Sunday, July 22, 2018

Healing "tendinitis"

See end for an important update to this post.

I thought it was time for a post about what I've learned due to my injuries—but not what I've learned about life, the woods, and God this time. Just what I've learned about tendons.

This does mean that if your tendons are fine, you could skip this one—but maybe don't? I'm writing this in hopes of being useful to a few beleaguered people out there, and one of them just may be someone you know. And maybe you could point them to this post, today or sometime down the road. I hope so. Because as I've learned, injuries like mine—repetitive stress injuries of all kinds—can be truly horrible for people whose livelihoods depend on the very muscles and tendons they've been stressing. It can be extremely hard to recover, and extremely hard to find answers as to what, if anything, can truly be done.

And the truth is, there are answers now. They're new (in a way at least), and not very well-known yet. But if I can help spread the word, I may help restore strength to a few people who desperately need it, and I want to. I don't want anybody else to have to go through this.

1. It's not tendinitis, exactly

It's tendinosis.

This has actually been accepted medical doctrine for a while, but most people don't realize it because doctors have tended to use the familiar term tendinitis with patients, while officially diagnosing tendinosis.

So is this just semantics? Not quite.

The suffix "-itis" denotes inflammation. Tendinitis basically means an inflamed tendon. This does happen, but the newer medical research suggests that it's less common and much briefer than the condition I've got, and is usually caused by a sudden strain or injury—not by repetitive stress. Chronic tendon pain like mine, they now believe, is almost always tendinosis.

Now "-osis" suggests, not inflammation, but degeneration—actual changes to the tissue. That's why complete rest and anti-inflammatories were not enough to heal me. Something was wrong in the tissue itself, something that needed active physical treatment. I can't give a full explanation of exactly what was wrong (although if you have lots of time you can get one here) but here are the main things I understand: the repetitive stress I imposed on my hands & forearms caused scar tissue to form in my tendons. This scar tissue is matted and tangled whereas normal tendon tissue lies straight and smooth, and so it impedes function. This scar tissue also is far more sensitive to pain than normal tissue—and so using my tendon causes pain.

The scar tissue will never go away. I'll always have it. But there are ways to change it, re-align it into a healthier configuration that—though I'll always have to be a little careful with it—will allow me to work pretty much as I did before without pain.

Actually, there are almost too many ways…

2. Scar tissue treatments

The first time I ever heard of a therapy that could actively begin to reverse my condition was on the website of Dr. Schierling down in Missouri—and let me tell you, within an hour or two of finally deciding he was for real, I was on Google Maps looking for campgrounds in the Ozarks. (Fortunately, since our only option for travel to a rural area in another state would have been someone else's car, that didn't prove to be necessary.) It did take me a little while to decide he was for real—if you have a look around his website, you'll notice a few of his opinions are a little far out—but I do think that he is, and I think his distrust of the medical establishment is understandable in light of the fact that for years he's been using a therapy they didn't recognize but which did wonders for at least certain of his patients. He doesn't have to be right about everything—just as long as he's right about scar tissue, and how to change it.

Because that's the key. There are quite a few different versions of the technique by now, but the fundamental thing is this: what this type of condition needs is a direct therapy to break up the scar tissue that has formed in the tendon and remodel or recondition it. The scar tissue doesn't go away, but it can be changed enough by the therapy—and the stretches prescribed alongside it, which help the tissue to heal in the right configuration—to turn the tendon back into something that's usable without pain.

Like I said, there are different versions. And they're practiced by different types of practitioners. The first clue I ever had about scar tissue therapy, weirdly enough, was a guy telling in a forum how the only thing could ever heal his "tendinitis" was a strange balm bought in a little Chinese store in Chinatown and rubbed into his tendon by the seller, painfully hard (an extremely important part of the process, he was told.) Immediately following this story, someone else chimed in to say his chronic tendinitis never went away until he visited a bodyworker/massage therapist who gave him a similar painful massage.

I've learned since then that scar tissue work is indeed something that many massage therapists are trained in, though it's not well known to the public. (I have one story of a massage therapist who chose not to pursue training in it because she realized most massage clients don't want painful therapies. They want massage to feel good—it's seen as a luxury, not as therapy.) Which is too bad! It seems to me that in their not-officially-scientific way, they've held out answers for a long time, and science has only recently caught up. As many of us learned in math class, just because you're not able to show your work doesn't necessarily mean you got the answer wrong…

But like I say, science has caught up. There are now scar tissue therapies done by physical and occupational therapists, covered by insurance, Medicare and Medicaid.

