Shannon Clinic

In Q1 2025, Melbourne Sports Chiropractor Dr. Nicholas Shannon and WTA Tour Coach Carlos Martinez will release their ebook titled “Injury Prevention in Tennis: A Comprehensive Guide”. This ebook pulls together the experience and knowledge Dr. Shannon has accumulated in sports and tennis medicine over the last 18 years, including 8 years working at the Australian Open and published academic work on injuries in elite players. Together with Coach Carlos’s wealth of experience in tennis, ranging from his competitive playing days, to academy coaching, to Pro Tour coaching both in women’s singles and doubles with top 10 players, including his wife Nicole Melichar-Martinez. This unique combination blends the best of both worlds to give readers a deeper insight in injury prevention in tennis.

How The Book Came To Be

Injuries in elite tennis have been an ongoing problem on the pro tour, with reports every fews weeks of another top tennis player being struck down with an injury, resulting in time off court. Dr. Shannon’s paper on injuries in elite players highlighted playing load management and players often returning too early from injury as potential problems leading to injury.

When Dr. Shannon met Coach Carlos, he shared his own experiences of seeing players across all levels not being coached correctly, players playing too much and not undertaking the proper conditioning, resulting in tennis players getting unnecessarily injured. Coach Carlos suggested the two work together on an ebook to share their combined experiences and information to help players, parents and coaches be better informed about injury prevention in tennis.

Deciding What Is Important in Injury Prevention

The next step was to decide what to include in the ebook as injury prevention is an extremely broad area. Coach Carlos and Melbourne Sports Chiropractor Dr. Shannon had their own ideas on areas they consistently see as problem areas for tennis players, coaches and parents. However, to create a more holistic book, both asked their colleagues (professional players, coaches, amatuer players, sports medicine physicians, researchers) and the broader tennis world for their input. The results from this feedback built the foundation for the book and what wad deemed important to cover in injury prevention in tennis. These areas included:

Principles of load management
Overtraining
Burnout
Training periodization (including strength and conditioning)
Principles of injury prevention
Common injuries in tennis
Interventions for injury prevention for the upper and lower limb
Warm-up and recovery
Sports nutrition and hydration

Keeping the Tennis Injury Prevention Information Relevant

A primary objective of Dr. Shannon and Coach Carlos was to have information in the ebook that is timely, relevant, evidence-based and most important, easy for the target audience (parents, players and coaches) to be able to understand and digest. In many cases this involved reviewing the literature, it also meant consulting with other experts in fields like sports orthopaedic surgery, sports scientists, sleep specialists, sports medicine physicians, sports dieticians, physiotherapists, professional players, stringers and coaches. Together, the input from these experts helped to refine the ebook, making sure readers can feel confident in the knowledge being dispensed.

Where to Find “Injury Prevention in Tennis: A Comprehensive Guide”

Dr. Shannon and Coach Carlos’s are working hard to have their ebook available for purchase by early January 2025 to line up with the Australian Open in Melbourne. It will be available on Amazon books. For those looking for extra assistance Dr. Shannon and Coach Carlos will be providing a consultation service to help players and coaches with anything from injury assessment and reviews, managing training loads, technique analysis, nutritional support, managing the demands of travel, to reviewing more complex or chronic injuries hampering players or players looking for ways to improvement their on court performance.

Additionally, you can follow Coach Carlos and Dr. Shannon on social media. For anyone looking to book an appointment with Coach Carlos or Dr. Shannon, they can contact Coach Carlos via social media or book online with Melbourne Sports Chiropractor Dr. Shannon. If you would like to learn more about training load management, have a read here. Finally, Dr. Shannon and Coach Carlos would like to give a big thank you to all those who helped bring this ebook together, without their help the ebook wouldn’t have been possible.

Book Appointment

Ice baths or (cold water immersion) are recovery tools which have long been used in professional sports, particularly in sports such as tennis where recovery is vital with short turnaround times in between matches and tournaments. Ice bath use is now on trend in the general population as individuals look for the same recovery benefits of athletes. In this blog, Melbourne sports chiropractor Dr. Nicholas Shannon explores the theory behind ice baths, whether they provide any real benefit and identifies the optimal temperature and duration one needs to spend in an ice bath, as not all ice baths are the same

What Is Cold Water Immersion?

Cold water immersion (CWI) has been around for decades and as the name implies, it is the process of immersing the body in cold water, usually 15 degrees celsius or less for 5 to 20 minutes following intense exercise, in an attempt to attenuate the stress and damage the body undergoes during exercise, to aid in a faster recovery, to mitigate fatigue and optimize performance.

