Potential reasons behind bilateral tendinopathy symptoms

: On today's episode, potential reasons behind bilateral tendinopathy symptoms. Welcome to the podcast helping you overcome your proximal hamstring tendinopathy. This podcast is designed to help you understand this condition, learn the most effective evidence-based treatments and of course, bust the widespread misconceptions. My name is Brodie Sharp. I'm an online physiotherapist, recreational athlete, creator of the Run Smarter series and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. you the right knowledge along with practical takeaways in today's lesson. Thanks for joining me once again. Happy New Year. I hope the festive season has been kind to you. I have just got back from the beach and have recharged my batteries. I feel great, feel excited, looking forward to 2022. And have some good exciting business ideas to carry me through just to, you know, build up some passion for the year that is to come. This episode. Revolves around bilateral symptoms and it came from a listener, Harvey Cooper, and this kind of sparked the idea around the episode. And Harvey wrote in and said, thanks for your ongoing PhD podcasts. I have, I found them very helpful. I've had PhD bilaterally for close to a year and have had bilateral chronic plantar fasciitis for many years. On one of the podcasts, you mentioned that there are When there are bilateral tendon issues, there may raise some red flags that have, that may raise some red flags. There may be another contributing factor going on. Any suggestions of other medical areas beyond muscular that I should consider looking into would be greatly appreciated. Thank you again for your educational and enlightening sessions on PHT. Well, thanks Harvey. Thanks for submitting this question. I think this was submitted just for a Q&A episode, but I decided to do it as an entire episode as I like to do with topics such as this, which it's a bit tough to answer. There's a lot of... info behind this particular answer. And I may have said red flags in the past, um, in, I guess, just the general sense, in the medical sense, red flags usually point to or indicate a serious pathology. Um, but in this case for like red flags, if I was to say that in the past, it was probably just indicating that it's, it may be something else going on. It might not just be a tendinopathy, So I thought I would dive into this particular topic. I found a very helpful paper. It was, I might bring up the actual, I have the title and the authors here, but let me just Google the year and that sort of thing so you guys can find it. So the title is called Pathogenesis of Tendinopathies, Inflammation or Degeneration. And the authors are Michelle Arbate and Karin I'm familiar with Sylvan Argel, her work, she's done a ton on tendinopathies, especially Achilles tendinopathies and there were some other colleagues involved in there but they were the two first that were listed in a list of about 10 different authors. It was in 2009 was the year that this was released in the Arthritis Research and Therapy And so if you want to find that, I think I might include it in the show notes if you're interested in it. So this contained the pathology, the pathogenesis, the pathway, the reasons behind tendinopathies around the whole body, not just PHT specifically, but just looking at the pathology of tendinopathies in general. And within this paper, they contained about five or six potential reasons why It might happen bilaterally. And so I want to pick some of those out. This isn't the entire paper. The entire paper covers so much more, but I've just taken out a little section that is relevant to this topic and decided to talk about it. So I have one, two, three, four, five topics to talk about here. And the first one is around genetics. So this paper says that a genetic background may also play a role in a tendinopathy. Um, there's a whole bunch of gene terminologies I don't fully understand, but I'll say it anyway. So it says sequence variation within the type of V collagen. So they have two specific, um, variations or two specific genes that may play a potential role. So it's col 5a1. Um, so C O L 5a1 and Tennyson. Tennyson C which is abbreviated to TNC. So both of these genes have been shown to be associated with chronic tendinopathy, a genetic component that may give rise to abnormal collagen formation. Patients affected by this syndrome are prone to having multiple problems which may include rotator cuff pathology, tennis elbow, carpal tunnel syndrome, triggering of a long finger flexor tendon, wrist extensor pathology and, oh, wrist extensor pathology, such as de Quoven syndrome. So they've just listed off a bunch of common tendinopathies in this paper and showing that someone who might have a variance in these two genes might have frequent episodes of these particular pathologies, just because these genes tend to create an abnormal. college in formation, like the tendons are forming differently, and may increase the likelihood of a tendinopathy being present. And I think it probably goes without saying that an overload or a change in the external load still needs to happen, but these people would be more prone to developing a tendinopathy. We know some people might train really carefully and try and do all the