We started working with Kingsley Tay a couple of months ago. He approached us for help with knee pain, previously diagnosed as quadriceps tendinitis, because it doesn’t seem to be getting better. He had been receiving treatment from sports doctor and physiotherapist for nine months prior to seeing us.
This was his Instagram post:
I’M TRULY DELIGHTED TO SQUAT WITH ZERO PAIN AGAIN.?
I sustained a knee injury specifically on my quadriceps tendon from a series of back to back competitions since June last year. It was also mainly from the repetitive jumping movement required by the nature of this sports.
Besides affecting my sports performance, it has also restricted heavy lifting in the gym for both squatting and lunging movements..
I’ve tried multiple injury management methods ranging from sports massage to physiotherapy but to no avail. These methods provided me with short-term relief to my injury and failed to solve the root cause of the problem. Hence, the pain keeps coming back whenever I push my body to its limit.
Today marks my 3rd session with @squareoneactive . I’m pleased to say that after merely 3 sessions with them, I was already able to do weighted squat with NO knee pain. Although my knee still feels sore after my beach volleyball practices, it doesn’t hinder my performance during the practice which is AWESOME!? #roadtorecovery
Square One has a unique method when it comes to injury management. They use almost exclusively exercise to treat pain. Following an evidence-based approach, this has proven to be the best long-term pain solution.
Of course we are super stoked that he is getting results from just three treatments in a span of 10 days! This is not our regular approach to tendinitis though. We usually see our clients for four to seven visits across a three-month period.
Kingley’s case was special because he was training full time and we wanted to monitor him more closely.
Who is Kingsley Tay?
Kingsley Tay is a Singapore national beach volleyball athlete. Kingsley started playing indoor volleyball from the age of 13. He represented Singapore in Indoor Volleyball at the 2015 South East Asian Games in Singapore. For the 2019 SEA Games in Philippines, he will be presenting Singapore in Beach Volleyball.
How did Kingsley start with Jesse Cai?
Kingsley approached Jesse after reading our blog entry on tendinitis. In a separate occasion, his friend who is a chiropractic student, suggested he sought treatment from Square One.
We decided to work together after an email interview and in-person meeting.
Is Kingsley a sponsored athlete?
While we work with Kingsley on a pro bono basis, Kingsley is not a sponsored athlete per se.
There is no formal or informal sponsorship agreement between us. All of Kingsley’s social media post about Square One are done out of good will on his part.
FIVB Beach Volleyball World Tour
Just last week, we caught up with Kingsley again. He sprained his ankle during FIVB Beach Volleyball World Tour in Manila. He was also experiencing bottom of the heel pain consistent with Achilles tendinitis.
We did pick up issues with his ankle during his earlier sessions with us but did not manage to address them because of his competition schedule. Unfortunately, this is the plight of working with full-time competitive athletes. They travel a lot and our time with them can be limited.
(For perspective, Kingsley has competed in 10 tournaments around the world between January and May 2019.)
What is Achilles tendinopathy?
Probably one of the most studied tendinopathy in the world. The Achilles tendon is the connective tissue that connects your calf muscles to your heel bone.
Under prolonged repetitive stress, the tendon may become inflamed (tendinitis) or may start to show signs of “degeneration” tendinosis. As such, Achilles tendinitis causes are often associated with overuse or over training.
Signs and symptoms of Achilles tendinopathy include back of heel pain or a sharp shooting pain in the heel. Warm and swelling in the region is also common.
Achilles tendon treatment day #1:
At this stage, it would have been about seven weeks since we last saw Kingsley.
He reported his knee was going on well. He experiences mild soreness at the end of his second game if he plays back to back events.
We went through our clinical examination and moved on to develop an Achilles tendinitis exercises program for Kingsley
The most conventional evidence-based approach to managing Achilles tendonopathy is the use of isometric or eccentric exercises. Generally, most studies recommend isometric exercises for pain-relief. As for eccentric exercises, they work for both pain-relief and loading. The caveat is that the patient must be able to tolerate load within reason.
Exercise #1: Eccentric heel raises
We started with the eccentric heel raises on the edge of stairs. While pain was minimal for Kingsley to perform the exercise, I realised his range of motion was rather limited under load. He was unable to tip toe on one leg (i.e. unable to perform a full-range heel raise). We decided to move on a different exercise at this stage.
Exercise #2: De-loaded heel raises
Since Kingsley was unable to achieve full range of motion at his ankle in a loaded position (standing upright), I decided to try a deloaded heel raise. For this exercise, we got him to lean into a box to take some load off the ankle. In this position, he was able to plantar-flex (i.e. go into a tip toe position). Given the minimal discomfort, I decided this would be a good home exercise for Kingsley.