Intense exercise results in physiological changes and damage to the body including muscle damage, oedema, hyperthermia, dehydration, glycogen depletion and tissue inflammation. The proposed effects of CWI have been attributed to hydrostatic pressure and/or reductions in body tissue temperatures which impacts tissue blood flow (vasoconstriction), post exercise fluid retention and metabolic activity. This may accelerate the recovery process by reducing muscle tissue damage, swelling, inflammation, muscle spasm pain and thermal stress.

The Effects of CWI on Performance

At a high level view, it would appear that sitting in an ice bath after exercise for a few minutes will lead to faster recovery, reduce inflammation, muscle soreness and fatigue, as well as improved performance. However, the literature paints a more complex picture which can be situation and dose-response dependent. Furthermore, there is wide variability in testing protocols used to examine CWI (temperature of the water, duration of time spent in the water, follow up time points analysed, exercise interventions etc) making it more challenging to pool data in the quest for more accurate findings.

Inflammation and Cold Water Immersion

In terms of reduction of inflammation within skeletal muscle the evidence is mixed. One study suggests CWI is no more effective than active recovery (slow, warm-down) for minimizing inflammation and the stress response following resistance exercise. Moreover, a 2017 study examining CWI and whole body exposure following a marathon found similar results which showed CWI was no more effective than active recovery. While a 2023, meta-analysis showed that CWI reduces inflammatory markers including creatine kinase (CK), interleukin 6 (IL-6) and lactate at 0, 24 and 48 hours post exercise, which is consistent with other studies; although CWI did not produce any effect on CK or IL-6.

Resistance and Aerobic Performance and Cold Water Immersion

A 2020 systematic review and meta-analysis found regular use of CWI following resistance training had a negative effect on maximal strength and strength endurance, this included 1RM, maximal isometric strength, strength endurance, and ballistic efforts which were all reduced following CWI. This is reported to be due to the effects of cooling on myogenesis (new muscle formation) which negatively impacts skeletal muscle strength and growth development, therefore blunting the tissue adaptation response to resistance training. Additionally, the paper found CWI did not impact performance gains associated with aerobic training.

A 2022 systematic review and meta-analysis found CWI was effective in promoting recovery in muscle power after eccentric exercise at 24, 48 and 72 hours; CWI was effective in promoting recovery in muscle power 24 hours after high intensity exercise. However, CWI was not effective in recovering muscle strength at 24 hours following either eccentric exercise or high intensity exercise, lending some additional support to the notion that cooling blunts myogenesis.

Interestingly though, a 2023 systematic review and meta-analysis looking at the effects of CWI on the recovery profile of physical performance conversely found CWI impairs muscle power production 1 to 6 hours post CWI. Furthermore, their analysis showed CWI was effective in the recovery of muscle strength 24-48 hours post following endurance exercise, again in contrast to the two prior review papers. Their findings on CWI recovery following endurance performance was consistent with the 2020 and 2022 reviews within 1 hour of exercise showing reduced perceived fatigue and soreness, thermal and cardiovascular strain.

Flexibility, DOMS, CK Levels and Cold Water Immersion

Additionally findings from the 2022 review paper found,

CWI had no effect on the recovery from flexibility performance
CWI was effective at recovery from delayed muscle onset soreness (DOMS) at 48, 72 and 96 hours following eccentric exercise and was moderately effective in reducing DOMS following high intensity exercise at 24 and 48 hours
CWI was not effective at 24 hours in reducing perceived recovery with a small effect at 72 and 96 hours post eccentric exercise. It was however effective at 24 hours post high intensity exercise
In reducing CK levels following eccentric exercise CWI was only effective after 7 days, but was effective at 24 and 48 hours following high intensity exercise
The CK findings were supported by the 2023 review paper, which found a reduction in CK levels following endurance exercise at 24 to 72 hours.

Making Sense of the Literature

Cold Water Immersion and Aerobic Exercise

It is important to note the variability in study designs brings with it the risk of biases which can influence the results. That being said, there are some areas where the literature appears to be slightly more consistent and other areas where the literature is mixed. In terms of recovery from endurance or high intensity exercise there is a more consistent picture that CWI is beneficial for recovery. Endurance or high intensity training is more representative of athletic training and often involves high volumes of running which results in the greatest rise in CK levels and therefore muscle damage in the lower limb, potentially one explaination for why CWI may be beneficial.

Cold Water Immersion and Resistance Exercise

The picture is less clear with respect to resistance training with mixed data on the recovery of both power and strength following eccentric (resistance) training and the overall effects of CWI on blood inflammation markers. With evidence to suggest CWI attenuates the physiological adaptation responses to resistance training (ie. muscle hypertrophy, strength, power) and no evidence indicating CWI is beneficial or augments the adaptative responses to strength training.

