Acute tendon changes in intense CrossFit workouts

Study: Acute tendon changes in intense CrossFit workout

Habitually overloaded tendons often thicken and increase the tendonopathy risks -- nothing new here.
However as this study points out "it remains unknown whether acute overload caused by strenuous, high-intensity exercise will exert changes in tendons and if these changes can be detected and described by ultrasonography."

This study (note: Achilles, and plantaris tendon ultrasounds were performed before and after a specific workout in 34 healthy subjects)
. . . .noted "a significant increase in the thickness of the patellar and Achilles tendons" in response to strenuous, highly intense CrossFit exercises. Cross fit is not the culprit here, it is the load and load rate. None the less, it is good to know that an aggressive workout can leave us more vulnerable. This is why adequate rest and recovery must be part of your regular weekly workouts. One cannot keep fully stomping on the gas pedal over and over, workout after workout, and not expect problems to creep in if adequate recovery time has not been afforded to the working parts. This study showed changes after just one workout. No rocket science here today, we should see changes, load was applied. This is just good old fashioned "well duh, that makes sense". Here is the problem, we don't always listen to logic, nor do our clients who have goals and timeframes. We live in the "more is better" world now, so stay vigilant on logic gang. Dial your foolish clients in a little, save them some grief.  Yes, this goes for runners and all other venues of activity, there is a reason why we see problems in people with speed workouts more frequently than base miles.

Acute tendon changes in intense CrossFit workout: an observational cohort study. F. Y. Fisker et al
http://onlinelibrary.wiley.com/doi/10.1111/sms.12781/full

“Is your client feeling better because they are truly fixed, or have your prescribed corrective exercises merely raised the capacity and durability of their compensation ?  Welcome to a global industry problem.”  -Dr. Allen

Which hip will have troubles extending ?

Remember this quiz question from 2 weeks ago ? I talked about how the body will compensate to level the pelvis (and eyes and vestibular apparatus).

Lets go further down the rabbit hole.  Here is your question of the week (you may have to go back and review the prior blog post if you are unsure of how the body will cope with the slope.  Here is that first blog post.

Question: Which hip will have troubles getting into hip extension and thus terminal glute-hip-pelvis stabilization ?

Answer:  scroll down (at least think about it for a second)

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Answer:

The leg on the up slope of the beach, the non-water side leg will have to be in a modest degree of knee flexion to shorten and accommodate to the slope. A Flexed knee is not an extended one and it will be far more difficult to extend the hip and get into the glutes. Propulsion will also be compromised.  For you indoor small track runners this will happen to you on the inside leg on the curves of the track. This is why we see so many hamstring injuries during indoor track.  Think about it ! It is not just bad luck.  Go ahead, tally up  your teams history of hamstring injuries, you should find more on the left leg for track runners. It is simple applied biomechanics.   Also, imagine the altered demand on the quadriceps on that flexed knee (the right knee in the picture above, and the left knee in circle track runners). Furthermore, what is the likelihood that the right pelvis will deviate into an anterior tilted posture ? You bet ya, a greater tendency, and thus a possibly shortened quadriceps/hip flexor mechanism.  Do you think this could inhibit hip extension and gluteal function ? You bet ya.  Oh, and one more thing, if you are true gait nerd, you should have asked yourself one more question, what about ankle rocker ?  Yes, you will need more ankle rocker on the beach side foot (flexed knee side). When the knee flexes, there must be more ankle rocker for this to occur, if not, you may implode into some unwelcome arch collapse, because arch collapse offers more false ankle rocker. What a mess huh !   Now, do not be shocked EVER again when your client’s come back from a sunny beach vacation from walking the beaches for hours every day, and find themselves a stark raving mad mess.  It is not the salty ocean air or the tequila, it is the slope. One could make a case that walking up and down the beach should balance things out, but that is only if we are balanced and symmetrical when we start out. Gravity always wins.

One final rant. If you are offering “corrective exercises” to your clients, you had better know at least the basics of movement and biomechanics. And further more, you had better know how to examine for them, and that means hands on assessment of the body, not just looking at how your client moves through a battery of tests. If the prior blog post (here) and today’s blog post principles are not remedial principles of knowledge for you, offering corrective exercises without this knowledge and a physical exam to confirm your assumptions is fraught with disaster, or at least helping your client to build deeper compensations on their prior compensations. Is your client feeling better because they are truly fixed, or have your prescribed corrective exercises merely raised the capacity and durability of their compensation ?  This is the kind of stuff that keeps my new patient scheduling booked at 4-8 weeks out … . .  frustrated clients.

This is why we do not offer online consultations like some do. Because, we have not figured out how to obtain the third dimension needed in our gait and movement observation (thank you Oculus Rift, the future is near) but more so, we cannot take that information and put it together with our own physical examination to determine whether if what we are seeing is the actual problem, or a compensation. Here in lies the pot of gold.

Another clinical pearl from Dr. Allen

Isometrics for patellar tendonitis?

We are familiar with different modes of exercise: isometric, isotonic and isokinetic. Isometric exercises have a physiological overflow of 10 degrees on each side of the point of application (ie; to do the exercise at 20 degrees flexion, and you have strength gains from 10 to 30 degrees); isotonics and isokinetics, 15 degrees. Taking advantage of physiological overflow often allows us to bypass painful ranges of motion and still strengthen in that range of motion. 

In this study, they looked at immediate and 45 minute later pain reduction (not function) comparing isometric (max voluntary quadricep contraction) and isotonic (single leg decline squat) exercises. They also looked at cortical inhibition (via the cortico spinal tract) as a result of the exercises. 

Here is what they found: “A single resistance training bout of isometric contractions reduced tendon pain immediately for at least 45 min postintervention and increased MVIC. The reduction in pain was paralleled by a reduction in cortical inhibition, providing insight into potential mechanisms. Isometric contractions can be completed without pain for people with PT. The clinical implications are that isometric muscle contractions may be used to reduce pain in people with PT without a reduction in muscle strength.” These same results were not seen with the isotonic exercise. 

Did the decrease in pain result in the decrease in cortical inhibition (muscle contraction is inhibited across an inflamed joint: Rice, McNair 2010; Iles, Stokes 1987)? Was it a play on post isometric inhibition (most likely not, since this usually only lasts seconds to minutes post contraction) ? Or is there another mechanism at play here? There has been one other paper we found here, that shows cortical inhibition of quadriceps post isometric exercise. Time will tell. In the meantime, start using those multiple angle isometrics!

The Gait Guys

Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J.Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy Br J Sports Med. 2015 May 15. pii: bjsports-2014-094386. doi: 10.1136/bjsports-2014-094386. [Epub ahead of print]

http://www.anatomy-physiotherapy.com/28-systems/musculoskeletal/lower-extremity/knee/1163-isometric-exercises-in-patellar-tendinopathy