Tag Archives: pain in sport

09Jul/17
Andy Murray's hip

Pain and injury at Wimbledon

Why is there so much pain and injury at Wimbledon this year?

Pain and injury at Wimbledon

Seven retirements and a very painful injury on-court yesterday at Wimbledon have given the tournament a different feel. Pain and injury are part of sport, but many people have been surprised by the turn of events. Federer has called for a review of the system and several players have complained about the state of the courts. All are factors of course. The game is simply made up of the synergy of players, court and tournament. When all are ticking, we see great tennis.

The very painful moment

Bethanie Mattek-Sands was screaming out in pain this week after her knee appeared to give way. One report suggested that she could have sustained a knee cap dislocation. This can be extremely painful until relocated. Seeing the dislocation can add to the trauma. When our body does not appear as we expect, the sight can trigger feelings of aversion.

Why so much pain?

Pain is a part of the way we protect ourselves. There are many other things going on when we are in state of protect: change in movement, change in sense, altered thinking and emotion, change in perception. In other words, the world looks different and feels different as we take action in the name of survival. This is a normal shift of state in the face of a perceived threat. Pain is a lived experience when there is a perceived threat. Pain is not well related to injury. This is the common misunderstanding. Just because it hurts a lot, it does not mean that the injury is more severe. We have known this for a long time ~ see here: pain in sport, 3 key points.

When thinking about the reasons for the pain response, the context is key. In other words the situation plays a significant part in the pain experience. As well as potential tissue injury, where that possible injury occurs and what is happening is highly relevant — it always has to happen somewhere! The full picture perceived creates a learning opportunity. If this is possibly dangerous, I need to remember what happened and where so that next time I can react differently.

All of this information is processed together with sensory information from the body, based upon what is already known about injury and the situation. In essence we make a best guess about the possible causes of the sensory information on a background of our previous experiences. In effect, we weigh up the evidence: new information vs what we know, which then suggests a scenario. If this is a potentially dangerous situation, pain can then form part of the experience. The more danger perceived, the more intense the pain.

How much danger did Bethanie perceive when her knee gave way at the biggest tennis championship in the world, in front of a big crowd, when each game is career shaping?

Whatever the outcome for Bethanie, I wish her well.

Messi’s knee

In 2012 Lionel Messi was running into the box when he brushed the keeper as he came out to meet him at speed. Messi managed to get a shot away (he missed) before he hit the ground clutching his knee. He was quoted as saying that he thought his career was over because of the pain.

How dangerous was the situation to Messi? Consider: the perceived injury (he did not know about the extent of the damage at that point), the game, the crowd silent, the body part involved, how knee injuries are thought of in the culture of football, the immediate thoughts about injury and what it means and much more.

Messi was taken off the field on a cart and whisked to hospital where he was scanned. What was the injury? A bruise.

Pain and injury are not the same. The terms are often used synonymously, but this is not correct usage. A further example is phantom limb pain. The person suffers pain in a limb that no longer exists.

Pain and injury

Why have there been so many injuries?

We have seen multiple retirements during games at Wimbledon this year. Whilst some people have been frustrated, we must also consider that these players have to make choices. These are based on the culture of the sport, the system, their career, their income and their understanding of pain.

There will be a weighing up of the pros and cons, and each individual will consider different factors before deciding. We do not know what those factors are in each case, so we cannot make any specific assumptions or criticise. In life, how many assumptions are made when someone is being critical of another without knowing the full picture?

“aches and pains are part of sport

In sport, the day to day aches and pains are a well known part of the deal. Simple measures are taken to address theses responses so that the athlete can continue to perform: e.g./ physiotherapy treatment, massage, ice baths, stretching, periodisation. However, despite the level of fitness, each body needs to adapt to the demands of the training and play. Without this time, there can be a tipping of the ‘build-breakdown’ balance towards the breakdown (inflammation). A state of chronic inflammation is likely to explain a range of common problems that can become significant.