It makes recommending ice baths following resistance exercise with short turn around times between sessions less robust, particularly if the focus of the sessions are strength gains and hypertrophy. There may be resistance training subgroups who might benefit from CWI, such as chronically trained elite athletes or during periods of high training loads, where the focus is on short-term recovery rather than physiological adaptations.

Optimal Cold Water Immersion Time and Temperature

Finally, the burning question on most readers’ minds no doubt will be, “what is the optimal immersion time and temperature?”. Two papers looked specifically at the optimal timing and temperature for CWI which indicated 11-15 degrees celsius water temperature, for 11-15 minutes of immersion provided the best results for both immediate and delayed effects. While those undertaking high intensity training should look for a shorter duration, at a lower temperature for optimal results.

Final Thoughts On Cold Water Immersion

In summary, based on the current state of the literature CWI following endurance exercise appears to be beneficial for recovery and could be considered as part of an overall recovery plan. However, with mixed data on the recovery benefits following resistance exercise, coupled with evidence suggesting CWI may have a physiological blunting effect on muscle adaptation following resistance training, CWI would best be considered on an individual basis and may not be beneficial in all cases following resistance training.

Optimizing training and athletic performance involves a raft of different strategies including ice baths, mental imagery, sleep, nutrition. We have you covered with blogs on the importance of all of these. Additionally, we recommend regular treatment including remedial and sports massage to help keep your body fresh. If you would like to make a remedial massage or sports chiropractic appointment, you can book on the link below. Our sports chiropractic clinic is centrally located on the corner of Swanston Street and Collins Street, in the CBD of Melbourne.

Book Appointment

Nicotinamide Mononucleotide (NMN) is a supplement that seldomly comes onto most people’s radar, yet it is a supplement that holds a promising future with some researchers suggesting NMN should become a staple supplement to help improve longevity. Melbourne sports chiropractor Dr. Nicholas Shannon takes a look at literature on NMN to see if it is something you should consider.

What is NMN and How Does NMN Work?

NMN is synthesized in the body via two pathways, the Salvage and Preiss-Handler pathways, with the former synthesizing NMN from vitamin B3. Once synthesized, NMN acts as a precursor to a metabolic coenzyme called NAD+ (nicotinamide adenine dinucleotide).

NAD+ is an important coenzyme involved in a variety of processes including cell death, aging, gene expression, neuroinflammation and DNA repair.

NMN is found naturally in plant and animal sources including soybeans, broccoli, avocado, tomatoes, cucumbers, mushrooms, raw beef and shrimp. The levels of NMN in these food sources vary from around .25mg/100g to 1.88mg/100g. For comparison, studies investigating the efficacy of supplementing with NMN range from 250mg to 2000mg per day.

Why is NMN and NAD+ important in aging?

As we age there is a reduction in energy production in the mitochondria (the power factory of cells) in a variety of organs including the brain, adipose tissue, skin, liver, skeletal muscle and pancreas as a result of decreased NAD+ levels. This depletion of NAD+ occurs naturally with aging, due to an increase in consumptions of NAD+ consuming enzymes. Additionally, the metabolic pathway which produces NAD+ can be inhibited by chronic inflammation, high fat diets and, oxidation which can further negate the levels of NAD+ in the body. This in part, leads to biological changes associated with aging such as, reduced endurance, strength, cognitive impairment and DNA damage.

Supplementation with NMN has been shown to boost NAD+ levels by 2-3 times. Furthermore, fasting, and reducing energy intake may also improve NAD+ levels. It is for this reason, NMN supplementation research has moved from NMN being a source of cellular energy and a precursor to NAD+, to it’s potential impact on other disease such as age-induced type II diabetes, obesity, cerebral and cardiac ischaemia, heart failure and cardiomyopathies, Alzheimer’s disease (AD) and other neurodegenerative diseases, corneal injury, macular degeneration and retinal degeneration and acute kidney injury.

Safety and Efficacy of NMN

NMN has been extensively studied in mice and rodents, where results have shown significant improvements across a variety of areas including AD, age-related physiological changes, as well as renal, cardiac, vascular and skeletal muscle function. However, impressive results in animal studies do not necessarily correlate to the same changes in humans.

The first step in the human trial process is to establish if an intervention is safe, efficacious (does it work) and if are there any adverse reactions. To this author’s knowledge, there are at least 9 randomized controlled human trials which have explored dosage ranges from 250mg to 2000mg per day, over various time periods ranging from 30 days to 3 months, across a variety of groups; healthy middle aged adults, healthy older aged adults, recreational athletes, obese and overweight, males and females.

