A chiropractor who gets it right

I was surfing around the Net today and found a chiropractic site that gets the whole tendonitis/tendonosis issue exactly, 100% right. Now among the people I talk to, chiropractors aren’t generally known for having the strongest scientific background. And on most chiropractor internet sites it’s true that you’ll be hard-pressed to find much in the way of scientific references. But this one has four, and if the entries are a bit dated (1998-2000), the information given is good.

In a post called “Goodby Tendonitis, Hello Tendonosis”, Doctor of Chiropractic Warren Hammer posts the following:

Tendonitis is now considered a relatively rare condition. The good news is that with the diagnosis of tendonitis, patients were expected to get well in a short time, but with the realization that it is really tendinosis, more time is required (six weeks to six months, depending on the chronicity) for treatment and healing. In many cases such as Achilles tendonitis, patellar tendonitis, lateral epicondylitis and rotator cuff tendonitis, a good percentage of cases do not get well as soon as we might desire. We do not have to blame ourselves. What we have to do is explain to the patient the underlying tissue damage that exists. Corticosteroid injections and NSAIDs cannot really heal a noninflammatory condition.

There is so much good information in that paragraph it’s just amazing. The acknowledgment that “tendonitis” generally isn’t tendonitis at all, but tendonosis. That it’s not going to get better with just a shot of cortisone. That there is actual tissue damage. That the usual anti-inflammation protocols simply aren’t going to work.

Despite the fact that Dr. Hammer’s article is short (just four paragraphs), he has several scientific references at the bottom (including two from KM Khan, who has to be my all-time favorite when it comes to debunking the terminology associated with tendon conditions). When you compare this to some of the more popular “health” sites out there – most of which are full of self-serving ads and don’t bother to look at even a shred of real science – well, I hope the difference is obvious.

I really have to emphasize this point. No matter what word you use, chronic tendon pain is a medical condition, and if you want to get the best results you’d better be working with real, scientifically proven methods. Not doing so is like needing an appendectomy and choosing some jungle-dwelling witch doctor over a Johns-Hopkins trained surgeon. Silly!

Dr. Hammer goes on to say:

Our treatment should emphasize the prevention of collagen breakdown, which requires rest and strengthening […] We must prevent collagen damage and, most importantly, stimulate collagen synthesis.

Again, right on target. Chronic tendon pain is not inflammation, but actual degeneration of the tendon itself. As such, your first priorities should be to (a) prevent further damage and (b) start exercises to make the tendon regain its lost strength. (Target Tendonitis explains how to do this in detail.) Done right, it shouldn’t actually take more than a week or so to start seeing really significant results. Two months (not the six given by Dr. Hammer; there have been some advances in knowledge since the year 2000) and you should be pretty much back to 100%.

That said, please don’t just run out and buy yourself a pair of dumbbells. Traditional exercise will only make the problem worse. But there are ways of structuring your rehab to get the benefits of strengthening exercise without causing further damage. So no matter how many useless cortisone injections you’ve received, no matter how much unnecessary frostbite your elbows and ankles have suffered from icing to get rid of misdiagnosed “tendonitis”, don’t give up hope! There is actually a method of treatment that you can do at home, on your own time (and for free!) that will work.

A doctor who gets it (somewhat) right

I was surfing around the web a bit and came across Dr. Stephen M. Pribut’s Sport Pages.

I don’t have a lot good to say about how most doctors deal with tendonitis (generally not even calling the condition by its proper name), but here’s one who does at least gets that part right. On his page, Dr. Pribut has this to say about Achilles tendonitis (the emphasis is mine):

While the term that most people use and that most individuals will search for on the web is “tendonitis”, most Achilles tendon problems could better be called a tendinopathy and more specifically a tendinosis and are a non-inflammatory problem of the tendon. Inflammatory cells are not found on microscopic examination.

So for all the people who think that I’m blowing smoke, here is a gen-u-ine MD saying exactly the same thing. It’s enough to make me weep.

Of course, the good doctor then goes on to prescribe more or less the usual treatment, including ice massage and NSAIDs. If he realizes that “tendonitis” is not really tendonitis (i.e., not inflammation) but tendonosis (degeneration of the tendon), this is a little hard to understand, as both ice and NSAIDs are for, um… inflammation. Maybe he’s worried about getting sued for malpractice if he doesn’t toe the party line, maybe he’s just covering his bases. Or maybe it’s because he hasn’t taken a look at any research later than 2002, as is shown by the references at the bottom of his page. (At least he has references, which is better than most other websites.)

Another quote:

At this time there are few significant clinical studies with valid results for treatment. There is often disagreement on approach and much is likely to be changed in the future. At this point treatment and treatment recommendations for this problem remain an art practiced with varying degrees of success. When evaluating new research, it is hard to recommend major paradigm changes in thought and recommendations based on studies of fewer then 20 cases or even 50 cases.

Actually, a quick search on PubMed will show that there have been more than 100 well-designed studies on various treatments for all kinds of tendonopathy in the past decade or so. If you’re having problems with your tendons, you can go spend a few weeks wading through all of that research yourself… or you could just buy my book on tendon pain, which is 34 pages of easy-to-understand English and will show you exactly what to do to fix your problem. 😉