possible things properly to avoid abrupt changes in training, but they still develop a tendinopathy. Particularly if it's bilateral, particularly if it's on the right and left in both the knees or the ankles of someone who's dealing with, say, four tendinopathies at once might raise your suspicions. So genetics was the first one out of these five that I wanted to discuss. The second one was around alignment. and I'll chime in with my own thoughts of this in a second, but let me read out this paper. Malalignment of the lower extremity, which favors Achilles tendinopathy, is proposed to increase forefoot pronation, limit the mobility of the subtailer joint, which is just a joint in your ankle, decrease or increase the range of movement of the ankle, lead to a varus deformity in the forefoot, and increase hindfoot inversion. and impingement. So just talking about various different angles or pronations or altercations, malalignments around the foot and ankle. All these factors independently or together may affect the running or walking pattern in turn affect the way the Achilles tendon is loaded. Now this is more referring to the Achilles tendon when talking about these malalignments. There is a very... I've seen a paper around risk factors for Achilles tendinopathy and pronation is in there but it's very, it's kind of in the middle of the list. So I think age, previous injuries in the past, previous Achilles tendinopathy in the past, external loads such as training errors, abrupt changes in training, these are all quite high up on the correlation of Achilles tendinopathy. And then you have further down the list, things like pronation and things like obesity, things like diabetes, and just trying to rattle off a couple of them, trying to remember what that list was. But alignment, malalignment may, when it comes to PHT is probably less relevant. Maybe if you have a contralateral hip drop, so when you're in mid stance of running, when the foot is directly underneath your hips, So in that stance phase, the opposite hip, so if your right foot is directly underneath you during the running pattern and the left hip is dropping further towards the ground beyond what someone who has level hips might do, I guess it could put a little bit more strain on the tendon if you adduct your hip or if you have a narrow step width. Again, that could cause a little bit more pull during running. There hasn't been research on this, I'm just hypothesizing. Um, but I believe this wouldn't be a huge factor as the body adapts to mild irregularities or a pelvis shift. If one leg is longer than the other, if one side of the hip is, um, anteriorly tilted more than the other, the body just adapts as long as your training is appropriate and as long as the body's used to being in that position. It's just going to adapt that way. Um, so keep it in mind, something to keep in mind. I do think therapists over prescribe and say, Oh, your hips are out, or you've got one leg longer than the other. You have this pelvic shift, you have this pelvic tilt. And I do think that would prescribe that too much. I don't think that's a very high relevant factor, um, because this paper does mainly refer to Achilles tendinopathy, not PhD, so I'd be wary about that one. The third I wanted to talk about was what the paper talks about training, which is just the external factors, which we talk about a lot on this podcast. But since they mentioned it in the paper, I think it'd be good to repeat. They mentioned among the extrinsic factors, as well as overuse linked to sport activities, training errors and fatigue must be considered. So they're just talking about all those training loads, all those abrupt training yourself or exercising to fatigue, all of these need to be considered. And they say, for example, in Achilles tendinopathy, excessive distance, intensity, hill work, erogenous running technique, as well as in changes in the playing surface seem to be a predominant factor in acute injuries. So for PHT, we're talking about overuse. And if we're talking about PHT and we're talking about bilateral symptoms, let's just imagine that you're training for a triathlon. and you flare something up, you flare up your PHT because of the abrupt change. That's what happened to me initially. I went from marathon training, quite slow long distance to then trying to do faster running, faster efforts on the bike, then get off the bike and have to try and sprint. Those particular activities was just too much for one of my tendons. If you can imagine that happening and then you develop a PHT, if you continue to train, Um, you have the potential if that tendons quite sore or it can't produce the same force, you might compensate and start producing more power on the opposite side, maybe on the bike or maybe once you get off the, um, for the run. And so you're overloading due to that compensation, you're overloading the other side. And then eventually the other side might develop symptoms as well. When it comes to sitting, I know people if they've got PHT on one side, they like to shift around, they like to adjust how they're sitting and some of them like to just put weight on their other side. So if they have a right PHT, they like to carry their weight all the way onto the left side and just weight bear as much as they can on that left