These studies have consistently shown NMN is safe and well tolerated. The data is favourable to seeing an increase in NAD+ concentrations in the blood, however it should be noted there have been some studies which haven’t shown a statistically significant change. Furthermore, it should be noted that currently there is no agreed definition of what low, normal or high NAD+ levels are.

Reported Benefits of NMN

A 2023 randomized, controlled, double blinded placebo trial (the gold standard study design) investigating the effects of NMN at 300mg, 600mg and 900mg versus placebo on a cohort of 80 healthy male and female adults over 60 days, found increased blood concentrations of NMN, significantly improved 6 minute walking test (endurance), minimal to no change in blood biological age, and improved health scores (SF-36 questionnaire) in the NMN groups compared to placebo. In addition to NMN being safe and well tolerated across all doseage levels.

Additional clinical trial data has shown the following.

Sleep – no detectable changes in sleep quality scores
Physical activity (older adults) – significantly improved gait speed, grip strength, 30s chair-stand test indicating a potential prevention in age-related muscle decline
Physical activity (middle-aged adults) – significantly increased oxygen consumption in ventilation and energy consumption. In addition to significantly improved aerobic capacity when exercise and NMN were combined, suggesting NMN could be used to improve athletic performance
Nervous system-related – improvements in hearing in older adults, no change in cognition or vision
Diabetes – improved muscle insulin sensitivity which may improve impaired glucose tolerance
Anti-aging – significant improvement in telomere (a biomarker for monitoring aging)

Where To From Here?

The early human data for NMN looks promising, it’s safe, it is well tolerated, and there is evidence in adults that NMN may play an important role in anti-aging. The data specifically related to improvement in endurance and strength for older and middle-aged adults looks extremely promising, and this should be an area of great interest to those in the sports and exercise medicine field.

Overall, the early data suggests NMN might have a bright future, which will be solidified as more data comes out. Some of that data needs to provide clarity to understand the full impacts of NMN supplementation on the body; to establish agreed measurements of NAD+ to determine what are low, normal and high levels; to identify if there are specific age-related dosages; and to study the safety of NMN supplementation over the long term (years).

It is also important to note that supplementation is only one component to improving health and longevity. Additionally sleep, diet, fasting and exercise are essential to the process.

If you are interested in exploring the benefits of NMN for yourself, Melbourne sports chiropractor Dr. Shannon has analysed the market providers and prefers Renue by Science, as their products are third party tested to confirm their supplements purity, and their manufacturing plant is FDA approved. To read more about why third party testing is important for supplements have a read of our blog on sports supplements.

If you would like to book an appointment a chiropractic or massage appointment at our Melbourne city chiropractic clinic on Collins Street in the Melbourne CBD, click on the link below.

Book Appointment

The Game Changers, a movie promoting the benefits of a plant-based diet on athlete performance has been gaining a lot of traction. With big sports stars involved like Lewis Hamilton, Novak Djokovic, Arnold Schwarzenegger, Jackie Chan and backed by Hollywood heavy weight director and producer James Cameron one can see why. However, for the uninitiated majority of those involved with this production including the chief science advisor are supporters of plant-based diets, leading to a somewhat biased slant. Therefore, the question needs to be asked “what does the research really say about plant-based diets and athletic performance”.

“love to put Viagra out of business, just by spreading the word on plant-based eating.”

James Cameron – The Independent 25/04/2018

Diets for athletic performance are extremely individualised and are geared towards the specific demands of the athlete and sport the individual competes in. In a very simplistic manner, it requires a balance of protein, carbohydrates and fats to aid with the development of lean muscle mass, energy production and recovery matched against energy expenditure or calories burned throughout the day.

Gluten Free Diets

Athletes are always looking to find that extra edge over their competitors and diet is one area that can be utilized to good effect however, all that glitters may not actually be gold. A few years ago with the explosion of gluten and wheat intolerances and celiac disease a few athletes decided to go gluten free and claimed it was responsible for improving their athletic performance, even though they hadn’t been diagnosed as celiac.

Interestingly though these claims aren’t currently supported by the research, with a study in 2015 that took 13 competitive endurance cyclists with no history of celiac disease and compared their time trial performance while on a short term gluten containing diet and on a gluten free diet. The study showed athletic performance didn’t improve for the athletes on a gluten free diet with no history of celiac disease. Given, this study had a small sample size of 13 athletes and was conducted over a short time period (7-day diets) it is however currently the only study comparing gluten free and gluten containing diets on athletic performance in non-celiacs.

Ketogenic Diets

Ketogenic diets have been another diet trend amongst athletes, especially in the world of sports like CrossFit. Ketogenic diets are low in carbohydrates and high in fats, which at first glance seems counterproductive to athletic performance when carbohydrates are an athlete’s main source of energy. In the non athletic population Ketogenic diets or low carbohydrate diets have been shown to be beneficial with weight-loss and reductions in the risk of diabetes.

