Statins And Their Effects On Tendons

Patella tendon pain

An article in today's Sunday Times (pictured below) mentioned that 50,000 people (or 1 out of 140) are at a very high risk of a heart attack due to an inherited gene mutation unless they take statins.

Sunday Times 200823

Statins (pictured below) are medications that reduce the levels of bad cholesterol or low level lipoprotein (LDL) in your blood and protect the insides of your arteries. When cholesterol is reduced, it lowers the risk of developing heart and circulatory diseases including stroke and heart attacks.

A study of 594,130 participants found that statin medications regardless of statin types were associated with a  significantly greater risk of all types of tendinopathy development compared with no statin treatment. This is inclusive of tennis elbow, trigger finger, rotator cuff tendinopathy, Achilles tendinopathy and De Quervain's (or radial styloid) tenosynovitis. There were 84,102 statin users and 168,204 non users (control) in that study (Kwak et al, 2023).

Tendinopathy is the term used now when there is pain and dysfunction in our tendons instead of tendinitis. It is associated with overuse in and around tendons and characterised by pain, reduced function and reduced exercise tolerance. There is seldom inflammation found in the tendons, it is more of a failed healing response of the tendon leading to disruption of collagen fibers in the tendon.

The oxygen consumption of tendons and ligaments during exercise is 7.5 times lower than skeletal muscles (Radak et al, 2013). This low metabolic rate and well developed anaerobic energy generation capacity are needed to carry loads and maintain tension for long periods when we are standing, moving and exercising. 

When blood flow (carrying oxygen) is restricted or reduced in tendons, it can lead to necrosis (or death) of the cells in the tendons. A low metabolic rate also results in slow healing after injury.

What we know about tendinopathy is that it does not improve with rest. The pain may ease but returning to activity/ sports is often painful again since rest does not increase the tolerance of the tendon to load. There is usually very little inflammation invloved in tendinopathy, hence it is not considered a classic inflammatory response. Anti inflammatory medication may help if you have very high pain levels, but it is still unclear what effect they have on the cells.

Tendinopathy can be caused by many different factors, the main factor being a sudden change in certain activities like running and jumping where the tendon is required to store energy. Some people are predisposed beacause of biomechanics (poor endurance or poor muscle capacity) or systemic factors (age, menopuase, elevated cholesterol and other metabolic factors). Predisposed people may develop tendon pain even with little changes in their activities.

Modifying load is very important in settling tendon pain. Reducing tendon load (at least in the short term) always helps.

Pathology on scans does NOT equal to pain. MRI scans often show tendon 'damage' (or abnormality) in people without pain. Even if you have 'tears' or 'severe' pathology DOES NOT mean you will have a better or poorer outcome. The pathology may not improve even with the best intentioned treatment (not on scans anyway), so treatment should be targeted at improving pain and function.

Tendinopathy rarely improves with passive treatments like massages, therapeutic ultrasound, injections and extracoporeal shock wave therapy (ESWT). Note that not all ESWT machines are the same. Most if not all physiotherapy clinics use hand held ESWT devices that do not require licenses. The doctor operated devices (with ultrasound imaging requiring a license to operate) usually cost over $250,000 versus the less than $40,000 cheaper versions that do not require licenses.

Eccentric (or lengthening) exercises seems to be the most evidenced based treatment for tendinopathy. This allows the tendons to be loaded progressively so they can develop greater tolerance that one needs for day-to-day activities or sports. I'm not a fan at all about getting our patients to do exercises, but even I had to do some eccentric strengthening exercise. The hands on fascia treatment I received definitely helped, but the individualised ecccentric exercise was the final part of the puzzle.

Tendinopathy responds very slowly to exercise, so patience is definitely needed while doing the correct eccentric exercises and it also needs to be progressed appropriately. Resist the temptation to accept 'short cuts' like injections and surgery.

References

Andres BM and Murrell GA (2008). Treatment Of Tendinopathy: What Works, What Does Not, And What Is On The Horizon. Clin Orth Relat Res. 466(7): 1539-1554. DOI: 10.1007/s11999-008-0260-1

Kwak D, Moon SJ, ParkJW et al (2023). Effects Of Statin Treatment On The Development Of Tendinopathy: A Nationwide Population-Based Cohort Study. Orth J Sp Med. 1197): 23259671231167851. DOI: 10.1177/23259671231167851

Radak Z, Zhao Z, Koltai E et al (2013). Oxygen Consumption And Usage During Physical Exercise: The Balance Between Oxidative Stress And ROS- Dependent Adaptive Signaling. Antioxi Redox Signal. 18(10): 1208-1246. DOI: 10.1089/ars2011.4498

What Is Ergodicity?

