INFLAMMATION'S RELATIONSHIP TO CONNECTIVE TISSUES LIGAMENTS, TENDONS, AND FASCIA
In order to understand today's post, you must understand two simple concepts; inflammation and connective tissue. Connective Tissues are just that --- tissues that physically connect various parts of you to other parts of you (FASCIA is a great example of this). Besides fascia, which is the most abundant connective tissue, the others include LIGAMENTS, TENDONS, CARTILAGE, and BONE. And as crazy as it sounds, blood is actually a connective tissue that certain individuals are claiming has a fascial component (HERE). But what about inflammation?
Inflammation is the name given to the group of chemical compounds made by your body for the express purpose of allowing cells and tissues to communicate with each other during the body's response to tissue damage. Thus, while a certain amount of local inflammation is vital for healing injured or damaged tissues (connective tissues included), any amount of inflammation over and above what is necessary is problematic, leading to a myriad of health-related problems (MINIMAL EFFECTIVE DOSE). So, when inflammation becomes "SYSTEMIC," it will adversely affect every cell, tissue, and organ in your body, as well as becoming a frequent contributor to CHRONIC PAIN. If you want to know more about inflammation (scratch that, you need to really understand inflammation), simply CLICK THIS LINK.
If you don't want to read this post in its entirety, all you really need in order to understand that inflammation always leads to fibrosis (thickened tissue that microscopically looks and acts more like a hair tangle than combed hair), and that fibrosis always leads to degeneration, is THIS POST. For the rest of you, allow me to show you some of the finer details of the many ways that inflammation wreaks havoc on your connective tissues, causing mechanical dysfunctions that not only lead to NEUROLOGICAL ISSUES, but are believed by increasing numbers of scientists to be the root of all sickness and disease (HERE).
For years there has been a raging debate over whether run-of-the-mill connective tissue injuries (PARTICULARLY OVERUSE INJURIES) are inflammatory, or purely degenerative. The best example of this phenomenon is found in the Tendinosis / Tendinitis debate. Starting about 35 years ago, researchers began publishing a wave of studies claiming that most tendon problems were not the result of inflammation (itis is the Latin word for inflammation, so Tendinitis would indicate an inflammation of the tendon), but are instead the result of an overuse-induced degeneration known as TENDINOSIS (osis means a derangement of).
This debate came to the forefront in a 2009 issue of Arthritis Research & Therapy (Pathogenesis of Tendinopathies: Inflammation or Degeneration?) in which the authors concluded, "It is conceivable that inflammation and degeneration are not mutually exclusive, but work together in the pathogenesis of tendinopathies." Below are some cherry-picked conclusions that helped solidify what I wrote earlier this year about a 2017 showing that yes, there is indeed an inflammatory component to Tendinosis (HERE).
"Historically, the term tendinitis was used to describe chronic pain referring to a symptomatic tendon, thus implying inflammation as a central pathological process. However, traditional treatment modalities aimed at modulating inflammation have limited success and histological studies of surgical specimens consistently show the presence of degenerative lesions, with either absent or minimal inflammation. Experimental findings suggest that acute inflammation may be involved from the start and that a degenerative process soon supersedes it. Observations in human tendinopathies further support the entangled roles of inflammation and subsequent degeneration within tendons. Inflammation and degeneration are not mutually exclusive, but work together in the pathogenetic cascade of tendinopathy."
We see something similar with fascia. If you are not familiar with FASCIA, just click the link and start reading. As many of you are already aware, fascia is an extremely important tissue, and thanks to increasing amounts of research on the topic, it's no longer the red-headed stepchild of anatomy and physiology, ignored at every turn. And although few seem to be aware of the fact, the very same debate seen with tendonopathies (inflammation -vs- degeneration) is going on with fascia. Nowhere is this seen more clearly than with PLANTAR FASCIITIS. Case in point, an article in Runners Connect by John Davis (Is Reducing Inflammation Really the Best Way to Treat Running Injuries?)
