What is Shockwave?

generating-a-pressure-wave-300x188

Extracorporeal shockwave therapy (ESWT) uses acoustic pulses to help to improve tissue healing and reduce pain. Pressure waves inside the shockwave unit are generated inside the unit balistically. Compressed air rapidly speeds up a projectile in the transmitter of the unit. The projectile is abruptly stopped by hitting the transducer head and the pressure wave is transmitted into the tissue using a water based gel. Within the target tissue the mechanical energy is converted to chemical energy.

How does Shockwave help?

The common treatment sites treated by shockwave are the tendons. In several areas of the body including the hips, knees, ankles, shoulders and elbows, these tendons do not have a good local blood supply. Over time micro trauma, small injuries without proper healing, can create a situation where the accumulated failed healing can result in pain. Research has shown that these tendinopathies areas do not respond well to techniques such as cortisone and anti inflammatory medication. When the target tissue is the tendon research has shown that energy produced by the shockwave unit during a treatment session affects the tendon at the cellular level. Through a chain of events at the cellular level, there is an increase in production of structural protein of the connective tissue known as collagen. Circulatory changes also occur resulting in improved blood flow to the area. This is dependent on the frequency used during the session as well as the intensity of the treatment waves.

What can I expect from a shockwave session?

Your physiotherapist will localize the area to be treated using a thorough assessment to determine if it is appropriate for you. A water based gel is used to conduct the pressure wave into the tissue and is not moved around to the same extent as an ultrasound head. Once the shockwave treatment has begun you will hear the noise of the projectile striking the transducer at a frequency determined by your therapist to maximize benefits and minimize discomfort. Since pressure waves are being used there can be mild discomfort that is felt during the treatment session however this is usually temporary. Your physiotherapist may increase the intensity of the shockwave slightly if the session is being tolerated well but will ask you before this is done. The shockwave treatment is generally complete after a few minutes after which your physiotherapist will utilize other techniques to address movement or strength imbalances that may have contributed to the pain. You may notice a slight discomfort or occasional reddening of the areas treated after the shockwave session. You will be able to return to work and even continue with sports after the session, however for a few conditions you may be asked to refrain from certain aggravating movements. Most conditions require between 3 to 8 treatment sessions usually spaced five to ten days apart. There can be immediate changes in pain after the session; however tissue regeneration will take time.

Conditions that can benefit from Shockwave

Studies have shown shockwave to be a beneficial treatment approach for a variety of orthopaedic conditions including:

Tennis elbow
Calcific tendinitis of the rotator cuff
Achilles pain
Hip pain
Patellar tendinitis
Achilles Tendinopathy
Muscle pain
Myofascial pain and more

For more information or to determine if shockwave is appropriate for your condition talk to one of the physiotherapists at Family Physiotherapy.

The physiotherapists at Family Physiotherapy are trained in the safe use of Shockwave for orthopaedic conditions. We serve the areas of Thornhill, Markham, Vaughan and Toronto

References

Mani-Babu S., Morrissey D., Waugh C., Screen H., Barton C. “The Effectiveness of Extracorporeal Shock Wave Therapy in Lower Limb Tendinopathy” The American Journal of Sports Medicine 43 2014

Speed, C. “A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence” British Journal of Sports Medicine 48 2014

Dreisilker, U. “Enthesopathies” Shockwave Therapy in Practice 2010

Breaking the Cycle of Injury: Treatment for Tendinopathies

By Brianne Burton, PT

What is a tendon?

A tendon is a tissue that connects muscle to bone. Unlike muscle, it does not contract, but it is connected to a muscle pic-1-235x300 that contracts so it sustains loading forces every time that muscle tightens. Tendons are made up of many bundles of fibers of collagen, which form a strong but flexible tissue.

The rotator cuff muscles of the shoulder connect to the

humerus or arm bone via tendons, shown above in white.

Image from Nucleus Medical Media / Getty Images

What is a tendinopathy?

The word tendinopathy refers to a non-rupture injury affecting a tendon. You may also hear people use the word tendonitis. There has been a shift in recent years favoring the word tendinopathy because it is a more general term, whereas tendonitis focuses the presence of inflammation, which may or may not be there. The two terms, however, are often used to talk about the same thing. Tendinopathies can occur at any tendon in the body. Some common sites include: rotator cuff tendons in the shoulder, tendons in the elbow (also known as lateral and medial epicondylitis), the hamstring tendons in the posterior thigh, patellar tendon in the knee, and the Achilles tendon in the ankle.