When an acute injury occurs in sport, there is pressure to resume play as soon as possible. Do players return too soon? Are they fully ready? Being ready means that the body tissue are robust to withstand the stresses and strains, movement patterns are normalised (and not guarded), body sense is acute and thought patterns focus on the game and not on the body.

“the clues are in the story

We do not know all the factors involved with each player at Wimbledon who had to retire, but the points described above are relevant and need consideration. When clinicians are assessing an injury, this is especially so. Each injury or pain moment (the two are different) occurs in a context as we have established. Nothing happens in isolation, we are on a timeline, and hence we must consider how the person may be primed by prior learning. What are the influences upon this current moment? Some will be obvious and some more hidden. This is why allowing the person to tell their story is vital. The clues lie within their narrative, so we must listen actively and be open.

This is a brief look at some of the key issues. Pain and injury are always going to feature in sport. We need to draw upon the pinnacle of our knowledge of pain and bring this into the athletic world. In other words, we need a shift in the thinking away from the biomedical model, instead looking at the wider picture: a true biopsychosocial, or sociopsychobio model. Here is a reminder of the key points:

The key points:
  • pain and injury are poorly related
  • pain is suffered by the (whole) person not a body part (e.g. tendon pain ~ the primary focus remains on the tendon rather than the person)
  • pain does change when it is understood by the person and they actively create new patterns

01May/17

High Performance Sport Knowledge Exchange 2017

High Performance Sport Knowledge Exchange 2017

~ some comments following a really engaging day when I was delighted to be asked to speak at the High Performance Sport Knowledge Exchange 2017 held at the Sport Ireland Institute last week.

I was fortunate to share the speaking platform with Dr Brian Cunniffe, Performance Lead from The English Institute of Sport, and Jason Cowman, Strength & Conditioning Coach of the Irish Rugby Football Union.

It was a great day of discussion amongst people involved with optimising performance, both their own and athletes ~ S&C coaches, elite performance coaches, physiotherapists, support staff, doctors, military personnel and more. I say ‘their own’ because the success of an athlete or sportsperson is intimately related to the way in which the coaching and support staff operate. We are all seeking to do our very best, every day.

Here is a brief summary of some of the points that were raised and talked about in relation to my talk and Q&A. Some great questions were asked.

~ Make each day a masterpiece ~ John Wooden

Despite the talks appearing to be very different, there were in fact some common themes. The emphasis was upon how the team can best function to deliver results, considering communication, facing challenges, developing relationships and trust, and creating a team that delivers. At the heart of this of course, are people with differing backgrounds, views, beliefs, experiences, knowledge, cultures and professions. Everyone has strengths and something to bring to the table, which is where the potency arises once these are clarified.

** As you read and take note, consider that these skills of performing and well-being are as relevant to the coach, physio, doctor, support staff as to the athlete.

Language & the inner dialogue

Language is powerful ~ the language we choose to use with others as well as the language we use to ourselves, the inner dialogue or script. Certainly in my talk and in the Pain Coach day on Tuesday I put an emphasis on developing skilful use of our inner dialogue. So much of what we experience and how we experience it comes from what we are telling ourselves. Realising this and harnessing the potential from running a positive script is hugely empowering. This is a skill that a performance coach, a strength and conditioning coach and a physiotherapist (anyone actually!) can foster and nurture in themselves and those they work with, the athletes and colleagues. Here are a couple of great questions to self that allow you to calibrate and make a new choice:

How am I choosing to feel? How am I choosing to think?

What you are telling yourself right now impacts upon your emotional state and quality of life. Which seeds are you watering? The ones that foster positivity, understanding, compassion, openness and patience or the ones that harness anger, frustration, impatience, and resistance? Developing one’s awareness of the workings of the mind and how thoughts are embodied creates a great opportunity to live increasingly well. This includes the ability to focus and hence perform. There is only this moment in which to focus and perform, whereas the inner dialogue can tend to take us off into the past or future. Of course this will happen but there is a difference between the drift away from the now with awareness and on autopilot. We do not have to be slaves to the wanderings of the mind. Simple attentional training and mindful practices help to develop this skill. We know that a wandering mind is an unhappy mind, so this kind of training is a key skill.

