From: greenla@umich.edu (Lee Green MD MPH)
Newsgroups: rec.bicycles.misc
Subject: Re: Patellar Tendinitis
Date: Sat, 20 Apr 1996 19:03:09 -0400

In article <4l4n9t$oql@nuacht.iol.ie>, Garry Lee <glee@iol.ie> wrote:

> Your chiropracter did not cure you. Time did.
> Whether your muscles were warmed up or not made no difference to the
> pressure on your tendon. How could it?
> 
> A vital thing for everyone with an injury to consider is that almost
> all soft tissue injuries get better in the course of time. Therefore
> what you did or had done to you may not have affected the outcome at
> all, and may have even delayed the inevitable recovery.
> 
> Garry Lee  (Dr.)

What Garry said.  One more point to consider, too.  Soft tissues heal, but
at different rates.  Muscle heals pretty fast, as it has a great blood
supply to bring in the oxygen and nutrients needed.  Tendon and ligament
have abysmal blood flow, and heal quite slowly.  The same thing true of
healing is true of growth, by the way, which is why so many new cyclists
(or those increasing their miles suddenly) end up with patellar
tendinitis.  The quads lay down new muscle rapidly and become capable of
generating high tensions soon, but the tendons lay down new collagen
slowly and can't keep up with the quads.  The patellar tendons become
overloaded and accumulate microtears from the stress.

It gets better when you stop ripping new microtears in the patellar
tendons and let 'em heal.  That doesn't, as a rule, mean no activity. 
Rather it means some, enough to provoke the body to lay down new collagen
and strengthen the tendons, but not so much that the wear rate exceeds the
healing rate.  In my experience, this usually works out somewhere between
half and two-thirds of what the sufferer was doing before the suffering
began.  It especially, in the case of cycling, means *lower peak loads!!* 
That means spin, don't mash.  Climb in low gears.  The maximum, not the
average, load is the primary determinant of damage to the tendon.

Which is why I have such trouble treating patellar tendinitis... getting
macho young males to spin their leisurely way up hills when 40 yr old
women are passing them is damn near impossible.  But that 40 yr old woman
has been doing it for 20 years and has tendons long since work-hardened,
while the young stud has killer quads but not the tendons to transmit the
force safely.

Anyway, there is no miracle cure for patellar tendinitis.  If anyone tells
you of one, you should smell snake oil.  You fix it by letting those
little fibroblasts lay down new collagen fibers.  Tedious, hard on the
patience, you betcha.  Ain't no free lunch.

-- 
Lee Green MD MPH          Disclaimer: My postings are my doing, not
Family Practice           a service of nor in any way the
University of Michigan    responsibility of the University of
greenla@umich.edu         Michigan.

From: "Steve Harris" <sbharris@ix.RETICULATEDOBJECTcom.com>
Newsgroups: sci.med,sci.med.occupational
Subject: Re: tendinitis: am i being treated properly? -- UPDATE
Date: Mon, 4 Aug 2003 12:03:42 -0700
Message-ID: <bgmamf$gd1$1@slb2.atl.mindspring.net>

Is this one hand or both hands?  You use "hand" and "hands"
both in your description. Big difference. If "tendonitis"
strikes in both hands at once, it's much less likely to be
the correct diagnosis.

Bilateral total hand swelling is a fairly common allergic
reaction; allergy and autoimmune problems are the most
common causes of it.  If it's an allergy or autoimmune
problem it's quite possible Vioxx did it no good (though I
can't think of why it would make it worse unless you just
happen to be allergic to Vioxx too). It's possible an
autoimmune process was triggered by repetitive strain
injury.

In any case, I would suggest you stop *all* drugs
completely, and see an allergist. And get a course of
steroids if you haven't had one.

There is an entity called "reflex sympathetic dystrophy
syndrome" (RSDS) which can develop as a secondary problem in
anybody with hand problems due to a number of different
causes. They all end up in some kind of final common pathway
of autoimmune and autonomic dysfunction that can include
swelling and sounds something like what you have. It's hard
to get this cycle stopped except with steroids. In any case
it requires a specialist, and is probably outside the normal
work comp repetitive strain carpal tunnel sort of thing.

