Chronic Tendinopathy and Cultural Insights from Team China's Chiropractor | Podcast Ep. 270

Foreign.

Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Langmaid. And on today's episode I have an awesome interview with Dr. Yvonne Chang. This is the farthest interview I have ever done. She was taking this interview from Malaysia. I was sitting in my office here in Tampa, Florida and, and it's in. It's a fantastic interview. We break down clinical topics like tendinopathy. We talk about how she's become involved with the speed skating team on Team China, the cultural differences, her journey and much, much more. This episode is jam packed and without further ado, here's my interview with Dr. Yvonne Chong.

How did you get either? Which one came first? A passion for speed skating or involvement in Team China? Which. Which of those two came first?

Actually, none of none.

So how I go about getting that job was quite interesting. So one of my friend actually was talking about this job in sports, like how, you know, we were starting this conversation about like how Cairo really, you know, are not being. Being a very primary option to work in sports team is always a physio. It's the exact same thing that I.

Just told you just then.

And then we stumbled upon this job ad online and said, hey, Team China is looking for physiotherapy to, you know, to work with national team sports. So we were like, you know, the requirement was a master's degree, a few years in experience and a few other, you know, other things. So I just say what the heck, we just apply for it, you know. And little did we know, like we, our initial intention was like, we're probably not going to get it because we're kairos, we're not physio. But for Chinese people, they, they don't know the difference. So they don't quite know. Like they don't have the distinction, they.

Just physical therapists there.

So they do them all. Yeah. So little do you know, we both got the job and then, yeah, that's where our adventure starts. So once we get that job, we, you know, we get to China, we get to the company and then they.

Assign us to different sports.

So obviously they asked us about our sports preferences but they never follow them. So they just sent us to whatever sports team that required. Physical therapist per se. Yeah. So we got this job without them understanding what chiropractic is. So I got assigned to speed skating and I'm glad that the coaches there, they are mostly from Canada and from the Netherlands, so they understand distinction. Chiro vs physio vs TCM, the traditional Chinese medicine.

Yeah.

So we worked great from there. So that's how I started working with the speed skating. I had to admit that I didn't really know much about a sport when I first got that job. So I actually had to learn what it is and the nature of the sport, injury pattern and things like that. So, yeah, I'm growing to like that sport very much.

I can imagine. So that's super cool. When you started working with Team China, I guess being working in a, working in a different country, I mean, was that like intimidating? Was it not intimidating? Was everybody super accommodating? What was the process as you got.

Up and running, like traditionally speaking, China, Chinese, the country, China, it's very, in a way, communism, like, you know, fundamentally speaking. So people have the perception of, you know, they're very closed out, they're not as modern. You know, people have stereotypically, like stereotypical thinking about what Chinese people are. For me, because I was born and raised in Malaysia and have a Chinese heritage, I thought I, I thought like, you know, it wouldn't be a cultural barrier, like it wouldn't be a tough thing to, to adapt to because, hey, I'm Chinese in nature. But little did I know, yeah, the Chinese in China really quite different cultural, culturally, language and also, yeah, the way they practice.

So it's very different.

So I had like, I had a ton of tough six months about adapting to it.

Yeah.

Because I just couldn't understand what they say.

I thought I could, but yeah, no.

So yeah, it took me six months to start to grasp what they, what, you know, what, how they work culturally and how they do things. So it was an adventure. I would say it was quite an adventure.

But yeah, I cannot imagine. So as you started to get, as you've gotten comfortable, what's been, what's a day? What's like a day in the life? Walk, walk everybody through, walk me through. What's it like when, you know, you're, you're training with the team for the day, you're taking care of the team, when's the day start? When's the day kind of end? What are you looking for? What goes on a day working with Team China.

Right. So I can't say for other sport, but for speed skating, Team China speed skating, specific. Specifically speaking, long track, that is. So the practice, normally they do two sessions of practice per day. Each session probably lasts around two hours. So as a full time, almost like a full time physical therapist or medical stuff in China, there's no distinction again. So yeah, they just know that you're the person to go to when there's anything medically related.

Yep.

Right.

