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To Inject Or Not To Inject That Is The Question?

When having a steroid injection to combat pain, this is usually given by the healthcare professional alongside anaesthetic. This gives immediate pain relief, but dependent on the site of injection the length of relief will vary. Injections have been commonly prescribed in the treatment of tendinopathies, however, despite the widespread use, there is a controversy surrounding the usefulness and safety of the injections.

On the whole steroid injections have very mixed results depending on the site of injury. Short-term pain control, up to 6 weeks, has been reported as good in patients suffering from tennis elbow and shoulder impingement. However, the efficacy of the steroid injections for the long term has not been demonstrated. In comparison to rehabilitation with a qualified professional, the steroid injection provided no true long-term benefit (6-12months after).

In addition to the question of the efficacy of corticosteroid injections in the medium-term treatment of tendinopathy, there is a question of safety with using these medications in this setting. Several cases of Achilles tendon rupture have been reported after corticosteroid injections to this region. More recently, a study completed in 2004 described a series of 83 injections to the Achilles region without serious complication. These injections were performed under fluoroscopic guidance, simply put this is multiple x-rays taken in one go. Of note, only 40% of the patients in this series reported improvement after the procedure at the 2-year follow-up appointment. As previously mentioned, the effects of the steroid injection have shown to be beneficial in relieving pain in thew short term, but how does the combination of steroid and anaesthetic affect the body?

The healthcare professional will combine the steroid with an anaesthetic to provide an immediate pain relief. It has been reported that there are significant negative effects on tendons when a steroid injection is administered. There is an increase in collagen disorganisation, reduced collagen production and a decrease in cell proliferation. Further to this, the mechanical properties of the tendon are significantly reduced. So what does this mean?

It has been reported that the use of a corticosteroid injection has caused a decrease in the tensile strength of isolated fascicles but it is unknown how the injection affects the whole tendon. This weakening, can make the tendon more susceptible to rupture. It does boil down to what you want. IF you have been suffering with this pain for a long period of time and rehabilitative exercises are showing no signs of improvement, then yes maybe think having an injection to allow you to perform pain free. Remember, this lasts up to 6-weeks maximum, you may only have relief for a few days. This is then tied in with the cost of the injection, unless you are willing to wait long periods of time to get referred on the NHS then you will go privately. This can cost more than £200 a time, and the fact there are no true long term benefits it is up to you whether you see if it is worth it.

All I can recommend is that you speak to a physiotherapist or a sports therapist so they can guide you on whats best for you. We are happy to answer any questions you may have contact jason@cardysportsclinic.co.uk or book in to work out whats best for you in the long term.

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What is your tendon pain and how to best manage this?

Tendon pain is often referred to as a tendinopathy, this can be defined as the failed healing response of the tendon. This is typically associated with many conditions that are brought about through overuse in and around the tendons. This is a common pathology observed in runners.

In comparison to muscles, tendons have an oxygen consumption rate 7.5 times lower, this is essential to carry loads and maintain tension. Subsequently, the low metabolic rate leads to a slow healing rate in the tendon.

A term that has previously been used to define tendon pain has been tendonitis. Simply defined, this refers to the inflammation of a tendon. A tendinopathy has been previously classified as the degenerative change of a tendon with an absence of inflammation. Research has reported that this is not true, instead, chronic inflammation is present in the majority of these cases but the exact role this plays on pain and function is an unknown. Alleviating this inflammation isn’t necessarily the ideal answer, the use of NSAID’s* can be detrimental to the healing process.

The classic presentation of a tendinopathy is after a period of increased activity, whilst the increase in subsequent load relates to the pain that is felt. During the early stages of its presentation, pain can be felt at the start of an activity, disappear during the activity and then re-appear during a cool-down. This pain is typically localised and can be described as a severe or sharp type of pain. When this has been present for some time then this pain can be described as a dull ache in nature.