Good luck.

SBH


"Adam Golding" <adamgolding@adamgolding.com> wrote in
message
news:cd483cf9.0308041028.46d19a5e@posting.google.com...
> This is an update to the post quoted below.
>
> I recently stopped the Vioxx and have experienced:
>
> -increased range of motion
> -more 'normal' looking wrists and hands (no longer thin, weak and
> sore)
> -*less* pain
> -*less* inflammation!
> -less blotching in my hands, although more tingling sometimes
> -the tendons in my arms and connected to my pointer and middle fingers
> now feel tense, like a string you could pluck, they feel loose if i
> point my hand forward, perpendicular to my wrist..
> -i now no longer get severe headaches from rough bike rides (forgot to
> mention this before--does my body use inflammation to cushion my
> brain?)
>
> so, what's going on here?  Most of the changes have been positive.
> Does my body respond unusually to this medication?
>
>
>
> adamgolding@adamgolding.com (Adam Golding) wrote in message
> news:<cd483cf9.0307302029.5e393c3@posting.google.com>...
>
> > (if you're not interested in how in happened, kindly skip to my
> > shorter questions below...)
> >
> >
> >    My Condition:
> >
> >
> >    I am a pianist.  The Trouble started about 4 months ago.  I was
> > doing a lot of playing in full-hand, *loud* chords (working on a
> > composition using them), and noticed that my hands had become swollen
> > between the wrist and the middle of the hand.  I had no other symptoms
> > at the time, however, so i assumed it was fine, but this swelling
> > never really went down.  Later, in last minute prep. for my 'jury'
> > (exam), i went from practicing ~30 min. daily to practicing ~4 hours
> > daily--8 times as much!--and this included working on a Tchaikovsky
> > etude with long passages of repeated staccato octaves, etc--my hands
> > were in an octave stretch for the entire piece.  I spent one night in
> > some pretty abusive improvising on a grand at school with a *Very*
> > heavy touch--i had pain afterwards, but this sort of thing usually
> > went away in the past so i wasn't concerned.  Over the next 2-3 days i
> > felt *ok* but spent a lot of time practicing the tchaikovsky piece,
> > and the last straw seemed to be when i spent a solid hour repeating
> > bars from my mozart sonata in both hands involving outer fingers (1
> > and 5) alternating with one inner finger in eigth notes. After all
> > this I rapidly came down with pain, tension and inflammation, and had
> > to postpone my jury.  So this was overuse, but there were also serious
> > issues of bad technique as well.
> >    These days I experience pain and *tension* basically *everywhere*,
> > including most of my finger joints, across my hand, at the base of my
> > hand, in my wrist, along my forearm, and on both sides of my elbow,
> > all of this in both arms.  I also have limited motion: spreading my
> > fingers is the easiest way to aggravate my condition: i used to reach
> > a 10th comfortably, and now it can hurt playing octaves. In bending my
> > fingers backward i now have only about 20 degrees of motion
> > compared to the near 45 i remember i had before.
> >    Additionally my Hand is still swollen and thick near the wrist and
> > thinner near the fingers (my hand never looked like that before!).
> > Similarly, my forearm is thick near the elbow, and unusually thin and
> > weak near the wrist--and is painful to the touch. As you might expect
> > i also have CTS symptoms such as redness, tingling and blotching in my
> > hands--but what is more concerning is that sometimes--such as after
> > attempting to play piano, my fingers *twitch* and *shake*.
> >
> >
> >
> >    My Treatment:
> >
> > Initially i was told to rest totally and to take ibuprofen when i felt
> > i needed to.. then i was put on vioxx.. later they doubled my dosage..
> > eventually they sent me to a specialist (at a 'Musician's Clinic').
> > He told me to stop resting and to play a little each day and to do
> > stretches.  He also said i needed to eat more Protein and specifically