Super-teams

Super-teams can be created to nurture the abilities of the athletes. One of the problems of chronic pain is that people can fall in the cracks between different disciplines. This need not happen with a super team in place that has a clear vision of success that has been clarified and stated. This is known by all team members who have identified their strengths, their reason and purpose and their individual roles. Communication is effective, regular and uninhibited. Strengths are developed and areas of improvement identified and worked upon with a complete focus upon growth together. Naturally this includes the athlete ~ there is no separation between team and athlete, athlete and team. Regular meeting and clarification maintains momentum. The team is steered by a leader who is prepared to truly lead and inspire action by exhibiting courage, authenticity and compassion. This takes time but is of course worth the effort in terms of outcomes.

The problem of pain & pain in sport

Pain is a huge global health burden. Pain costs society because of investigations and treatments, many of which are unnecessary or ineffective, and loss of productivity. The suffering for individuals is immeasurable and of course those close by also suffer the consequences.

The existence of such a significant problem in society means that this is a public health concern of major proportions. Without new thinking this will likely worsen. Arguably we are seeing this in the younger generation as they grow in a world that validates materialism, unhealthy communication (e.g. social media), thinking that the individual supersedes everything (i.e. selfishness), success based on ‘A’ grades or income and pressures to conform to practices that do not nourish self-compassion. 1 in 5 children suffer chronic pain and the statistics on mental health are horrific. I do not use that word by mistake.

I do not believe that the term mental health does justice to the reality that the ‘mental’ condition is embodied, which is why in most cases chronic pain and depression or mood changes come hand in hand. Thoughts are embodied, which is why practices that develop healthy use of the inner dialogue are vital. 

This problem reaching across society means that it does exist in sport. One of the challenges is to differentiate between the pain of being an athlete, the pain of a new injury (expected and understood) and the persistent pain that is due to a range of biological and behavioural factors. This will need athletes and coaches to learn about pain and communicate together with the athlete to establish what is happening and what needs to be done. The super-team vision will include these scenarios in the planning.

~ pain and injury are poorly related

There is no single clinician or therapist for pain. This is a problem and indeed perhaps part of the wider problem (the misunderstanding of pain in society), as the person suffering receives many different ideas about the possible causes and suggested solutions. This is the reason for Pain Coach, which is a blend of the latest understanding of pain together with known coaching methods that work to maximise learning and potential. The over-arching aim of the Pain Coach Programme is to change the way society thinks about and hence addresses pain. And there are exciting times ahead on the basis that we need to be talking about and enacting overcoming pain, not just managing and coping.

#upandrun

In relation to sportspeople, we can focus upon an understanding of pain that works for performance coaches, S&C coaches, clinicians as well as the athlete himself/herself. Working together to understand will be key and there is no reason why workshops cannot be run with the super-team that includes all these people. In fact, everyone needs to understand pain ~ the reason for UP | understand pain.

Chronic pain in sport is a blight upon the careers of many. Open discussion and an open forum for athletes to talk and express their fears is important as this provides an opportunity to face the problem, or rather the challenge, learn and overcome. Only by facing our challenges can we truly surmount them and move on. Distracting, avoiding and circumnavigating do no good in the long-term. I acknowledge that there is a place for a ‘patch up’ before an event if need be, but thereafter the challenge must be addressed. Again, the super-team creates the environment and context for this to happen.

Communicating

Language and the content of the inner dialogue has been mentioned but what about delivery: Who? When? How? And there’s the vital part, active or deep listening. Only through listening deeply can we truly hear what is being said. Paying the fullest attention (there’s the practice of paying attention again!) to this moment and what the other person is saying creates a trusting bond and an opportunity to gain insight. This insight delivers all you need to know right now. Sometimes just listening is all that is needed right now. The gifts of ‘you’ and time are two of the most valuable in life. This is easily practiced both at work and at home and soon enough you find yourself to be proficient and increasingly effective.

