muscle Research Centre, Bispebjerg Hospital, Copenhagen NV, Denmark.

Connective tissue of the human tendon plays an important role in force transmission. The extracellular matrix turnover of tendon is influenced by physical activity. Blood flow, oxygen demand, and the level of collagen synthesis and matrix metalloproteinases increase with mechanical loading. Gene transcription and especially post-translational modifications of proteins of the extracellular matrix are enhanced following exercise. Conversely, inactivity markedly decreases collagen turnover. Training leads to a chronically increased collagen turnover, and dependent on the type of collagen also to some degree of net collagen synthesis. These changes modify the biomechanical properties of the tissue (for example, viscoelastic characteristics) as well as the structural properties of the in collagen (for example, cross-sectional area). Mechanical loading of human tendon does result in a marked interstitial increase in growth factors that are known potentially to stimulate synthesis of collagen and other extracellular matrix proteins. Taken together, human tendon tissue mounts a vigorous acute and chronic response to mechanical loading in terms of metabolic-circulatory changes as well as of extracellular matrix formation. These changes may contribute to training-induced adaptation of biomechanical properties consisting of altered resistance to loading and enhanced tolerance to strenuous exercise. Understanding of such changes is a pre-requisite in the development of measures aimed at prevention of overuse tendon injuries occurring during sport, work or leisure-related activities. PMID: 15788870 [PubMed - indexed for MEDLINE]

Squat = good: Just had to throw this in

The Allan McGavin Sports Medicine Centre and School of Human Kinetics
University of British Columbia, Vancouver, Canada.

OBJECTIVES: To compare the therapeutic effect of two different exercise protocols in athletes with jumper's knee (this is the tendinitis in question which is referred to by this common term)

METHODS: Randomised clinical trial comparing a 12 week programme of either drop squat exercises or leg extension/leg curl exercises. Measurement was performed at baseline and after six and 12 weeks. Primary outcome measures were pain (visual analogue scale 1-10) and return to sport. Secondary outcome measures included quadriceps and hamstring moment of force using a Cybex II isokinetic dynamometer at 30 degrees/second. Differences in pain response between the drop squat and leg extension/curl treatment groups were assessed by 2 (group) x 3 (time) analysis of variance. Two by two contingency tables were used to test differences in rates of return to sport. Analysis of variance (2 (injured versus non-injured leg) x 2 (group) x 3 (time)) was also used to determine differences for secondary outcome measures.

RESULTS: Over the 12 week intervention, pain diminished by 2.3 points (36%) in the leg extension/curl group and 3.2 points (57%) in the squat group. There was a significant main effect of both exercise protocols on pain (p<0.01) size="4">The Challenge
'Quad Sets' or, in other words, leg lifts are the standard protocol for the first stage of therapy for a knee injury because it allows the quadriceps to fire due to hip flexion without further aggravation at the joint. The CrossFit version of that is the classic L-sit which again features hip flexion as the focus. With a stop watch, accumulate 2 minutes of hold in the L-Sit or with the assistance a band, do 100 2-second holds.