side. And so if they're compensating during their running or their training, and then they're sitting and putting all the weight on the left side, that could develop a bilateral tendinopathy because you're compensating and switching things around. And that's what I thought I'd mentioned when it comes to bilateral symptoms, because it doesn't need to be genetics. It doesn't need to be malalignment. It could just be due to training and compensating in different ways. So another thing to think about. This podcast is sponsored by the run smart to series. If you want to take your knowledge building to the next level, I have built out a proximal handshake, tendinopathy video course, which compliments the podcast perfectly. Sometimes it's tough. delivering concepts and exercises through an audio format. So the course brings a visual component full of rehab exercise examples, graphs, and visual displays to enhance your understanding. Even if you sign up now, you'll have access to all current and future modules that I create. Sign up through my link in the show notes, then download the Run Smarter app, and you'll instantly have unlimited access to all the course resources on any device. And to say thanks for being a podcast listener, I want to give you a VIP offer. There will be a link in the show notes in every episode that will provide you 50% off the course price. Just click on the link and it will automatically apply your 50% discount. We have two more to go. So in this paper, the fourth one that they talk about was intrinsic ailments. Now this is quite important, something that you might not be aware of. So the paper goes on to say, several... pathological conditions must be considered. And they reference another paper, Holmes and Lin evaluated the association between tendinopathy and endocrino metabolic diseases. And they referenced such as obesity, diabetes, and hypertension and found a positive association between Achilles tendinopathy. So obesity, diabetes, hypertension, I don't see too many obese people with PhD. It's usually athletic population, so potentially hypertension, potentially diabetes. There is a link between Achilles tendinopathy, so tendinopathy is in general, well I shouldn't say tendinopathy, tendinopathy is in general, but diabetes and hypertension have been linked to Achilles tendinopathy because there's been so much research on that specific condition. But they go on to say that hypertension was statistically associated with tendinopathy. only for females, whereas diabetes had a statistical association for men younger than 44 years old. So you have two associations here. Hypertension for women and diabetes for men under 44 years old. There's an association in developing a tendinopathy. They go on to say, these findings suggested that factors influencing microvascularity, the blood flow in the capillaries that may have some importance in the development of a tendinopathy. So I'm guessing hypertension and diabetes is like a bit more medical that beyond my training but the hypertension and diabetes would affect the blood flow to the capillaries could affect the blood flow to the tendons and therefore associate be correlated with a development of tendinopathy and we do know with specific injuries that blood flow oxygenated blood does help the healing process. We know areas of the body that lack blood flow take longer time to heal so maybe that's one of the reasons. The paper goes on to say in diabetes condensation of glucose with amino groups results in the accumulation of advanced glycation end products in tendon tissue. Again, this is something that goes over my head, but glycated tendons can withstand more load and tensile stress than non-glycated tendons, but the tissue becomes stiffer. So I guess in diabetes, the glucose abundance or the absorption of glucose into tendons is affected or changed. And they say that it's been shown that high amounts cause a fusion in collagen fibrils which display larger diameters. So I'm guessing it just affects the amount of load, the amount of stiffness, the amount of size that these tendons can have. Other diseases that have been found to be associated with tendinopathies include systemic diseases, neurological conditions, infectious diseases, chronic renal failure, psoriasis, parathyroidism and hyperthyroidism. And like again, not the medical side of things escapes me. Um, but a lot of these have changes in hormones, um, changes in blood flow, uh, a lot of dis changes in the body, which yeah, has been found to be associated with tendinopathy. I don't see too many, like I said, usually PhDs in the athletic population. And I think this would be a lot less likely. I don't know too many athletes with chronic renal failure or psoriasis, but, um, some athletes can have like changes in their thyroid, so hyperthyroidism. I like when it comes to say tendinopathy, say let's use Achilles tendinopathy or like plantar fasciitis. It seems to be two populations that get it. One is the athletic population because of their, um, external loads because they push themselves, they constantly challenge the loads on the body. And the second is like the obese, sedentary, overweight population, because they're overloading their tendons purely based on their size. Their tendons are quite weak because they don't exercise and then