"What is the role of inflammation in running injuries? For a long time, inflammation has been identified as the main culprit for pain resulting from running injuries. But is this inflammatory model valid? By definition, inflammation has features that are observable both on the macroscopic level of sensations in your body (like pain, redness, swelling—things a doctor would call “clinical features”), and on the microscopic level of the inner workings of your cells—this consists mainly of special inflammatory cells which flood an inflamed area and mediate your body’s response to the injury. Using tissue samples taken from patients with chronic tendon or plantar fascia injuries who undergo surgery (and are hence being sliced open anyhow), recent studies have demonstrated a lack of inflammatory markers at the cellular level. Instead, what they observe in injured tissue under a microscope is profound damage and degeneration in the microscopic structure of the tissue."
The Merck Manual is the "Physician's Bible" --- historically the most common reference book used by doctors (I have a copy from my school days). Listen to what Dr. Kendrick Alan Whitney says in an online article for the Merck Manual called Plantar Fasciosis. "Plantar fasciosis is sometimes referred to as plantar fasciitis. However, the term plantar fasciitis is not correct. The term fasciitis means inflammation of the fascia, but plantar fasciosis is a disorder where the fascia is repeatedly stressed rather than inflamed." In a similar article written for the site Evidence for Exercise (Plantar Fasciitis – Inflammatory or Degenerative Condition?), author David Evans quotes peer-review, revealing that, "studies report a predominance of degenerative changes at the plantar fascia. Direct evidence of inflammation has rarely been detected histologically in chronic plantar fasciitis."
What's my opinion? We know that under certain conditions (we'll get to those momentarily) fascia undergoes physical changes consistent with a scar. But does fascia get inflamed or does it not get inflamed? I think that it's hard to argue that it doesn't. Before we discuss the common ways that inflamed fascia causes pain and dysfunction, let me show you the uncommon ways (these are fascia-related inflammatory problems that few of you will ever have to worry about).
For the record, after almost three decades of experience, my opinion is that yes, fascia commonly becomes inflamed for a wide variety of reasons. These reasons include various forms of trauma (WHIPLASH INJURIES are a common one), repetitive injuries which we spoke of earlier, and even POSTURAL DISTORTIONS --- all of which can not only be caused by inflammation, but can actually generate inflammation as well. In this next section I want to show you how inflammation affects fascia, and in the final section show you what you can do about it.
TENDINOSIS OR FASCIAL ADHESIONS?
(DOES IT REALLY MATTER?)
"The concept is that there is a loss of inflammatory response and chronic scar formation with fascia and tendon injuries. The proper terms for such injuries are fasciosis and tendinosis rather than the more commonly used terms of fasciitis and tendonitis. In fasciitis and tendonitis cases, there is good blood supply to the problematic region but there is an inflammatory response that is painful. In fasciosis and tendinosis issues, the fascia and ligament have a decrease in inflammatory response, a reduction in the growth/healing factors and a chronic scar formation that prevents the healing process." Dr. Babak Baravarian from the May 2009 issue of Podiatry Today
If you have read my MAIN PAGE or BLOG POSTS on Tendinosis, you already realize that there are many experts saying that Tendinitis (the word 'itis' means 'Inflammation') does not exist --- or if it does exist --- is extremely rare. What is common, however, is something called Tendinosis. But who really cares whether a person is dealing with an 'osis' or an 'itis'? In other words, isn't it just a word game --- a matter of semantics that doesn't really mean anything? No it's not. Sit up and pay attention as I show you why.
According to an online Medical Dictionary, the suffix "osis" means, "a diseased or abnormal condition; an increase in a pathologic condition; production of an abnormal substance; increased production of a normal substance; a derangement of". When it comes to Tendons or FASCIA (the membranous cover of muscles, organs, and other tissues), even though most of the problems found in these two tissues are believed to be more along the lines of an "osis," they are usually treated as an "itis". In other words, even though the peer-reviewed literature says otherwise, these problems are almost always diagnosed as Inflammatory conditions and subsequently treated as such --- with ANTI-INFLAMMATION MEDS and CORTICOSTEROIDS. But is this the best option? Listen to a bit more of what Dr. Baravarian; a UCLA-affiliated foot doctor, has to say.
