Category Archives: Knee injury


Tendinopathy & Tendon Pain | Guest Blog by Dr Peter Malliaras

Thanks to my friend and colleague Dr Peter Malliaras for this blog on tendinopathy – here is his bio

Painful tendon injury or tendinopathy is common and often difficult to manage. Previously this type of injury was known as tendinits, and the suffix ‘it is’ suggesting an inflammatory pathology. For over three decades now researchers have known that longstanding tendon pain may not be inflammatory, so now the popular term is tendinopathy. The pathology that is seen in laboratory studies is effectively a failed response of the tendon to adapt to forces places upon it with daily activities and sport. This is largely because tendon responds very slowly and sluggishly to changes because its infrastructure of cells and blood flow are not as extensive as some other tissues.

It is generally accepted that the key treatment for tendinopathy is exercise. Exercise is the only intervention that can restore a painful tendons ability to take the loads that it needs to in everyday function and sport. A simple formula that I use in clinical practice is to consider the loads that a patient needs to endure in their day to day function and then design an exercise program that progressively allows them to endure these loads without the tendon becoming painful. The key is to make sure that exercise is commenced at a level that will not cause the tendon to become irritable and that it is progressed at a rate that the tendon can tolerate. Every patient that I see is different and how they progress with their rehabilitation and this depends on many complex individual factors, including musculoskeletal, systemic, motivational, psychological factors, etc.

Over the last 15 years the most popular form of exercise that clinicians prescribe is eccentric exercise. This is where the muscle is loaded whilst it is lengthening (e.g. the downwards phase of a biceps curl) and is in contrast to concentric exercise where the muscle shortens whilst under load (e.g. the upwards phase of a biceps curl). An international research group I am involved with, including two physiotherapist PhD clinician-scientists (Dr Peter Malliaras, Dr Christian Barton), a Senior Human Movement Research Fellow (Dr Neil Reeves) and a Public Health Professor (Prof Henning Langberg) recently published a review questioning eccentric exercise treatment for Achilles and patellar tendon injury.

There were four studies that compared loading programs in the Achilles and six in the patellar tendon. Only two studies were rated as high quality. The most surprising finding was that very few studies have actually compared eccentric training to other forms of exercise. For example, only one study had compared eccentric training in the Achilles tendon. Overall, there was no evidence that eccentric training is better than other exercise in treating these injuries. In fact, there was equivalent (Achilles tendon) or more evidence (patellar tendon) to support exercise that involved both eccentric and concentric contractions in combination. So combined eccentric-concentric contractions may be useful in tendinopathy. Clinically, I see mainly second opinion tendinopathy cases and one of the most common reasons they have not improved with eccentric loading is that they have marked weakness of their concentric function. Due to a very well established principle of known as ‘specificity in exercise’, people will tend to get better at the type of exercise they do. So, I always give eccentric-concentric combined loading to patients with concentric weakness. Another important point is that no studies to date have investigated isometric loading in Achilles and patellar tendinopathy rehabilitation. Isometric exercise enables muscle-tendon unit load at a constant joint angle. Clinically, I use this to exercise people at a painfree joint angle that limits compression whilst still loading the tendon. Tendon compression is associated with pathology. It is very effective in the very painful or very compressive tendon presentations, and our review has highlighted that we need more research in this area.

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What does your pain mean to you? Learning from the #Messi injury

“I sincerely thought it was the last ball I would be touching for a long time because of the pain,” Messi said. “I tried to go ahead and shoot but I didn’t have the strength.”

Last week Lionel Messi, arguably the World’s best footballer, thought that his career had come to an end with a knee injury. The crowd thought the same as they watched him fall to the ground having collided with the Benfica goalkeeper. Messi was rounding Artur when the players came together at speed. He continued to run and kick the ball but then fell to the floor clutching his leg. Messi’s first thought was that it was the end of his career because of the severity of the pain.

The moment of injury triggers a range of physical and behavioural responses. If tissues are damaged, the healing process begins with inflammation. In many cases this is painful but not always immediately. The first thoughts arise automatically based on the saliency or meaning of the situation and will influence the pain perception. In Messi’s case, the pain was severe, he was holding his knee without knowing the extent of the injury and made a split-second assessment. Understandably his and the crowd’s thoughts were catastrophic, playing out unimaginable scenarios that provoke further responses in the body. There was silence in the stands by all accounts.

The brain is firing on all cylinders at this point, working out what is going on in the body as it receives danger signals from nerves around the knee. We are unaware of the processing of this information from the body. Blending with existing knowledge and past experiences, the brain responds with a range of protective measures if it deems that there is a threat to the body. This can include pain to attract our attention, spasm to reduce movement of the area, altered movement patterns to escape or protect (e.g. limping) and autonomic responses that are triggered by a perceived threat (e.g. sweating, increased heart rate). Clearly Messi’s brain had decided it was a good idea to protect his knee.

Of course, the meaning of a knee injury is very different to a professional footballer in comparison to someone else. Similar to the violin player with a paper cut on his index finger on the day of a big concert. In the clear light of day, Messi and his fans now know that the injury was not serious and that the recovery will be straightforward. The meaning has changed and so will Messi’s pain experience. This was clearly demonstrated by two goals scored in the next game.

This episode is a great example of the fact that pain is not an accurate indicator of tissue damage. The alarm system rang out in full volume for Messi and for good reason. So why did it hurt so much, and it really did, when we now know that there was only a mild injury (a bony bruise)?

Science and clinical experience tells us that pain is an output from the brain in response to a perceived threat. The sensation of pain is allocated to the part of the body deemed to be in danger via the body’s representation (maps of the body) that exists in different parts of the brain*. With pain being an output from the brain, it means that there are a number of modulating factors that can amplify the experience, including the meaning of the situation, catastrophic thinking and expectation. Hence the salience for Messi: his leg, his career. Understandably then, the brain is going to protect and potently so.

The science of pain also helps us to understand why players can be seemingly severely injured and a few minutes later be sprinting down the field. The set of behaviours that we see can of course be play-acting to make certain gains. However there will be those who are tackled, experience intense pain that lasts for just a few moments and then resolves as the brain diminishes the threat value of the situation.

Fortunately for Messi and his fans, he has resumed normal service. Now that the footballing world has breathed a sigh of relief we can look at the sequence of events and learn from Messi’s experience: the context of the injury is key, the meaning is vital, responses do vary and the pain is real. Understanding pain is very important. Arguably it should be part of a player education programme so that responses to pain and injury can be optimised in terms of recovery and rehabilitation.

Richmond Stace MCSP MSc (Pain) BSc (Hons) | Specialist Pain Physiotherapist

Pain Education Programmes for Athletes 

We deliver group and individual pain education sessions to develop the understanding of pain. Knowledge of the experience of pain, including the neurobiology and range of influences, optimises positive responses to injury and conditions.

* This can be a difficult concept to grasp although phantom limb pain can help with the understanding. In this condition, the individual has lost a limb yet feels pain and other sensations in the body part that is no longer there. This is very real pain.