Some good questions for self:

~ after a training session, who speaks first? Who does the most talking? Who has the key information? 

Summary

There was much more discussed through the day and in the Pain Coach day on the Wednesday before. Hopefully this has provoked some new thinking and realisation. The beginner’s mind is open to possibility and opportunity. We are designed to change and grow as each moment passes. It is a matter of choosing which direction, which begins with realising that we have a choice. The awareness of choice is empowering and exciting but comes with responsibility.

All of us in the room have great jobs that we are passionate about and feel inspired to perform each day. We have meaning and purpose. This drives us to be successful because we always strive to be the best that we can be. That is exciting and fulfilling.

Choose to feel excited.

RS

For further information about Pain Coach training and mentoring, please do get in touch: [email protected]

Facebook & Twitter @painphysio or frequent updates

23Nov/14

Why do Arsenal and MUFC have so many injuries?

Arsenal Football Club have apparently reported 30 injuries since August, and Manchester United 37 injuries. Why so many?

Injuries are more complex than perhaps initially thought. It is not simply that a player runs out onto the field, clatters into another player, changes direction or bursts into action. There is a huge amount of multi-system activity, both conscious and unconscious that biologically underpins every injurious situation.

For example, a seemingly ‘simple’ ankle sprain is this: a disrupted ligament releases inflammatory chemicals that excite the normally quiet danger receptors on nociceptors; nociceptors send danger signals to the spinal cord to communicate with secondary neurons that are influenced by a flow of signals coming downwards from the brain. The sum of this give and take reaches the brain. According to whether a threat is determined or not, the appropriate response is pain, drawing attention to the affected area so that the right behaviour can be assumed, promoting recovery and survival. Pain is a need state, driving and motivating action.

The danger signals, for there are no pain signals or even a pain centre in the brain, are chemical messages until given meaning by the emotional centres of the brain. This is based on the context of the situation, beliefs, immediate thoughts, previous experience and the environment to name but a few. The injury is deeply embedded within all these factors, none of which are stand alone.

To illustrate, a professional footballer who sprains his ankle could think: ‘how will this affect my career?’, ‘how long will I be out?’, ‘will this affect selection?’, ‘is this the end of my career?’, ‘what will this cost me?’ etc. The question to ask is how is this thinking likely to affect pain? Are those thought threatening? Of course they are, and hence affect the way in which the body protects. As well as promoting the right environment for healing (bottom up), one has to create the right conditions in all body systems (top down) by cultivating the right thinking and with definite action. Until thoughts and beliefs flavour nociceptive signalling, there is no meaning, and without meaning there is no pain. We need pain to survive, but we also need a logical and rational meaning.

Within the culture of football, there are certain beliefs and memes around injury. This will be the case regarding ankles, hamstrings and groins. Just listen to the pundits to hear their comments on these injuries to know this fact. How much of it is fear-based rather than being based on pain science and basic biology? Tackle this and you are more than half-way towards creating the right conditions for recovery.

Injury is incredibly complex because we are incredibly complex. Drawing upon this modern way of thinking about pain and injury and I believe we can tackle this increasing problem of recurring injuries in sport more effectively.

Persisting sports injury? Recurring injury? Football injury? Call now 07518 445493

18Oct/14

More Premiership injury woe

Headlines today in The Guardian sport section report that Daniel Sturridge is suffering from a further strain, this time in his calf. I do not know if this is the same leg as the thigh strain from which he has recently recovered, but if so, I would not be surprised. In addition, we learn that Raheem Stirling told Roy Hodgson that his legs were sore. Anyone who plays sports will know that feeling.

A second injury or pain on the same side — why?