So.

So yeah, so they start practicing in the morning, usually at 9am so I'll be there in the practice, sitting in the rink while they doing their warmups and then go on night. So sometimes I assist them with their warmup based on the individualized prehab program that I gave them. So they normally use that as, you know, some incorporated into their warm up.

Routine, some of them.

So I assist them with them with that. And then two hours after, when practice are over, then we head back for lunch. So Chinese athlete normally take naps after lunch. It's almost, it's almost like every Chinese athlete that I've talked to do swear by taking naps because they think that hour and hour and a half nap after lunch is crucial, you know, to give them energy to practice the second sessions. Right. So yeah, so they take naps and then normally I just go about doing my own thing in that hour or so. Then normally 3 o' clock comes. Normally 3 o', clock, that's where the second practice starts. Normally they do one ice session per day, meaning they skate on ice once per day and then the remaining session is on land, whether strength training or skating related drills on dry land. And I normally do the same assisting with rehab. And if there's any injured athlete, I'll take them separately to the gym and run the rehab routine or rehab session with them.

Separately.

Yeah, and then after that they'll go home for dinner, I'll do the same, we'll have dinner together. And after dinner that's where night treatment starts. That's where most of them will have their manual therapy done. That's where I'll be the most busy.

Gotcha. Okay.

And then after that's the end of the day.

That sounds like a full day. When you're, when you're at the facility or even at nighttime, do you do a lot of sort of low tech rehab? Is there a huge gym? What's the, what's the work environment like? What's the practice environment like?

It depends on where we, where we are actually. So sometimes like we oftentimes do training camps. So almost half a year we'll do our training camps in Canada. So we spend almost six months in Canada.

Oh, interesting.

Yeah. So it depends on where we are. But nighttime, like after dinner, it's normally the time is reserved for manual treatment. Like so we just either either the athlete would go to the massage therapist or if they have any existing injury, I'll do More either adjustments or any form of other modalities like soft tissue work or art, you know, a bit of fascia training or fascia stretching. Some of them, yeah. So but normally those rehab and prehab work for like severely injured athlete where they can't really participate in normal training. That's where I do them during the training time. So just to get the team working.

At the same time.

Yeah, that makes sense. And what are the most, what are some of the more common injuries and challenges that you see the athletes having?

So for speed skating, for those that are not familiar with speed skating, so the athlete requires to be in a stoop position, so almost like a flexed position for a long time. So their training involves skating and also cycling. Cycling is a big part of, big part of training in speed skating, especially for those mid distance. For shorter distance athlete, it's probably less common, but they still do. So you can imagine there's a big chunk of time that athletes spend in lumbar flexion, like a prolonged sustained flexion. So for those athletes that do not have a good motor control, lumbar pelvic motor control especially, I do see a lot of this pathology, whether it's gouge or herniation or like just, you know, annual irritation. Yeah, it goes from there. So quite often we get low back pain as a main complaint as well as patellar issues, like kneecap issues.

Okay, is and are the patella issues, As a non sport specific doc myself, are they like tracking issues, are they overuse issues? What do you more commonly see?

It's always a combination of all of them, I have to say. So tracking issues, to me it's always a symptom of an underlying problem.

Whether you have.

A weak kinetic chain, a weak posterior chain, for example, making your quads maybe too overloaded and hence tracking issues.

That could be one of them.

Secondly, it could be, you know, basically your core is not strong and it affects your lower limb, how you position your pelvis, things like that. So tracking, to me it's a symptom. But what I see most is patellar tendinopathy, which a lot of which you know, can't be completely solved by manual therapy. It provides some relief for sure, but it's because the demand for muscle loading, for tendon loading is so high in athletic performance, there's no way that we can solve patellar tendon issue without proper rehab and training. So that's what I find most common. That's where I had to learn from scratch as well. Yeah, initially I was struggling with getting a Good outcomes with that. But after doing some research, reading and.

Asking the appropriate people.

Yeah, I do, yeah. I finally understand the issue a little bit more. So I'll say patellar tendinopathy, it's quite common. And also low back pain.