One could argue that reducing body mass might be an important goal in endurance and weight based sports however, the current limited literature looking at ketogenic diets and athletic performance does not support the use of ketogenic diets for athletic performance. Although ketogenic diets do not negatively impact performance, they may lead to unwanted decreases in lean body mass or a drop off in skeletal muscle hypertrophy. For more detailed information on ketogenic diets and athletic performance check out Melbourne city chiropractor Dr. Shannon’s blog.

Plant-Based Diets

As it is becoming quickly evident the current literature investigating diet and athletic performance is sparse and generally low in quality. This trend continues when comparing plant-based diets versus omnivore (animal and plant) diets and athletic performance, especially in the elite athletic population which is the premise of The Game Changers documentary.

A search of PubMed found only one review paper which systematically reviewed the current literature comparing vegetarian and omnivore diets with physical performance. The paper included 8 studies, 7 randomised controlled trials and 1 cross-sectional study and found there were no differences in athletic performance between a vegetarian-based diet and omnivore diet.

“As someone who follows a plant-based diet, I believe we need a healthier high street option that tastes amazing but also offers something exciting to those who want to be meat-free every now and again.”

Lewis Hamilton on his Neat Burger company – The Sun 29/08/2019

With such limited and low-quality evidence currently available comparing diets and athletic performance, it is extremely important in this commercial and marketing driven age that we step back and ask questions to understand where the truth lies, rather than letting a documentary “inform” us. Plant-based diets and reducing animal meat intake has been associated with health benefits, with a large section of the research on plant-based diets focusing on its potential risk reduction in chronic preventable diseases such as cardiovascular disease.

At present there is limited research available analysing its effects on athletic performance with no known larger scale multi-arm studies comparing a variety of diets on athletic performance. Currently the evidence does not show a positive association between a plant-based diet and athletic performance compared to other animal meat with plant based diets.

Final Thoughts on Plant-Based Diets

Diets for athletes, especially elite athletes are extremely individualised and what works for one athlete might not necessarily work for another. Whatever diet is chosen, plant-based or omnivore it should be driven by a nutritionist, dietitian or health professional with sports nutrition training and be grounded in the best evidence available.

If you are looking for some guidance on sports nutrition or are wanting to optimize your bodies performance, Melbourne city chiropractor Dr. Shannon is well placed to help. For an appointment with sports chiropractor Dr. Shannon or our sports massage therapists, Paula Pena at our Melbourne CBD chiropractic clinic you can book below. Our chiropractic clinic is located in the Melbourne CBD on Collins Street, oppposite the Melbourne Town Hall.

Book Appointment

Achilles Tendinopathies

Achilles tendon pain is a prevalent condition that is an extremely frustrating and challenging condition to treat for both patient and practitioner. Fortunately there is a strong and ever growing body of evidence that supports the use of heavy tendon load exercises in the treatment of tendinopathies, especially achilles tendinopathies (AT).

In September 2019, Melbourne city chiropractor Dr. Shannon published an article in the Chiropractic Australia, COCA News magazine examining AT and what the evidence currently tells us.

Taming Achilles Tendinopathies

By (Dr. Nicholas Shannon PGDipSEM, ICCSP)

Introduction

image:magazine article on achilles tendinopathies

Tendinopathies, including Achilles tendinopathies (AT) are prevalent injuries that can affect anyone from a sedentary office worker to an elite athlete. AT classically present with pain, swelling of the tendon and impaired function (1). Tendinopathies are difficult cases to treat and often patients present having tried multiple treatment options without success.

There is evidence suggesting a genetic link to tendinopathies, with ABO blood typing being linked to tendon ruptures, the Tenascin C gene being linked to Achilles tendon injuries, as well as COL5A1 being linked to Achilles tendon pathology (2–4). There is also evidence associating high cholesterol with tendon pain, as well as a link between fluroquinolones (antibiotics), tendinopathies and tendon ruptures (5,6). Of more clinical importance is the link between tendon loads and tendinopathies (7,8).

The Role of Tendons

The role of tendons are to capture and release energy which occurs through type I collagen fibres and a well organised tendon cell structure (9). When excessive loads are placed on a tendon it results in cell breakdown including apoptosis, disorganisation and changes in the collagen fibre quality with an increase in type III collagen, break down of the cell matrix, and an increase in fatty tissue, proteoglycans (responsible for swelling in the tendon) and tenocytes (7,10–13). The break down and disorganisation of the tendon cell structure directly affects the tendons ability to store and release energy resulting in tissue breakdown, neovascularisation (infiltration of new blood and nerve vessels) and ultimately degeneration of the tendon (7,10–13).