Ankle sprain: Sense of balance vs. foot stability
Since Kingsley has a history of current strain, we have decided it will be a good idea to work on his ankle stability as well. It is common for clients with long-standing ankle issues to bring up having difficulties with balancing. More often than not, they are refer to a stability issue.
We refer to balance issues as the inability to hold yourself upright with minimal postural sway in relation to GRAVITY alone. A sense of balance issue is usually the direct result of vestibular, visual, proprioceptive malfunction. Motion sickness is an example of a vestibular-visual disconnect condition that commonly results in the inability to stay upright.
Stability, on the other hand, refers to the ability to hold or return to a desired position regardless of external disturbances (i.e. perturbation). Being able to stay upright, or return to an upright position despite me giving you a big push, is an indicator of being stable.
For most patients with recurrent ankle sprains, their inability to hold a single leg step up has more to do with their foot stability than their sense of balance.
If I am unable to hold a hand stand, would you consider that a balancing issue?
Most likely not. I just do not have the strength and coordination to support myself in the position. It is not a matter of being able to orientate myself upright in space in relation to gravity.
Either way, we decided to work on two things: 1) to isolate the big toe movement from the other toes and 2) train the short muscles of the foot
Exercise 3: Toe isolation
Toe isolation is a classic foot or ankle rehab exercises. To perform the exercise, you raise your big toe and your other four toes independent of each other. This means when the big toe is point up, the other four toe stays firmly on the ground. When the four toes are lifted off the ground, the big toe is firming press into the ground.
The purpose of this exercise to increase joint awareness (proprioception) and coordination in your toes. You may be surprised to learn that muscles that are involved in pointing your big toes up are different from those that point your other four toes up.
These muscles also cross the ankle joint. They facilitate with pointing your foot up and down, as well as turning it to face inwards and outwards.
Exercise 4: Towel toe curls
Towel toe curls is an exercise used to strength your intrinsic foot muscles. The movement involved is simple: just crunch up your toes.
Start from the edge of a small towel, you’d flex your toes and pull the towel in under you. Repeat the motion until you manage the bring the entire towel under your foot. Your heel should remain in contact with the ground at all times.
Heel pain exercises ankle sprain exercises
It should be noted that Kingsley’s heel pain was significantly more evident than his ankle sprain. Therefore, our rehabilitative exercises were biased towards the Achilles tendon.
There are different types of ankle sprain. In Kingley’s case, there was no ankle laxity. It was likely a grade 1 ankle sprain that is not associated with any ankle ligament tear.
Mild ankle sprain symptoms may include ankle pain on the insider or outside of the ankle. In higher grade sprains, it might be a painful to weight-bear. I.e. unable to put weight on the affected leg.
Square One’s approaching to Achilles tendinopathy treatment
Again, we are a rehabilitative/clinical exercise clinic. Most of what we do is to help our clients manage their pain or treat their injuries with exercises.
Our Achilles tendinopathy treatment plan is to work on isometric exercises and possible eccentric exercises if there is significant pain. If there is no significant pain, we add load to the exercises and see how the patient responds.
Once the patient is load tolerance we start to introduce heavy loads. This can either be done as eccentric exercises or heavy slow resistance training. We generally prefer the latter because research has shown that heavy slow resistance programming yielded higher patient satisfaction.
Evidence based Achilles tendinopathy rehab protocol
We posted a video of Kingsley performing one of the exercises online and we had some safety concerns from a sports doctor.
The sports doctor had decades of experience working with athletes from various national teams to even regional games such as the Asian Games. His main concern was that applying load to an injury which was caused by loading may be counter-intuitive.
The truth is that I spend most of my time with evidence based practitioners. Loading a tendon is actually the best research treatment for tendon injuries and, therefore, a norm within our community. As such, I didn’t consider it a novel approach.
I understand how loading a tendon injured from excessive loading may sound like a terrible idea. As such, I am sharing 5 papers to demonstrate that tendons actually respond best to load.
Study 1: Alfredson et al (1998, some papers cite it as 1995): Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis
Probably one of the most commonly cited papers when it comes to eccentric exercise protocol for Achilles tendinopathy. At week zero, the intervention group couldn’t run and at week 12, they are back to pre-injury running. Control group: unsuccessful recovery, all were surgically treated.
It’s a really basic study and has a small-ish sample size but I want to point out that it’s published 20 years ago. This was also not the first paper looking at eccentric exercises being beneficial for tendinopathy. The first was Curwin and Stanish in 1984.
