As the understanding of tendon injuries has shifted paradigms over the years, so has the treatment style. While tendinopathy conditions were initially treated as inflammatory stages, treatment was built around addressing the inflammation in the tissue. Treatment involved icing, anti-inflammatory medications, bracing, and rest. ​As the research shifted towards identifying degeneration in the tendon instead of inflammation, eccentric exercises and instrument assisted soft tissue mobilizations (IASTM) became a primary focus of treatment. Eventually, the paradigm would shift again, revealing limited evidence behind both eccentrics and IASTM.

At this point, we still have not discussed arguably the most important topic for treating tendinopathy: Pain Science Education! Much of the research regarding pain that has come out over the last decade has shown the lack of correlation between pathological imaging findings and pain.  Under an MRI or Ultrasound, a tendon may show degeneration or inflammation, but these findings don't relate to one's individual level of pain. Understanding the function of pain, it is clear that a single snapshot of the tendon at one point in time is not as important. For this reason, I promote the tissue irritability treatment strategy discussed further in this post.

Tendon Training: 
​Concentric, Eccentric, or Isometric Exercise?
When it comes to tendon strengthening, eccentrics have not shown to be any more effective than concentric exercises. In fact, isometrics have been shown to have a pain-modifying effect almost immediately! What appears to be most important with exercise selection is choosing the appropriate load at each phase. Isometrics tend to be more useful early in the treatment protocol with a gradual progression to concentric and eccentric based exercises.

While tendon pain may start with a specific event, it is more likely associated with a repetitive motion. For example, a single jump during a basketball game will not cause tendinitis, but rather jumping hundreds of times during a game may cause damage to the tendon if not properly trained. Tendons, like most tissues in the body, are adaptive. When regularly stimulated through exercise or movement, the muscle and tendon contract and stretch. 

​As a general rule, remember that slowly strengthening, then appropriately resting are two keys to a healthy tendon. If someone has been running two miles regularly and wants to increase the mileage to eight miles per day, slowly increase the training volume every week or two. Start with three miles per day, then progress up to four miles, and then five or six miles per day. Do not forget about rest! Rest is the component most often missed. As the volume of running increases, more rest days must be built into the training plan. Pre-emptively take a rest day between running days and always listen to subtle signals of soreness, discomfort, and pain that may indicate overtraining. 

I distinctly remember the first few times I performed manual therapy on the cervical spine. My hands were sweatier than normal, and I had an unusual shakiness in my fingers. For some reason, I thought everyone with cervical pain was on the verge of having upper cervical instability. While this mindset was irrational, it may have been something that was instilled in me during physical therapy school. This fear was likely due to a lack of experience with the cervical examination and techniques.

In many instances, the examination begins in sitting following the subjective history. Depending on the subjective information, various safety tests and measures may need to be completed. While all safety tests may not be completed on every cervical evaluation, having them accessible is important. Assuming the patient is appropriate for physical therapy, many other tests can be performed in the seated posture to assist in making the appropriate physical therapy diagnosis. For example, shoulder active range of motion should be performed to determine if this region is a pain generator or contributing to the cervical pain. Additionally, a seated upper rib mobility assessment should be performed to determine if the ribcage is contributing the one's symptoms. The complete flow of tests and measures can be seen in the picture below.  ​

During my residency, I had the pleasure of hearing Dr. Cohen, D.D.S. speak on the TMJ. Dr. Cohen is an Orofacial Pain Specialist that works out of the Phoenix area. As you may have noticed, we have not exactly covered the TMJ significantly before on this website due to what we thought was a low prevalence. However, as you'll soon see, it couldn't be further from the truth. For example, did you know that the American Dental Association does not require Dental schools to teach the temporomandibular joint? In fact, treatment techniques for TMJ issues by dentists (distraction, surgery to alter the bone/joint structure, etc.) often actually cause a greater TMJ issue or sometimes a TMJ issue that otherwise did not previously exist. As physical therapists, we are in an excellent position to screen for dysfunction at this joint and direct the patient to proper clinicians if appropriate.

References:
Cohen, Richard. "Temporomandibular Dysfunction." Scottsdale Healthcare Orthopedic Residency Lecture. Scottsdale Healthcare Osborn Campus, Scottsdale, AZ. 21 Jan 2014. Lecture.

Ho S. The Temporomandibular Joint: Physical Therapy Patient Management Utilizing Current Evidence. Current Concepts of Orthopaedic Physical Therapy, 3rd Ed. La Crosse, WI. 2011.

Neumann, Donald. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd edition. St. Louis, MO: Mosby Elsevier, 2010. 427-438. Print.
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Young PA, Young PH, Tolbert DL. Clinical Neuroscience. 2nd edition. Philadelphia PA: Lippincott Williams & Witkins, 2008. 145-149. Print.
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Whether you are studying for a PT school practicum, the OCS examination, or simply brushing up on your cervical spine knowledge, these infographics can help! 

In many cases, the patient's subjective history alone should be enough to diagnose the musculoskeletal issue. Whether it's the mechanism of injury, location of pain, and/or pattern of pain, we are often able to formulate our treatment plan from the patient's subjective report. That being said, there are cases where the subjective report doesn't match the typical presentation and is, therefore, insufficient in evaluating the patient. It is for this reason that we must be thorough with our examination.

Recently I had a patient that presented with a subjective history of Lumbar Extension Movement Impairment Syndrome (MIS). However, when I got to the objective examination, all the findings matched with a Lumbar Flexion Movement Impairment Syndrome. Cases like this can be challenging due to the conflicting presentation. This is where implementation of an asterisk sign or a system that utilizes asterisk signs can be useful. 

The Atlantoaxial Joint is made up of the atlas and axis, C1 and C2 respectively. The atlas has inferior and medially directed convex facets that are about 20 degrees inferior to the horizontal plane (Neumann, 2010). The axis has superior and laterally directed convex facets that match the 20 degrees of slope inferior to the horizontal plane of the atlas. The joint results in convex-on-convex surfaces (Abernethy, 2013). Due to the anatomy here, there is no sidebend possible at the AA joint. Instead, this joint is responsible for almost half of cervical rotation. Additionally, there is some flexion and extension possible here via bilateral C1 rolling anterior and gliding posteriorly for flexion; the opposite occurs for extension. The axis is different from typical vertebrae because of possession of the dens (odontoid process) (Neumann, 2010). It is theorized that the dens is the remnant of the body of the atlas. This base provides a rigid axis of rotation at the AA joint. The dens is held against the anterior tubercle of the atlas by the transverse ligament, forming a synovial joint between the dens and anterior arch.