a day of walking around shopping, Christmas shopping or spending time with the kids can overload that as well. So you're looking at both of both those demographics, those populations that can develop tendon issues. Um, and both for different reasons. One is cause of weight and weakness and sedentary kind of factors. One is due to really healthy, but pushing themselves too much, the athletic population. And so I would assume that the, um, systemic diseases is more on that obese sedentary type of people. But again, every Individuals different so that's why I thought I'd keep it in this podcast just to mention that the last topic that I want to discuss that this paper discussed was aging and so if you develop bilateral symptoms all of a sudden it might just be the general aging process because they say Finally aging in itself has a negative effect on the mechanics and the properties of the tendon which could be due to reduced arterial blood flow local hypoxia, which is just getting less blood to the area, free radical production, impaired metabolism, and nutrition. So if you are in your 40s, 50s, 60s, and you develop a bilateral PhD while you're exercising, while you're training for a marathon, you think, why is this happening? Why both sides? Do I have diabetes or hypertension or one of these correlated symptoms? It could just be due to aging because we know that as you age, your tendons, the properties in your tendons change and can lead more to a tendinopathy. And if you've developed it on both sides, maybe that's just only the reason. Maybe it's aging mixed with a training error. So they're the five that I want to discuss today. We had genetics, we had alignment or malalignment, we had training or extrinsic factors, the low doing too much too soon. We had the intrinsic ailments, which are all of your metabolic diseases, diabetes, obesity, hypertension, and then we had aging and one, none, all of these can be a factor in developing bilateral symptoms. So my key takeaways here, I have three of them. Chronic, if you do have a chronic tendinopathy, if it's tendinopathy in multiple locations. So if you have bilateral, say, wrist tendinopathies, and you also have bilateral PHT or bilateral Achilles tendinopathy, I would say get medically assessed. Try and find the whole picture. Try and find a better way to assess your conditions. Just, it wouldn't hurt to get medically assessed because, especially if it goes without major All of a sudden, grind yourself into the ground with like a trail ultra. And then you're just constantly pushing yourself and then you develop bilateral symptoms in multiple locations. There's a, an explanation for that. But if it comes on really easily without much explanation, maybe you've just upticked something slightly and then you've developed all these tendencies. Then maybe that's where we want to get a larger picture. Very easy to think this is you. Constantly when I was at uni and there was a lecture on a certain pathology or a certain disease. I'm like, yep I have that. Yep. This is me all the time It's it's within human nature just to naturally think that this is like you making the associations with your own conditions But I do say try not to draw too much conclusions until assessed so many people have bilateral sense in their behavior, in their past history, in the loading that's happened, in the compensations that they've made. It just makes mechanical sense. So don't get too worried about, oh my god, I might have hypertension or some of these other diseases. Just be very careful, be very open-minded and if you want to get assessed, you can. Don't draw any conclusions until some results come back. The third one is that most of these ailments can result in a healthy functional life. So if you do have diabetes, if you do have malalignment, if you do have this genetic association, keep in mind that you can still be an athlete, you can still train. It's not the end of the world. You can't, you don't have to give up anything. However, you just need to take more care in how you progress things. You need to take care on your buildups, how you prepare for a race, you need to make sure Um, take taking on all of the other strength and conditioning things, all the other advice around tendinopathy and recovery and prevention, um, like getting good sleep, good nutrition, all of these things, you can still thrive. You just might need to be more patient and be more careful than someone who doesn't have these associations. Very important to know. because a lot of people can find they have a genetic predisposition and think that, oh, my running life is over. Just be careful. Just make sure that you take these into consideration and train accordingly. Might need to be patient more than the person next to you, but if you take this on board, if you train appropriately, you still will be able to operate and thrive within your given chosen activity like running. I hope this made sense. I hope you enjoyed this episode. I know as I was, as Harvey made this comment, a lot of people commented on this comment, saying, yes, this would be really interesting. So hopefully, hopefully this is provide the information you're after and we'll catch you in the next episode. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future. And remember, knowledge is power.