When we injure a muscle or ligament, inflammatory chemicals are released locally. Danger-sensing nerves (nociceptors) are activated by these chemicals when their threshold of firing is lowered. Danger signals are sent to the spinal cord, where modulation takes place with signals being sent down from the brain — these are in response to thoughts, emotions, context, perceived danger etc. The danger signals are then sent up to the brain via a second neuron, where an analysis of what is happening takes place. On concluding that there is danger, pain emerges from the body in the place where it is thought the problem lies. The body uses cortical (brain) maps to allocate the pain in the body. Put simply, the biology of pain does not reside in the injured tissues but instead involves the protective functioning of many body systems working together.

Once protection kicks in, pain draws our attention to the area, our movement changes as does our thinking amongst other things. This does not involve only the injured body region, but widespread responses of body systems that protect us from actual and potential threat. The original injury goes through a healing process — we have incredibly potent healing abilities — yet the sensitivity and protection can persist. If, for example, the thigh is strained, it is all the ‘wiring’ that involves the leg that will be on alert. Without full resolution, and this includes confidence in the body, the systems are primed and hence during this period it is easier to ‘pick up’ another injury. Sometimes there is an actual injury and damage, but often there is nothing discernible yet it hurts in the same way. Differentiating an actual injury from the sensation of an injury is important. Players and coaches understanding these mechanisms (of pain) is vital in my view, so that these problems can be tackled efficiently. It would be straight-forward to deliver a mandatory, FA backed education package — contact me for details of an education programme.

In summary, why do pains appear on the same side? Because the initial sensitivity has not fully resolved in the case when no actual injury can be found. If there is a strain or sprain detected, there is a good chance that motor control, body sense and awareness and or confidence are not complete. Of course, there is always the possibility of just plain old bad luck, however I would suggest that it is more likely that the body remains in a degree of protection mode.

Aching legs and recovery

Briefly, the body needs time to recover from the demands of exercise. This can be all out rest for a short period but also active rest that would be a lower intensity of movement and activity; a skills based session for example. There are ways of enhancing recovery that include focused movements and body awareness exercises as well as the practice of mindfulness. We have a great ability to adapt, and in fact our body systems are continually changing and adapting to our lifestyles. This is one of the reasons for chronic health problems in a society that is ‘wired’ and ‘immediate’. Put simply, our bodies are not designed in this way.

Educating players about pain, injury, recovery and health empowers them to make good decisions. With coaches and managers also understanding these principles, it creates a positive culture with clear communication about injury and pain. A player should always feel that he can talk openly about how he is feeling, physically and mentally — although I would argue that these are one and the same because we are whole person: genes, character, personality, experience, knowledge, beliefs, mind, body etc., with no single feature standing above the others.

Contact me for information about pain seminars and training at your club — 07518 445493

 

27Aug/14

Murray’s attack of the cramps

Most active people have suffered the agony of cramping. The uncontrollable vice-like spasm squeezes the blood out of the muscle, the acids build and the oxygen level drops. End result: writhing or hopping around until the tightness eases and pain gradually subsides. It is not uncommon for the effects to be felt for a day or so afterwards, much like post-exercise soreness. Usually there is one affected part of the body whilst Murray reports to have felt the cramping in his thighs, his trunk and forearms, a more widespread pattern.

Murray’s health team will monitor his electrolyte levels closely and implement a diet that optimises his needs. Widespread symptoms that are more suggestive of a systemic biological response is then, less likely to be explained by an issue of ions through dietary or liquid deficiency. However, we cannot totally eliminate this factor as the demands of any particular game are unique, both physically and psychologically — the two being inextricably linked as the whole person responding to a situation. As Murray says, you cannot really prepare for a game via practice. Practice is just that, practice. Hence the requirements are always different.