"It is ironic that we usually try to treat such issues on the acute (fasciitis/tendonitis) cases with rest while we try to treat the chronic issues (fasciosis/tendinosis) with cortisone injections. This does not make sense as an anti-inflammatory injection such as cortisone has a better chance of working in the acute phase when there is still an inflammatory process that is working. With chronic injuries such as Achilles tendinosis and plantar fasciosis, cortisone injections do not help very much. There is no inflammatory process with these injuries and the injection only works via the trauma caused by the needle, resulting in an inflammatory response in the designated area."
Although Dr. Baravarian is speaking here about the foot, he could be talking about almost any part of the body. What is extremely intriguing is the fact that the Cortisone Injection itself is not only not beneficial, it's actually harmful --- extremely harmful as shown repeatedly in peer-review (HERE). The healing properties of the injection come about not from the medication, but from the INFLAMMATORY PROPERTIES OF THE NEEDLE that induces healing via the creation of an inflammatory response.
There are many different techniques that have the potential to create such an inflammatory response --- a response that is both necessary and vital for healing to take place (remember, it's too much inflammation that causes problems with the healing process). Acupuntcture is thought to do similar, as does the technique known as "Dry Needling" (see previous link). In this case, the physician takes a fairly heavy gauge needle and uses it to repeatedly puncture whatever area he is treating. Prolotherapy works by creating an inflammatory response with sugar water injections (HERE is a possible mechanism for creating such a response). Our SCAR TISSUE REMODELING is designed to work in similar fashion (HERE are some pictures of the local inflammatory response). CHIROPRACTIC ADJUSTMENTS may even do this on a small scale as does STRETCHING & EXERCISE. Among other things, these are all designed to create some degree of FIBROBLASTIC RESPONSE.
You must understand a couple of things here. When I say that Tendinosis is not an "Inflammatory" problem (HERE), what I mean is that it is not creating its own Inflammatory response. I do, however, believe that in many cases, SYSTEMIC INFLAMMATION has the ability to create, cause, or worsen local "non-inflammatory" problems. Let's put this in practical terms as far as helping suffering people is concerned. If we can create a LOCAL Inflammatory response, while inhibiting SYSTEMIC Inflammation, the odds of licking the sorts of problems commonly found in (LIGAMENTS, TENDONS, MUSCLE, and FASCIA) increases dramatically. Beyond our Tissue Remodeling Treatment, HERE are is a post that might be of benefit as well.
Oh, and as to the "does it really matter?" quote from the top of the page; it doesn't. The problem will be dealt with the same, whether it's Fascial or Tendinous.
CRISTIANO HAS TENDINOSIS IN HIS KNEE
A two-day-old article from Yahoo says that, "tendinosis is a non-inflammatory condition involving a previously injured tendon that heals with weak collagenous fibers, low weight-bearing resistance and has a high risk of future injury". BreakingNews.com describes Tendinosis as, "a degeneration of tendon's collagen due to chronic overuse". And in a June 4 article by Andi Thomas (Cristiano Ronaldo has Tendinosis. What the Hell is Tendinosis?) we learn even more. Listen to what Thomas writes...... "According to tendinosis.org, it's a "chronic injury of failed healing". Basically, it's when a lot of tiny tears to the connective tissue around the tendon start to have a cumulative effect on the strength of the tendon. Think pain, think stiffness, think mild swelling around the left knee. It's not to be confused with the more common tendonitis, which involves inflammation of the tendon itself."
Dr. Schierling completed four years of Kansas State University's five-year Nutrition / Exercise Physiology Program before deciding on a career in Chiropractic. He graduated from Logan Chiropractic College in 1991, and has run a busy clinic in Mountain View, Missouri ever since. He and his wife Amy have four children (three daughters and a son).
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