This cell structure breakdown occurs on a sliding continuum which is directly related to tendon load, with a healthy tendon at one end and a degenerative tendon at the other (7). When there is continuous excessive tendon load, the mechanically compromised tendon slides down the continuum from a normal tendon, to a reactive tendon, into tendon disrepair, ending at a degenerative tendon (7,14). During this degenerative process there is no frank evidence of inflammation hence the terminology shift from tendonitis to tendinopathy (15). To learn more about the tendon continuum read through our additional blog on Achilles Tendinopathy.

Clinical Stages of Tendon Degradation

Clinically the 3 stages of tendon degradation present as follows (7):

Reactive tendinopathy – most commonly seen in acute overload, usually in the young population, with no prior history of tendon pain. On MR and ultrasound (US) the tendon will appear swollen with no signal change (MR) and diffuse hypoechogenicity (US).

Tendon disrepair – can be seen in chronically overloaded young individuals, however it can be seen in a wide variety of ages across a spectrum of loading. The tendons are thickened with local changes in one area of the tendon. On MR and US, they will appear swollen, with high signal (MR) and small areas of hypoechogenicity and possible increased vascularity (US) within the tendon.

Degenerative tendon – is usually seen in the older population but can be seen in a young person or elite athlete with a chronically overloaded tendon. The typical patient is a middle aged, recreational athlete with focal Achilles tendon pain and swelling. There is usually a history of repeated tendon pain which self-limits with tendon load changes. These tendons have a higher risk of rupturing and cannot be rehabilitated. MR and US show an increase in tendon size, high signal (MR) and focal hypoechogenicity along with large and numerous vessels.

The most common type of tendinopathy seen in clinic will be the patient aged 40-60 years of age, with a past history of load exacerbations and an onset of increased pain following tendon overload (8). The tendon will be degenerative with reactive aspects. The next most common is the young person 15-25 years of age, acute onset of pain, swollen tendon, associated with a rapid increase in tendon load, aggravated by exercise and slow to settle (8).

Achilles Tendinopathy Treatment Interventions

Radial Extracorporal Shockwave Therapy (RESWT) – there is good quality, low level evidence to suggest RESWT is comparable to eccentrics for pain at 4 months and is superior to wait and see for pain and disability at 4 months for mid portion AT, as well as being superior to eccentrics at 4 months for pain and disability for insertional AT (16). A meta-analysis of randomized controlled trials showed RESWT had a positive effect on pain and function in AT, however the study had high heterogeneity and used the QVAS (VISA-A is the gold standard) as the primary outcome measure (17).

Exercise Therapy – exercise therapy has been advocated for AT with evidence supporting improvements in pain and function in mid portion AT (8,18). Exercise therapy for AT typically consists of differing loading programs involving isometric, eccentric and concentric exercises. Currently there is no evidence to support one loading program over another with all programs resulting in improvements (19,20). Commonly used protocols include the Alfredson protocol and a 4 stage tendinopathy rehabilitation program developed by Jill Cook et.al (8,21).

Platelet-Rich-Plasma (PRP) – a robust meta analysis of randomized controlled trials looking at the use of PRP and eccentric exercises versus placebo (saline) and eccentric exercises for chronic AT, found no difference between the groups for pain and function (VISA-A score) nor changes in tendon thickness (22). This is supported by another meta analysis that found inconclusive evidence to support the use of PRP in AT (23).

Corticosteroid injections – are associated with a high risk of adverse effects including tendon rupture, tendon atrophy, decreased tendon strength, there is also insufficient evidence to support the use of corticosteroid injections for AT (24,25).

Orthotics – there is no evidence to support the use of orthotics for the improvement in pain and function for AT (18).

NSAIDs – the use of NSAID’s in chronic AT appears redundant as there is no evidence of inflammation in the tendon. There is an argument they could be used to treat pain in the acute phase however, evidence shows they have little or no effect on the outcome of AT (1).

Surgery – there are a wide variety of invasive, minimally invasive and endoscopic techniques for treating mid portion AT. There appears to be no difference in outcomes between techniques (26,27). However, there are no studies comparing surgery to placebo or non-surgical interventions such as exercise therapy (27). There also appears to be highly variable complications risks associated with surgery (27).

Conclusions on Achilles Tendinopathy

AT and tendinopathies are challenging for the clinician and patient. Tendinopathy treatment needs to be individualised and should focus on removing the “abusive” tendon load, correcting any malalignment and biomechanical problems, as well as utilizing exercise therapy to strengthen any deficient areas and to manage tendon pain and improve function. Shockwave therapy should be considered for those not responding solely to exercise therapy or used in addition to exercise therapy. Clinicians also need to manage the expectations of their patients, as tendinopathies can take several months and sometimes longer to rehabilitate (28). With exercise therapy being the primary treatment modality, chiropractors are well placed to be the first-choice clinician in the management of AT tendinopathies.

