I once read that when Sonny Bill Williams was playing rugby league in Australia (a game that is known for its brutal collisions), his club had taken out medical insurance on his shoulders. Whether this is true or not, it opens up my discussion that occupational hazards are a real thing in whatever industry you work in. Being a physiotherapist comes with its own occupational hazards. I have been working for just five years as a physiotherapist, and picked up an overuse injury to my elbow (medial epicondylitis for those who speak the medical language).
The injury developed due to chronic overload during the busy season in the beginning of this year. In our line of work, having a full diary each week is what we want to see, but sometimes the workload takes its toll. Physiotherapy is a physical job, and as a result our bodies do take a physical pounding if overworked. I ignored the pain for about two months, until after travelling with the Bulls Craven Week team I just couldn’t work properly anymore. I had an ultrasound done, and the results showed a chronic insertional tendinopathy, as well as a 5mm intra-substance tear, of the common flexor tendon at the medial elbow. I began the process of recovery, as I could feel that by the day it was getting worse. Pain with work, pain with gym, pain with opening my car door, pain with brushing my teeth…it was a real problem.
We know from current literature that the best way to treat tendon pathologies is a strict loading program. However, because tendons have a poor capacity to heal efficiently, I sought the use of Platelet Rich Plasma (PRP) injections. Basically, they draw blood from your one arm, spin it in a centrifugation process, retract the PRP (white/yellowish substance in the picture), and inject it into the site of pathology. The short end of the theory behind it is that PRP is a concentrate of platelets and growth factors, which when injected into a site of pathology amplifies the healing process (these processes include neovascularisation, tenocyte proliferation, fibroblast proliferation, and recruitment of inflammatory cells). I did a literature search to identify the efficacy of PRP use in tendons, and unfortunately the evidence is varied. There is strong evidence that it has positive results in patella tendons and lateral elbow tendons, but there are also conflicting studies that show poor significant results for these areas. At the end of the day, I decided to try the procedure as I believe that, although the evidence is not extremely convincing for its use, there have been positive results. For me, I think it is a hard decision to make when deciding on medical procedures or treatment techniques, as academic literature may tell a different story to clinical experience. There is reasonable evidence for PRP use, and that was good enough for me to try it (I think my curiosity of the potential success of the procedure was more of the deciding factor).
As I stated earlier, tendons respond to load. To supplement the PRP therapy, I followed an eight week progressive loading program for the tendons of the wrist flexors and pronators (all having attachment to the site of injury). I unloaded the area by learning to work with my left hand, taking out gripping exercises in gym routines, and taping/bracing to unload the tendons (by the way you won’t find my taping technique in a textbook, but it worked!!). I had three PRP injections over six weeks (spaced out every two weeks). The results were painfully slow, but positive. This is the key factor in treating tendons, it requires patience. And this needs to be conveyed to the patient from the initial session of therapy. It took me six weeks of focused rehab and load management to get to a point where I felt I could return to normal routines (such as gym, and working with my right hand). But the issue is not over just yet as the final phase of functional progressive loading needs to occur in my exercise and work routines. I definitely have a new understanding of the tendon pathology recovery process, and believe that as therapists we need to educate our patients more on the lengthy healing process for these injuries.
Currently, eight weeks since beginning the rehab process, I am at appoint where I can work comfortably with no pain, have begun heavy loading exercises such as pullups and gym exercises (this was extremely painful eight weeks ago), and have progressed my local tendon loading (flexion and pronation) up to 12kg and 8kg of weight respectively. Next goal- have a round of golf with no pain!
Key learnings form this process of recovery:
- load management in tendon pathology is essential (work was my overload factor, and this had to be modified)
- pain diaries are useful to manage how much and when to load, and how to progress loading.
- it is essential to stick to the loading program BECAUSE TENDONS DO REACT TO LOAD!!
- PRP may be useful as a supplementary procedure to tendon loading
- patient education is the golden answer to recovering from tendon pathologies
- psychological effects of pain are big role players in injury management
- we need to set SMART goals for our patients (for me the first goal was working pain free)