Example rehabilitation for Achilles Tendinopathy

Level 1 - EarlyDaily Isometric exercises
- Seated heel raise: 3 set of 5 reps (each rep lasts 45 seconds)
Marker for Progression
- Decrease of pain to 3/10 or less
- Isometric exercise causes no pain or discomfort
Level 2 - IntermediateDaily Isometric exercises
- Seated heel raise: 3 set of 5 reps (each rep lasts 45 seconds)
Isotonic Exercises (3 x a week)
- Standing Heel Raise 2-legged, (2 sets 25 reps)
- Individually tailored hip abduction/extension exercises
Marker for Progression
- Pain less than 3/10
- Able to perform 20 DL jumps with no pain
Level 3 - LateDaily Isometric exercises
- Seated heel raise: 3 set of 5 reps (each rep lasts 45 seconds)
Isotonic Exercises (3 x a week)
- Standing Heel Raise 2-legged, (2 sets 25 reps)
- Individually tailored hip abduction/extension exercises
DL Jumps (3 x a week)
- 3 sets 60 reps DL with knee bend
- 3 sets 30 reps DL with stiff legs
- 3 sets 5 reps DL forward/back
- 3 sets 5 reps DL onto a step
Marker for Progression
- Pain less than 3/10
- Able to perform 10 SL hops with no pain
Level 4 - Return to PerformanceDaily Isometric exercises
- Seated heel raise: 3 set of 5 reps (each rep lasts 45 seconds)
Isotonic Exercises (3 x a week)
- Standing Heel Raise 2-legged, (2 sets 25 reps)
- Individually tailored hip abduction/extension exercises
DL Jumps (3 x a week)
- 3 sets 50 reps DL with knee bend (warm-up)
- 3 sets 30 reps SL with knee bend
- 3 sets 15 reps SL with stiff legs
- 3 sets 5 reps SL forward/back
- 3 sets 10 reps SL onto a step
Sport Specific Movements
- Steadily build load
- If symptoms increase regress the exercise
SL - Single Leg
DL - Double Leg

Tendinopathies can often hang about for a long time, depending on the type of care you have been given it can either get better or still be painful. This gets you wondering, how else can I alleviate my symptoms without having to do those monotonous exercises. A well known treatment technique for tendinopathies has been steroid injections. This is purely up to what you feel is best for you, here we talk about steroid injections. If your rehabilitation is completed to a high level and the exercises are targeted correctly the pathology should disappear over time. Ultimately, it boils down to the effectiveness of the exercises and your own buy-in to the exercise prescription.

We are able to treat and manage all tendinopathies that present themselves. Book in for you treatment so we can help and assist you.

*NSAID’s – Non-steroidal anti-inflammatory drugs

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Equipment that can help progress your Rehabilitation at Home

After the conclusion of your treatment with your therapist you should always be given exercises that can help you to further progress away from your injured state. You may think that the kit required to perform some of the prescribed exercises will cost a fortune and not benefit you in the long run. In no way are these products endorsed by ourselves, instead, they are options for kit that can be used to get you back to performing your activity at your pre-injury state.

Type of EquipmentWhy this kit?Product Link
Resistance BandsThere are a variety of ways in which resistance bands can be used. This can be used when stretching your muscles, for resistance strengthening exercises and are a great tool to isolate specific muscle groups.
Trigger Point Massage BallNothing beats having a sports massage and truly feeling the trigger points or knots releasing under the pressure of the therapist. When you don’t have as much time available you need a tool that can help keep the knots at bay, this piece of kit is cheap and very durable.
Foam RollerThis is a great piece of equipment to help relieve tightness in a muscle. Whilst you can use this during a warm-up or cool-down to help with your preparation for exercise or to help with recovery.
Exercise BallA variety of exercises can be performed with this bit of kit. Ultimately, a good level of core stability can help to reduce the risk of injury in the future. An exercise ball helps to work stabilising muscles in the core and lower back. Whilst the ball can be incorporated into a strengthening programme.
Balance BoardThis is perfect to help build proprioception following injury or a period of immobilisation. Proprioception can be defined as the awareness of joint position in space. This is usually used for lower limb injuries but having a high level of proprioception can lead to a reduced risk of injury. A balance board can be used for the upper limb too, for example, performing a press-up whilst on a balance board.