Yep. So you can choose either one kind of walk me through, how do you case manage that? Whether it's a disc injury, whether it's a patella injury, how do you think about it? What are some of your go to modalities? I guess what's kind of your treatment paradigm in general? I know everybody's a little bit different, but how do you envision those and what do you typically use to help people get well and get back to full function?

Right. I'll probably go with patellar tendinopathy because it's quite like.

Yeah, because that's the issue that needed.

A bit more comprehensive management plan. So to first identify, to first identify the problem, we first have to kind of know the symptoms. Initially I was struggling with that. I just thought, hey, the tracking symptoms, I just release the quad, strengthen some vmo, then you know, there you go.

Little did I know that's, you know, that's not it.

It's really way more to that. So first of all, we need to recognize the symptoms. For me, takes a while. So the symptom goes with, normally it's pain that creeps in with time. So initially when you start the activity, it's normally fine. And then after say a minute or two, that's where the pain intensified. So for skaters, oftentimes they will complain about, hey, my knees just buckle after, you know, a minute of skating. I just, you know, like some of them had really pain, like high pain threshold. They just like, there's no pain, but my knees just buckle. Right.

So you know, normally with tendinopathy it.

Should present with some pain. Right. But for skaters, some of the skaters, no pain, they just literally buckle and you see them fall on ice. Interesting. Yeah. So that, that was something that, you know, was interesting for me too. And yeah, and then you investigate. So initially we start with treatment and.

You know, it is when, you know, multiple treatment doesn't work, doesn't even give.

Any change to the symptom. That's where we kind of go, okay, we gotta be a bit more specific to diagnosis.

And normally when that happens, I'll start with a isometric training.

The first phase of the rehab. I'll say I'll normally start with isometric training because it has been proven to provide some analgesic effect. Now, although some of the Skaters don't present the pain, but some still do, even though for those that doesn't present with pain, you can see, after a session of isometric, you can see them, hey, you can actually last on ice for slightly longer. So for me, it's a good sign that, hey, you're responding to the stimulus that I'm giving you. So I'm going to keep on doing that until your ability to flex on.

Ice or create a single leg knee fraction on ice increase. So I normally start with isometric because it's, it's not creating too much, it's creating maximum muscular tension, but not creating too much kind of compression on the.

Joint, depending on how you position it, of course.

And then after, when they responded to that, I'll slowly progress them to a heavy, slow, resistant training sometimes involve eccentric loading. So from there, normally you can see their time on ice or the ability to handle loads start to increase. Then it is also, for you, an outcome measure. For me, and it's an outcome measure that they're responding to the dosage that I'm giving them. Because with loading, we kind of need to know how much to load and when to load. So for me, tendon, I normally load them heavy on one day, and I'll give one or two days rest in between just to maximize the collagen resynthesis. And then the third day, I'll load them again, but maybe with slightly different movement pattern, but still loading the same tendon. That's how, in general, I would approach them, but with the issues of tendinopathy, what I'm trying to bring to attention is that we need to load them with weights for them to respond or for them to at least increase their ability to tolerate load just by manual therapy in itself. Sure. We can do spinal adjusting, si adjusting, all the adjustment. Yes, it does. Like, we know that even from your podcast, like things that I've read in your or listen to your podcast, it has the ability to change cortical activity or improve sensory motor coordination. So that's also important in athletic performance. So I use my adjustment in that sense when it comes to treating patellar tendinopathy. But the bulk of the treatment really comes down to how you load it and how often you load it, what you load it with. So, yeah, so in a general sense, I would say that's how I treat patellar tendinopathy.

That's fantastic. Do you find that most of. And that's an interesting point that I wouldn't have thought of first. So thank you for sharing that. Do you Normally see that the athletes that have that sort of tendinopathy, do, they get back to 100% function and then they can sort of lay off the load. Is it a chronic condition that requires ongoing management? Is every athlete a little bit different? How have you seen that play out?