We actually knew exercise is good for Achilles tendon pain for a very long time.
Study 2: Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy (2015)
Study 1 is an old study so let’s look at more recent publications.
Does eccentric exercises work for Achilles tendinopathy? What happens if we compare that to just very very heavy exercises?
At the end of 12 weeks, both rehab protocols yielded equally good results with higher patient satisfaction with heavy slow resistance (100% vs. 80%). At the end of 52 weeks, there’s no difference.
This is why we prefer transition to heavy loads as soon as reasonably possible.
Study 3: Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy (2009)
This looks at the patellar tendon. For perspective, let’s compare how eccentric vs. heavy slow resistance training HSR vs. corticosteroid perform against each other.
Results: “Tendon mechanical properties were similar in healthy and injured tendons and were unaffected by treatment. HSR yielded an elevated collagen network turnover. At the half-year follow-up, treatment satisfaction differed between groups, with HSR being most satisfied. Conclusively, CORT has good short-term but poor long-term clinical effects, in patellar tendinopathy. HSR has good short- and long-term clinical effects accompanied by pathology improvement and increased collagen turnover.”
Paper 4: Ten treatments to avoid in patients with lower limb tendon pain (2018)
So this is probably more like a commentary by Jill Cook. Easily one of the favourite tendinopathy researcher.
Point 4: Don’t prescribe incorrect exercise.
“Understanding load is essential for correct exercise prescription. High tendon load occurs when it is used like a spring, such as in jumping, changing direction and sprinting. Tendon springs must be loaded quickly to be effective, so slow exercises even with weights are not high tendon load and can be used early in rehabilitation. However, exercising at a longer muscle tendon length can compress the tendon at its insertion. This adds substantial load and should be avoided, even slowly, early in rehabilitation.”
If we understand how tendon works:
– Slow exercises with weights can be used early in rehabilitation (the two papers on HSR to support this)
– Exercising at longer tendon length should be avoided. I believe this would refer to excessive loading at dorsiflexion
Study 5: Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy (2018)
The recommendation for exercise progression:
#1 On early stages, we keep a daily isometric work … The load needs to be high but avoid muscle fatigue.
#2 Slow isotonic exercises on alternate days. Increase the load (2kg, 4kg, 6kg–12kg).
#3 Increase the speed with functional exercises when base strength is adequate
The paper continues with even more recommendation but we won’t go into details.
So as you can see, research consistently demonstrates exercise is the best approach to tendinitis recovery. I know it’s shocking but data also does show heavy-type rehab programming to be superior in outcomes as well.
Traditional approaches to tendinitis treatment
The sports doctor provided several recommendations for us to consider:
- Where is the deficit, the weakness, the imbalance and what is the compensatory movement and mechanics?
- Insertional Achilles tendinitis happens when the muscle is compensating for another weakened muscle – hence the overload issue. Hence working the tendon even more is not going to solve the issue either. You have to hunt for and work that weakened muscle/s instead
- Check his extensors? Also check his landing mechanics.
Upon multiple requests, the doctor was unable to provide references to support this treatment approach.
While such recommendations are common – even among sports physiotherapist, sports chiropractors, and even sports medicine textbooks – none of the suggestions have been highlighted in any of the papers above.
This is a short insight into what we do in cases of tendinopathy or tendinitis and why we do things our way. If you are suffering from a chronic tennis elbow, supraspinatus tendinitis or patella/quadraceps tendinitis, the above research and strategies will apply to you as well.
Next week, we will post an update on how Kingsley is responding to our care and the next steps he will need to take to achieve full recovery.
Seek Chiropractic First
What is a chiropractor? A healthcare professional trained to diagnose, treat, and manage musculoskeletal disorders (i.e. back pain, frozen shoulder).
What do chiropractors treat? More than back pain. Rotator cuff syndrome, runner’s knee, tennis elbow, and of course injuries of the Achilles tendon and ankle. Pretty much anything relating to your muscles and joints.
What can a chiropractor do? Help you find freedom from pain. At Square One, our commitment is helping our clients get to doing what they want. This is not just living pain-free. We want them to go back to playing professional volleyball at top form, we want them to be able to fly across the globe for a work trip without back pain,
We want to empower you to achieve your goals.
When it comes to sports injury, seeking chiropractic care might not seem obvious. However, sports chiropractors are trained to deliver high quality evidence based care.
Find a chiropractor who has experience working with professional athletes and one who is well versed with the latest research. You won’t regret it.