> > advocated MEAT.  He also said that there "wasn't much inflammation
> > *per se*" and seemed to suggest that my pain was psychological!--i had
> > been resting for 2 months so perhaps my symptoms were hard to verify
> > then..
> > 
> > others have reccomended contrast baths but all my doctors seemed to
> > think they were irrelevant.  My piano teacher reccomended a wrist
> > brace but none of my doctors mentioned the idea.  My dentist of all
> > people told me to massage my forearms...
> >
> >
> >    My Doubts:
> >
> >    1. Anti-Inflammatories
> >
> >    This is my biggest concern:  doesn't Inflammation exist to aid the
> > healing process?  How do i know the vioxx isn't doing more harm than
> > good?  I am seriously considering going off it totally and allowing my
> > own inflammation to tell me how much rest i need... doesn't the
> > inflammation also help to immobilze the injured area, and to speed
> > healing?  what is the difference between good and bad inflammation?
> > why are my doctors so sure they should STOP the inflammation?
> >
> >    2. Rest
> >
> >    Can rest be bad?  I have the impression that my tendons are somehow
> > 'bunched up' or retracted (which would explain the swelling/thinness
> > patterns).  Could too much rest prevent them from being stretched back
> > out again?
> >
> >    3. Stretching
> >
> >    My understanding is that stretching can lead to furher injury.  How
> > can i possible know how much is too much?  Since my condition is worse
> > than before, should i return to total rest and later introduce
> > stretches again?  or is there some kind of 'hump' i have to get over?
> >
> >    4. Protein
> >
> >    How much protein do I need to eat?  every website seems to be for
> > bodybuilders and not pianists!  Also, why the emphasis on meat?  When
> > I told him I eat plenty of peanut butter he laughed!  Is he just
> > insensitive to vegetarian-like diets?  What else can anyone reccomend
> > diet-wise for my condition?
> >
> >    5. Contrast Baths
> >
> >    I've always read you should END COLD? why?  I never do COLD at ALL
> > because it HURTS!  Cold water increases tension and pain, and
> > decreases my range of motion--Hot does just the opposite!  Is *hot
> > only* going to give rather different results?  Are there dangers to
> > hot OR cold?  Are they just for symptoms or do they aid (or even
> > hinder?) the healing process?  One pianist said that contrast baths
> > are to 'reset' the tendons--what's that all about?
> >
> >   6.  Massage
> >
> >   Is this just for symptoms again?  Or does it aid the healing
> > process.  I could imagine that massaging the 'bunched' area could push
> > the tendon down into its right place--is this nonsense? I also imagine
> > that massage could just irritate everything and increas
> > inflammation--is this nonsense?
> >
> >   7.  Braces/tensors
> >
> >   This is the area i'm most confused about:  should i sleep with a
> > brace?  wear tensors on my wrist or arms during the day? How can i
> > immobilize my *elbows* during sleep? What is the purpose of a tensor
> > bandage?  I've read that these things are useful but should not be
> > overused--why? what's the danger?
> >
> >   8.  My Diagnosis
> >
> >   How do I know this is real tendinitis? Someone gave me this list of
> > possible causes of my sympoms:
> >
> >    Carpal Tunnel Syndrome
> >    Tendinitis
> >    Bursitis
> >    Tenosynovitis
> >    Tendinosis
> >    DeQuervain's Syndrome
> >    Thoracic Outlet Syndrome
> >    Myofascial Pain Syndrome
> >    Cubital Tunnel Syndrome
> >    Trigger Finger/Thumb
> >
> >  couldn?t it be any (or any *combination*) of the below ailments?
> > Most Importantly, HOW DO MY DOCTORS KNOW WHICH OF THESE IS/ARE MY
> > PROBLEM?  Wouldn't the Treatment vary?
> >
> >
> >    Thanks in Advance:
> >
> >    I greatly appreciate any and all responses to any of my many
> > concerns.  I have been making no progress and I am tired of
> > debility--I want to be healthy again!