If you would like to read more about running related injuries which includes Achilles tendinopathy head over to our blog. With a wealth of knowledge and experience in treating tendinopathies Melbourne city sports chiropractor Dr. Shannon at the Shannon Clinic Melbourne Chiropractic and Sports Care are well placed to treat your tendon pain. Book an appointment today with chiropractor Dr. Shannon or remedial massage therapist Paula Pen at our Melbourne CBD chiropractic clinic which is centrally located on Collins Street in the Melbourne CBD opposite the Melbourne Town Hall.

Book Appointment

References

1. Li H-Y, Hua Y-H. Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. BioMed Res Int. 2016 Nov 3;doi:2016:6492597.
2. Magra M, Maffulli N. Genetic aspects of tendinopathy. J Sci Med Sport. 2008 Jun;11(3):243–7.
3. Mokone GG, Gajjar M, September AV, Schwellnus MP, Greenberg J, Noakes TD, et al. The guanine-thymine dinucleotide repeat polymorphism within the tenascin-C gene is associated with achilles tendon injuries. Am J Sports Med. 2005 Jul;33(7):1016–21.
4. Mokone GG, Schwellnus MP, Noakes TD, Collins M. The COL5A1 gene and Achilles tendon pathology. Scand J Med Sci Sports. 2006 Feb;16(1):19–26.
5. Tilley BJ, Cook JL, Docking SI, Gaida JE. Is higher serum cholesterol associated with altered tendon structure or tendon pain? A systematic review. Br J Sports Med. 2015 Dec;49(23):1504–9.
6. Lewis T, Cook J. Fluoroquinolones and Tendinopathy: A Guide for Athletes and Sports Clinicians and a Systematic Review of the Literature. J Athl Train. 2014;49(3):422–7.
7. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009 Jun 1;43(6):409–16.
8. Cook JL, Kahn K, Reiman MP. Why and How Exercise is the Best Treatment for Tendinopathy. Combined Sections Meeting of The American Physical Therapy Association 2016. 2016 Feb 17-20; Anaheim California USA.
9. Franchi M, Trirè A, Quaranta M, Orsini E, Ottani V. Collagen structure of tendon relates to function. ScientificWorldJournal. 2007 Mar 30;7:404–20.
10. Samiric T, Ilic MZ, Handley CJ. Characterisation of proteoglycans and their catabolic products in tendon and explant cultures of tendon. Matrix Biol J Int Soc Matrix Biol. 2004 May;23(2):127–40.
11. Danielson P, Alfredson H, Forsgren S. Distribution of general (PGP 9.5) and sensory (substance P/CGRP) innervations in the human patellar tendon. Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2006 Feb;14(2):125–32.
12. Yu JS, Popp JE, Kaeding CC, Lucas J. Correlation of MR imaging and pathologic findings in athletes undergoing surgery for chronic patellar tendinitis. AJR Am J Roentgenol. 1995 Jul;165(1):115–8.
13. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999 Feb;81(2):259–78.
14. Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports Med Arthrosc Rev. 2009 Jun;17(2):112–26.
15. Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 1998 Dec;14(8):840–3.
16. Korakakis V, Whiteley R, Tzavara A, Malliaropoulos N. The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. Br J Sports Med. 2018 Mar 1;52(6):387–407.
17. Liao C-D, Tsauo J-Y, Chen H-C, Liou T-H. Efficacy of Extracorporeal Shock Wave Therapy for Lower-Limb Tendinopathy: A Meta-analysis of Randomized Controlled Trials. Am J Phys Med Rehabil. 2018 Sep;97(9):605.
18. Wilson F, Walshe M, O’Dwyer T, Bennett K, Mockler D, Bleakley C. Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta-analysis. Br J Sports Med. 2018 Dec 1;52(24):1564–74.
19. Habets B, Cingel R. Eccentric exercise training in chronic mid-portion Achilles tendinopathy: A systematic review on different protocols. Scand J Med Sci Sports. 2014 Apr 1;25.
20. Murphy M, Rio E, Chivers P, Debenham J, Docking S, Travers M, et al. The rate of improvement of pain and function in mid-portion Achilles tendinopathy with loading protocols: A Systematic Review and Meta-Analysis Protocol. Sports Med. 2018 Aug;48(8):1875-1891.
21. Plas A van der, Jonge S de, Vos RJ de, Heide HJL van der, Verhaar J a. N, Weir A, et al. A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012 Mar 1;46(3):214–8.
22. Zhang Y-J, Xu S-Z, Gu P-C, Du J-Y, Cai Y-Z, Zhang C, et al. Is Platelet-rich Plasma Injection Effective for Chronic Achilles Tendinopathy? A Meta-analysis. Clin Orthop. 2018 Aug;476(8):1633–41.
23. Hussain N, Johal H, Bhandari M. An evidence-based evaluation on the use of platelet rich plasma in orthopedics – a review of the literature. SICOT-J. 2017 Oct 9;doi: 10.1051/sicotj/2017036.
24. Hart L. Corticosteroid and other injections in the management of tendinopathies: a review. Clin J Sport Med Off J Can Acad Sport Med. 2011 Nov;21(6):540–1.
25. Kearney RS, Parsons N, Metcalfe D, Costa ML. Injection therapies for Achilles tendinopathy. Cochrane Database Syst Rev. 2015 May 26;(5):CD010960.
26. Lohrer H, David S, Nauck T. Surgical treatment for achilles tendinopathy – a systematic review. BMC Musculoskelet Disord. 2016 10;17:207.
27. Baltes TPA, Zwiers R, Wiegerinck JI, van Dijk CN. Surgical treatment for midportion Achilles tendinopathy: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2017;25(6):1817–38.
28. Lipman K, Wang C, Ting K, Soo C, Zheng Z. Tendinopathy: injury, repair, and current exploration. Drug Des Devel Ther. 2018 Mar 20;12:591–603.