Ice baths for recovery

I did not know what the word 'ergodicity' meant. I had to look it up. It means when you do a test or research on a whole group, you assume the result applies to everyone. Say you get a hundred gorrillas to flip a coin 10 times. All 10 flips ends up with a head. You then conclude that all gorillas can always flip 10 heads in a row with 10 coin flips.

Can you see the error with this conclusion? Neumann and colleagues (2021), sugests that sports scientists may inadvertently be making errors like this frequently. Their research studied the relationship between training load and recovery. If you're into endurance sports, you know recovery is really crucial.

When you train more, your fitness improves, however, it also increases your chances of injury and burnout. This has led to all sorts of research to investigate how we handle different training loads and how quickly we recover so that we can train harder without breaking down.

So, is there a link between training load and recovery? Is it possible to measure training load and subsequent recovery in a large group of people and use those results to recommend or predict how you and I or any individual would respond?

Neumann and colleagues (2020) studied footballers from a top Dutch football league club, over 2 seasons. Daily training and recovery data were collected from footballers of their under-17, under-19 and under-23 teams.

The most basic question to address is if total training load in a workout affect how recovered the footballers feel before the next day's training session? This is done in 2 ways. 

For the whole group analysis, an average training load is calculated on a given day. The analysis is repeated for each workout day and you can average the results.

For each individual analysis, you monitor every pair of workout/ recovery scores for each individual over the course of the data. This data is then averaged. 

If both group and individual data produce identical results, then the training and recovery is ergodic, meaning the results of the group studies can be applied to individuals (like you and I). If results aren't identical then oops.....

Well, sure enough, the group and individual analyses produced different results. The correlations between training load and recovery did not match up. training loads varied far more for a given individual footballer over time than they did between individual footballers on a given day. How a bunch of people respond to a single workout session does not always tell how you respond to a series of workouts. 

I recall when running cross country in secondary school how all of us in the school team were given the same workout session and each of us responded differently.

You must be wondering now if all the previous research done on training and  on large groups apply to you, or whether they are invalid. Researchers use randomized placebo controlled trials to normalise the effects of individual variation. They also report individual results to group averages. 

Read and understand the recommendations from researchers to improve your personal training/ performance and recovery. But bear in mind that we are all an experiment of one (or n = 1). Age is also a confounder. What hurts now after a certain workout did not hurt when I was 28.

Reference

Neumann ND, Yperen NWV, Brauers JJ et al (2021). Nonergodicity In Load And Recovery: Group Results Do Not Generalize To Individuals. Int J Sp Physiol Perform. 17(3): 391-399. DOI: 10.1123/ijspp.2021-0126

Running With Ankle Weights

Picture by Megan

This week's post is requested by one of our blog's readers who asked about the benefits of running with ankle weights. This reader started using ankle weights when Covid-19 caused gyms to close last year and thought that by strapping on ankle weights, it would be like adding strength training while out walking or running.

Strangely enough, I've noticed a couple of ladies who run pass my home (now that I'm stuck at home mostly after my accident) with ankle or wrist weights too. I suppose once you're aware of them, you start looking out or noticing them.

Let's get into it. We shall start with the benefits first. Running with the ankle weight makes (some of) your leg muscles work harder since the extra weight makes it heavier to walk or run.  Over time, (some of) your muscles get stronger. For instance, if you were running with the ankle weights, it would work your hip flexors more than your hip extensors as the former have to work harder to lift your leg off the ground to prepare for the next foot strike. 

When you take the extra weight off, it makes it easier to run, you can run faster or you may find it easier to run longer distances. The heart and lungs work harder too and over time, your cardiovascular endurance improves. I found a study in 2016 which supports this (Yaacob et al, 2016).

Now for the not so good part of running with ankle weights. Your gait definitely changes when you run with them. There is now added load on your joints, especially your knees, hips, ankles and lower back. This can lead to improper or faulty technique, which may create muscle imbalances and cause injury.

What's worse is if your muscles cannot handle the extra weight, this added load gets transferred to your bones, joints and the articular cartilage. So the risk of carrying a heavier load may outweigh the potential improved performance for runners.

My take? If you have been using them and have no issues or injuries, you can probably carry on. However, if you're a new runner then I will suggest other ways to add training load to improve so as to minimize your chance of getting injured.

Would I run with ankle weights? Most probably not. The closest I came to using something similar was a weight vest. I did this way back in 2000 and 2001 when I was training for the Oxfam 100 km Trailwalker event and I used to walk (not run) up and down the steps in the spectator stands at the old National Stadium to get stronger. 

Reference

Yaacob NM, Yaacob NA, Ismail AA et al (2016). Dumbbells And Ankle-wrist Weight Training Leads To Changes In Body Composition And Anthropometric Parameters With Potential Cardiovascular Disease Risk Reduction. J Taibah Uni Med Sci. 11(5): 439-447. DOI: 10.1016/j.jtumed.2016.06.005