To see how we can help you book in or email us for advice on what would be the best course of action.

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The Causes and Meanings Behind Different Varieties of Pain

Pain comes in all shapes and sizes, and affects all of us in different ways. Most people assume that you only have pain when you have suffered an injury, however, pain can be due to infection, disease or an emotional disorder. Here we talk about the two types of pain with the particular symptoms related to the type of pain.

Acute Pain

This type of pain occurs as a result of an injury and tends to disappear when the injury has healed. In particular, acute pain is linked with injuries to the tissues of the body, whilst anxiety is commonly seen alongside acute pain. We talk about acute muscle injuries and their treatments here. You may suffer from acute pain following invasive surgeries, a strain of a muscle or a collision to name a few examples.

Symptoms of Acute Pain:

  • There is a known site of pain that is easily located
  • Sharp pain
  • A sense of burning around the area of pain
  • Cramping
  • Aching
  • A feeling of pressure
Acute muscle injury

Chronic Pain

We talk briefly about chronic pain here, but we will go into more depth regarding chronic pain. So this type of pain will last beyond the healing period of the injury, whilst the pain can be vague in nature with no indication on the source of the pain. Depression is commonly seen in patients suffering from chronic pain. This can then be subdivided into three types; neuropathic, non-neuropathic or unknown.

Back pain

Neuropathic Chronic Pain – This is usually caused by an injury to a nerve. You will often had tingling, numbness or a burning sensation whilst it is difficult to treat. Examples of the common reasons for neuropathic chronic pain are; diabetic neuropathy whereby the high blood sugar has caused nerve damage, pain from a viral illness, shingles or a peripheral vascular disease. Symptoms are:

  • Painful itching
  • Strange sensations
  • Extreme sensitivity to touch and temperature
  • Burning sensation
  • A painful numbness
  • Pins and needles

Non-neuropathic Chronic Pain – This is a pain that is not caused by an injury to a nerve. The most common reasons for this kind of pain is lower back pain, osteoarthritis or rheumatoid arthritis. Symptoms for this are:

  • Lack of location with the pain, may be unable to pinpoint the exact location of pain
  • Gnawing feeling
  • Pounding
  • Deep aching pain

Unknown: There are many causes of chronic pain that are neither neuropathic nor non-neuropathic in category. Symptoms can include a mixture of the symptoms outlined previously. Some possible causes of an unknown chronic pain are:

  • Fibromyalgia syndrome
  • Tension headache
  • Migraines
  • Irritable Bowel Syndrome
Headache

Treatment

Treatment for these types of pain will vary from patient to patient. Not one treatment plan should be the same. You can help prevent the onset of these types of pain through regular exercise and maintaining a healthy balanced diet whilst maintaining a healthy weight.

If you have any of these symptoms book in now so that we can get you back pain free doing what you love.

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Why do I suffer from pain in my muscles following exercise?

No matter how well prepared for an activity we can often find ourselves feeling stiff or sore 1-2 days following activity. This is called delayed onset of muscle soreness (DOMS); this explained is simply the damage of muscle fibres and inflammation following unaccustomed intense exercise.

DOMS commonly occurs in sports and movements that use eccentric contractions more so than concentric contractions. Eccentric contractions occur when the muscle lengthens under load, for example, a footballer trying to change direction quickly will eccentrically contract the quadriceps to maintain stability. Eccentric contraction produces a force over a smaller cross-sectional area of the muscle, this is due to the smaller motor unit recruitment during this contraction.

Following a bout of vigorous exercise, DOMS is likely to occur unless you have developed your training programme to build up intensity over time. However, there are ways that you can help yourself. Firstly, having a sports massage can help; this increases the circulation of blood to the area, whilst an active recovery can also help. What you will find is that pain will increase 24-hours following exercise, with this pain usually peaking around 48-hours post exercise.

You can become more accustomed to the demands of your activity through training. It is key that you understand this is a natural process to occur and is actually a good sign. This muscle soreness represents the muscle becoming stronger than its previous state in response to an effective training session.

If you would like a sports massage to aid your recovery from DOMS, feel free to book in so we can help you be pain free.