What causes a tendinopathy?

When a tendon is continually exposed to loading forces (such as compression, friction, or tension) that are beyond its capacity, a cycle of injury begins. The cycle of injury, inflammation, and repair happens repeatedly with each movement involving the tendon. This results in pain, swelling, and an accumulation of poor-quality tissue that never has the chance to fully heal. Overuse tendon injuries are common in athletes, but also common in less active people and people with jobs that require repetitive movements.

Why do overuse injuries happen?

It may be more correct to think about these injuries as ‘continued misuse’ injuries. Most often, overuse of the tendon in the wrong way is what actually leads to the injury. For example, if you have poor posture (slouched shoulders) and you continually reach overhead during volleyball, a tendon will be out of alignment; causing it to rub against the bone that sits above it. The repeated friction force starts the cycle of injury. This is what commonly occurs in a rotator cuff tendinopathy of the shoulder. The activity brings on the injury, but the root of the problem is improper positioning from poor posture.

Tendinopathies are also common with a sudden increase or change in load on a tendon, for example starting a new sport/activity or abruptly changing running surfaces. Use of improper equipment, for example worn out footwear or incorrect chair height in a workspace, also puts someone at risk for developing a tendon injury. Other risk factors for tendinopathies include smoking, obesity, hypertension, dyslipidemia and certain drugs like statins, flouroquinolones, and corticosteroids.

What happens to a chronically injured tendon?

When a tendon is chronically injured, some structural changes to the tissue take place. These changes lead to a disorganized, pic-2-263x300 thicker, and weaker tissue that cannot withstand loading forces and continues to cause pain and swelling. Structural changes to a chronically injured tendon include:

Disorganized fibers
A higher number of a smaller, immature type of fiber (type III collagen)
Fewer mature fibers (type I collagen)
Increased number of vessels and nerves
More swelling in the tissue lining
Areas of dead cells

What are the symptoms of a tendinopathy?

Each person will experience symptoms differently, depending on the specifics of their injury. Most commonly people with tendinopathies experience pain and weakness with specific movements (whenever you use the injured tendon), localized pain and stiffness, and pain with increased activity.

What are the treatment options for tendinopathy?

Each tendinopathy is different and it is important to develop an individualized treatment plan; however some common elements include:

• Rest from aggravating activities. An early return to the aggravating activity will increase the risk of re-injury and could have negative effects on the structure of the tendon. Studies have shown that continued exposure to inflammatory chemicals contributes to the break-down of the collagen fibers and encourages scar tissue formation, which will set back recovery time.

• Electrotherapeutic modalities, like ultrasound therapy or Extracorpeal Shockwave Therapy. Shockwave therapy can be effective for stubborn injuries that are slow to heal.

• Manual Therapy to stimulate healing and encourage proper alignment of collagen fibers

• Eccentric strengthening. An eccentric contraction is a type of muscle contraction where the muscle is lengthening instead of shortening. For example, slowly lowering a weight with your arm is an eccentric use of your biceps muscle. Studies have shown that eccentric strengthening programs have produced better results than other programs because this type of loading stimulates tendon remodeling and leads to improved collagen structure and organization.

last-pic-300x149

Image from http://www.mdhealth.com.au/eccentric-based-strengthening/

• Your physiotherapist will assess your movements and address any contributing factors that are specific to each person (such as improper posture or poor joint mobility). These factors may have either contributed to the injury in the first place, or developed since the injury occurred.

At Family Physiotherapy, we pride ourselves on providing a comprehensive assessment and individualized treatment for your tendinopathy. Don’t hesitate to contact us if you are experiencing these symptoms, have had a recurring tendon injury, or feel you are at risk for developing a chronic tendinopathy.

References:

[1] Scott, A., Backman, L. J., & Speed, C. (2015). Tendinopathy: Update on pathophysiology. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 833-841.
[2] Murtaugh, B., & Ihm, J. M. (2013). Eccentric training for the treatment of tendinopathies. Current Sports Medicine Reports, 12(3), 175-182.
[3] Coombes, B.K., Bisset, L., Vicenzino, B. (2015). Management of lateral elbow tendinopathy: One size does not fit all. Journal