Fluid or hydration status is extremely important in endurance sports like the marathon, Ironman and endurance motorsport, getting it wrong can have disastrous consequences. As such hydration is a balancing act, not taking in enough fluids will result in dehydration and taking in too much fluid will result in Exercise-Associated Hyponatremia (EAH). EAH can be a life-threatening scenario where an athlete or individual takes on more fluid than they are losing, causing a dilution and subsequent reduction in sodium levels within the body resulting in fatigue, nausea, vomiting, dizziness and alterations in consciousness.

Having first hand experience working at the Wanaka Ironman in New Zealand and in elite level endurance motorsport Melbourne city sports chiropractor Dr. Shannon discusses the keys to getting your hyrdation strategy right.

How Fluid Should Be Replaced

It is uniformly agreed that fluid replacement during exercise is important to prevent excess fluid loss (dehydration) and to avoid body weight loss of >2% and excessive changes in electrolyte balance which can compromise performance. How that fluid is replaced during exercise is currently of great debate with researchers unable to come to a consensus on which approach is best, drinking to a plan of 600-800ml per hour, drinking to thirst (using the sensation of thirst to determine when to drink) or drinking ad libitum (drinking whenever and in whatever volume).

In light of this lack of consensus it would seem reasonable that any rehydration strategy should be flexible taking into consideration the duration of the event, the outside temperature, the effort required, sweat rate, the terrain and gradient etc. It should use thirst as a guide while not straying too far from an intake of 600-800ml per hour, but essentially not drinking more than is being lost through sweat.

Sweat Rates

Sweat rates are highly variable between individuals with an average sweat rate of approximately 1.35L/hr. There are calculators available that can help determine ones specific sweat rate. Alternatively, a simple way to establish a rough sweat rate is to weigh one’s self prior to and immediately after a 60 minute workout. The weight loss during that period divided by the time (60mins) will provide a rough sweat rate estimate – it is important to be well hydrated before undertaking the workout. The benefit of establishing an individual sweat rate estimate is it aids in understanding how much fluid is lost to sweat per hour of exercise and therefore roughly how much fluid will need to be replaced per hour.

What To Drink

Armed with a sweat rate estimate and a rehydration strategy of drinking to thirst while making sure one isn’t straying too far from the amount of fluid needing to be replaced due to sweat loss, gives you 2 of 3 key components to a solid hydration strategy. The final component is the fluid type that should to be taken in; water, hypertonic (Gatorade), hypotonic (Mizone) or isotonic (Powerade) drinks. In endurance sports the simple answer to this question is all, it is important to use a mixture of water and drinks that contain electrolytes as well as carbohydrates.

Lastly, it is important to try different products and combinations during training to see what works best and to also get used to drinking while training, so when it comes to race day it is one less thing you have to think about.

If you are looking for more sports nutrition or supplement information, The Shannon Clinic – Melbourne Chiropractic and Sports Care blog has a myriad of blogs covering protein, diets, sports supplementation, hyrdation and so much more.

To book an appointment with Melbourne city chiropractor Dr. Shannon or remedial massage therapists Paula Pena click below. Our Melbourne CBD chiropractic clinic is centrally located on Collins Street, opposite the Melbourne Town Hall.

Book Appointment