But let's not get ahead of ourselves.

There are so many different versions of this, you guys. I don't know everything about them—I don't even know the names of all of them, most likely—but I want to give people a starting point for exploring and choosing. Most likely some of them are more effective than others, but it probably depends heavily on both the skill of your practitioner and how their technique connects with your condition. You can do your own research starting with the links here. So here's a quick overview with links.

Massage therapists:

Massage therapists tend to use manual techniques (as opposed to instrument-assisted techniques, which involve some type of metal or plastic instrument.) It seems to me there are advantages to this, and from my reading it seems a really skilled and experienced practitioner can feel how much scar tissue you have and where, as well as feel it breaking down. I gather that these manual techniques are sometimes painful and sometimes not—if you have concerns about that you'll probably want to ask your practitioner.

Here is an example of an apparently very skilled and experienced practitioner. She's in Australia:

And an article by her about her technique, which she calls scar tissue release therapy:

You'll find an abundance of different names in this business. These folks call it scar tissue massage:

It's also called scar tissue remodeling—a particularly accurate name, if I understand correctly, because the scar tissue is not destroyed but rather reshaped by the therapy. If I were still searching among different practitioners to find someone who knows some version of it, I would probably use the generic term "some form of scar tissue therapy" and maybe add "some therapy that can break down and remodel scar tissue." (I might also mention some of the names in the PT section further down, especially if I was talking to a PT.)


Like I said, the first place I ran across this kind of technique (scar tissue remodeling, in this particular case) was on a chiropractor's website. One interesting thing about this guy is that he learned of the technique (years and years ago) from another chiropractor who successfully treated him with it for the exact condition I have—tendinosis in both elbows. It seems to me that here is another very skilled and experienced practitioner—that does seem to count for a great deal in this business—and I can vouch that he responded to me promptly and helpfully when I inquired about coming down to see him about my elbows.

There are some other scar tissue therapy techniques practiced by chiropractors—I don't know many details about most of these.

Here's one called Active Release Therapy:

Another, called Rapid Release Therapy, which seems quite new and assisted by a type of instrument I've never seen before:

And another, apparently more widespread, called the Graston Technique. The Graston Technique is a type of instrument assisted soft tissue mobilization therapy (IASTM) using metal instruments. More on that in a minute.

But first I want to give a shout out to a somewhat local chiropractic practice, in Peoria. I spoke on the phone with a man named Carl (I unfortunately can't find his last name) who works there—I believe his official title was as a massage therapist. He was so extremely knowledgeable and helpful—completely familiar with the different techniques, clarified things for me, gave me excellent advice—that I very much wished he was nearer (and that chiropractic was covered for me!), as I would have felt I was entirely in good hands. Believe me, that was not the case with everyone I questioned on the phone! Only one other therapist even came close.

So if you have tendinosis or other chronic pain and are in or near Peoria, go to Benningfield Associates and ask for Carl.

Physical and occupational therapists

And now we get to the therapy that I actually ended up going with. But first let me mention the generic term usually used by physical therapists: soft tissue mobilization. There are manual versions of this technique, as seen below:

But one version that seems to be catching on and becoming more widespread—and of course the advantage of this is that you're likelier to find it near you, and covered—is called ASTYM. That acronym is a different version of the other that you saw before, standing for instrument assisted soft tissue mobilization. (This is important to note because due to the "stim" sound in the word, people tend to assume it's some kind of electrical stimulation therapy like an EMS unit.) It's an instrument assisted scar tissue therapy similar to the Graston Technique—I don't know the details, of course, but the obvious difference is that it uses plastic instruments, somewhat different in shape.

It seems like one of the advantages of an instrument assisted therapy is that it can be more generic—easier to teach a wide range of people, more replicable. This is probably why it's more widespread, and it solves the problem of finding a deeply skilled and experienced practitioner—you can be pretty sure of getting good therapy as long as someone has had the official training. And, of course, unlike massage therapy, it's more universally recognized by the medical community, and more likely to be covered.

And here it is:

Along with a more scholarly article about IASTM techniques in general:

My therapist—she is technically an occupational therapist, because apparently, at my hospital, occupational therapists work on hands and arms—has been in the field for 12 years but was only trained in ASTYM a year-and-a-half ago. She says it's given her better results than anything else she's ever done. She spreads cocoa butter on my arms and works them with various shaped plastic instruments, covering the whole forearm but with special focus on the elbow tendons and also a few particular areas of the wrists, hands, and shoulders (just one tiny place on the shoulder, actually, which is apparently a trigger point for certain forearm or hand muscles.)