Nothing happens in isolation. The cramps did not just come on. They were the end result of a mass of biological activity in many body systems before emerging as a response by the whole body and person in an attempt to stop Murray playing at that moment. Inconvenient as this was at the time, Murray’s biology prevailed as it must, and he is subject to his biology as are we all. This biology is influenced enormously by cognition, that is, the way we are thinking, and the way we are thinking about our thoughts (metacognition), how we feel, and how we are thinking about how we are feeling. Understood? For there are chemical underpinnings to thought as much as movement, and movement is far more complicated that one may think. Our motor system is really a sensorimotor system. Actually, it is a ‘sensorimotorimmunoendocrinogastroautonomomusculoskeletal system’. That is no joke either. We are complex.

A thought, ‘I am thirsty’ initiates action in this system because the plan begins at that point — to get out of this chair, walk to the cupboard, pick out a glass etc etc. You may not even do this, but the plan is enacted. In some people with sensitivity, these thoughts and plans alone trigger pain. The system responds to watching others move as well. This is usually
below our conscious level but affects the way we move. In fact, movement is affected by where we are, who we are with, what we are thinking about doing, what we have done, how we are feeling and many other factors. Fortunately this data is scrutinised by the brain on our behalf before producing the required movement. When all is well, the systems work magnificently. When things go awry, it can range from inconvenience to catastrophic. And if it is at the inconvenient end of the spectrum, catastrophic thinking can have a dramatic effect upon the pain. I wrote about Messi’s experience of severe knee pain in 2012 when he collided with the goalkeeper. He thought his career was over because of the intensity of the pain. Examination revealed a bruise. He was playing again the next week. Pain is moulded by the situation, past experience and immediate thoughts.

Having seen huge numbers of people with chronic pain, complex pain and dystonia (a movement disorder that is characterised by unwanted and involuntary movements), one could think of a sportsman’s cramp as a transitory form. In rare cases, paroxysmal exercise-induced dystonia (PED) is diagnosed. This is a type of dystonia that is triggered by physical exertion and characterised by a sudden onset of dystonia movements: involuntary, painful spasms, torsional movements. They come and they go.

Another problem that is familiar is the yips. Arguably best known in golf, this is when a well rehearsed and automatic movement becomes conscious and falls apart. This can only happen if you are an expert. On addressing the ball, the ensuing swing is so natural, honed via thousands of rehearsals and practices, under normal circumstances. When the yips grips, this is forgotten and literally, the player does not know what to do. This is a problem of conscious thought and focus but also an issue of movement, an example of how mind-body are so integrated and bidirectional in terms of influence.

Hopefully Murray will not suffer a further bout of widespread cramping. I am sure that the medical team are looking at the footage and talking to him to establish the possible explanations and causes. It may be a one-off but thought needs to be given to why this happened and what has happened to learn and then reduce the risks of recurrence.

17Apr/13

London Marathon 2013 | Dealing with the aches and pains

Most runners will have put in the hard yards by now and are set to go. Undoubtedly there have been quite a few aches and pains along the road so far. Sadly this will prevent some people from participating, say in the case of a stress fracture – click here.

It is entirely normal to experience pain as a result of exercising. We expect it after new or unaccustomed activity and recover quickly, often independently and sometimes with assistance (e.g./ physiotherapy, massage). The marathon will be no different as limbs and bodies will be sore on Sunday afternoon and evening, most likely building into Monday and Tuesday before starting to settle. This kind of sensitivity is an adaptive response to the demands placed upon the tissues and physiological systems. In essence it is the body asking for a rest, motivated by the unpleasant sensations.

If there have been more significant niggles during the training period, these may flare-up and require professional attention. For example an issue with a tendon. A diagnosis followed by a comprehensive treatment and rehabilitation programme will be needed to address such a problem or an injusy sustained on the day of the race.

For further information about post-marathon treatment and recovery please contact us on 07932 689081

Clinics in Chelsea – Harley Street – Temple – New Malden

Common running injuries include: shin splints, anterior knee pain, ITB syndrome, iliotibial band syndrome, hip pain, hamstring pain, calf strain, ankle sprain. We see the more persisting and recurring running injuries at our London clinics, delivering comprehensive treatment and rehabilitation programmes that are based on the latest neuroscience.

13Apr/13

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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