It doesn't hurt—in fact it feels pretty nice. She and I can both feel a certain roughness or "grindiness" under the skin when she hits an area that has a lot of scar tissue in it—that's actually the feeling of the scar tissue breaking up. It's not a painful feeling, it's actually rather subtle, and she can feel it better than I can. It takes maybe half an hour for both arms—she follows it with a short ultrasound treatment on each arm to stimulate healing—and she says it takes 8 to 12 treatments for full healing. (I expect in my case it'll take the full 12!) I've felt a huge amount of improvement. This week she instructed me to try weeding half an hour each day—carefully, wearing braces and icing my elbows afterwards—and I did it with no ill effects. This would have been completely impossible before we started the treatment.

Yes, I would like it to work faster. It's still possible (I mean very easy) for me to overdo and set myself back, and I did so this week—but so mildly. I didn't get pain, just a bit of warning discomfort, and I skipped the half-hour of weeding for a couple of days and am back where I was.

It's working. Lord willing—and accordingly to the usual progression for ASTYM—I'll be better by the end of the month.

And that's amazing.

Important update for the sake of anyone who visits this post for tendinitis/tendinosis information:

Boy, I'm a bit incorrigible in my wish to tie a nice bow on things before they're finished, aren't I? Here's the truth:

ASTYM didn't end up fixing me. It did a lot, and I suspect that in people with lighter repetitive-stress injuries (OK, people who hadn't injured themselves as relentlessly as I did), ASTYM would have done the trick. But as it was, my therapist told me we seemed to have reached a "plateau" where the ASTYM treatment seemed to be merely maintaining the status quo rather than improving me further, especially as we gently introduced more freedom to use my hands for both light and heavy work into my daily routine. Insurance doesn't like "maintenance" treatments and, frankly, I'm not crazy about them either. I wasn't even working that hard yet! And pretty soon some of the pain even came back...

So we went with what for us had seemed like the nuclear option. (A day's travel to the boonies is NBD compared to losing the use of your hands, I know, but we don't own a car.) Hungry World Farm kindly let us use their farm car and we drove to Missouri to Dr. Schierling, who was exactly as he appeared to be on his website--friendly, professional, and wildly experienced with, & interested in, scar tissue. He explained that in his experience, though the more widely-accepted therapies are very gradual, breaking up scar tissue is frankly "the harder, the better." It's perfectly understandable why the medical establishment would find this a hard kind of therapy to sell people on--Dr. Schierling is very upfront about how much it hurts and what you look like afterward, and that is why what he tends to get (including from out of state and even overseas) is desperate cases like me.

It hurt. A lot. I'd do it again tomorrow if I needed to, though that would mean hopping in a car this instant to get there by then. The fun thing is that Dr. Schierling turned out to be a World War II buff, and explaining to him the history behind Flame in the Night was very effective in taking my mind off the pain while he worked! (I also gave him a copy.) I looked head-turningly terrible on the drive home--as Schierling explained to me, scar tissue contains capillary blood vessels and you're not really breaking it up hard enough if you don't see bruising. A very unusual kind of bruising--just beneath the skin and bright red. I had it on my shoulders, the sides of my neck, and all down the inner sides of both arms.

(Whereas the official ASTYM treatment for elbow tendinosis basically restricts itself to the arms only. That's one reason I now strongly lean toward relying on a practitioner's experience rather than official training: you may need someone who knows where & how to look for something slightly out of the norm. Schierling relied on testing my range-of-motion and pinpointing places where he found it restricted, and also on his process--a rubbing/scraping similar to other instrument-assisted therapies but a lot harder--by which he can feel the presence of scar tissue and see the bruising as it breaks up. I watched him do my forearms, where we found very little scar tissue--the skin got red just as it would if I rubbed it hard, but there was practically no bruising.)

And here's the incredible thing: one session. (And three very intensive days of all-important stretching exercises--every half hour except sleep time!--afterward. That counts, oh it counts, especially as I was hosting a family reunion during them. Ah, timing.) One session! I had two or three months of trepidation afterward, gently introducing myself back up to a full working schedule, but especially as I began to prune fruit trees and do other farmwork and my arm strength renewed, it was clear--I was completely well. I'll never be as much of a fool as I was before, pushing and pushing myself with no break, but I've relaxed. I type, I scroll, I work--I feel fine.

Thank God.