So obviously every individual are different. Some of them presented with really chronic situation. So it comes down to cultural belief as well. So for some athletes, the way they were trained since young was that they were given this perception of pain is weakness. So you got to train until you, you can tolerate the pain. That's how you get stronger. You know, there's this, there's this misinformation there, but it is in, it is in the culture. I won't say all, but I've encountered a few Chinese athletes and yeah, most of them give me that feedback and that's why some of them develop a really high pain threshold for. I think it's attributed to some, to those cultural reasons. So, yeah, pain perception aside, every individual are different. So the most chronic cases, they still train. Some of them, they still trained. This is when they were under their provincial team. They're not in the national team yet. Those people progressed to national team once they did a selection competition. So they were very used to training in pain until the point where they okay with that. So some of them still training high, like really high volume at high load to the point where sometimes they buckle. That's where they stop. But they never, they never address the underlying issue and find out, hey, you know how I can be better and not buckle and fall on ice. They just think, I'll train to the point where I can't.

That's the best I can do.

Yeah, so I do see some very chronic cases. Those people, it's rather hard because the hardest part was to get them to stop training for a little bit because you can't just keep irritating the tendon before you make it stronger. So the hardest part was to pull them away and say, hey, there's alternative training that you can do. Being away from ice training for a little while, it's not going to make you weak. So it's developing that understanding and letting them understand that concept is the hardest. So sometimes I do struggle with that. So we kind of have to just do our best, really. And yeah, sometimes the prognosis can take longer in such cases. So it might take months, maybe two to three months. But for those people that you know that are in my group that has been training in Canada in different camps.

Since 2018, so they understand the concept a little bit, so it's easier to work with.

And, you know, and the coaches are really accommodating and say, hey, that's fine.

You don't have to train on ice.

Here's the alternative training. Do things that doesn't hurt. So oftentimes we work with strength coaches and the ice skating coaches to come up with a plan, you know, to maintain their fitness and maintain, you know, their muscular strength so that they don't lose too much from not, you know, being able to go on ice, but at the same time be able to do rehab training. Yeah. So for those people, the prognosis is a lot better.

I would say.

So. Yeah, I probably wear off a little bit, but I guess probably touch a little bit.

Yeah, I get it. I get it. And as those. As the athletes get back to full strength, one thing I'd love to touch on before we close is understanding how in the athletic world that you're a part of.

Do you take care of asymptomatic athletes?

Do they look towards your care for a performance edge in addition to the rehab care? Is that sort of separated out? What's been your experience with Team China and the speed skating team in terms of what, I guess what I'll call like, proactive chiropractic care? Is that a thing or is it mostly based upon rehab?

Initially, it's hard to just. Just be the chiropractor and just go, hey, I'm going to check your spine alignment, check your. I'm going to check, you know, your movement, your range of motion, and I'm going to adjust your spine and then you go to your physio for all the other stuff. Like, initially, it was hard for me to do that because they, first of all, they don't have chiropractors in, in.

China, and majority of their, like, traditional Chinese medicine people, they do.

They do adjust or spinal manipulation. Okay. So it's hard for me to kind of go like this. This is. This is chiropractic, and this is that it's hard to make that distinction. So I had to play a lot of roles. So whatever is needed for me to do, I do it, you know, medically speaking, or like, when it comes to physical health anyway.

And then after a while, I try.

To educate them as to, hey, spinal manipulation doesn't just, you know, increase your range of motion. It also does, you know, give you a better sense of response, you know, So I often try it with, say, lower limb or upper limb reflexes. Right. I do pre and post sort of outcome measure to your reflex. I mean, it's not the most accurate, but it's something that they, they can see and go, oh, hey, my reflex actually changes.

For us, we know that's 50, 50.

Like it changes, you know, can, can due to like, you know, your stretch, your muscles been a little bit more, more. But I'm just that trick to kind.

Of show it to them, hey, you.

Know, this is, there's more to spinal adjustment than, you know, giving you a relief or the sound that you want to hear. Yeah.

So I do tend to educate them.

Because I think it's important for the group that I consistently work with, the national team, that team A that consistently work with, they do understand the concept. They'll normally come to me when they, when their body kind of knows, hey.

Sample and adjustment, I think, or check.

My, maybe check my lower back today or check my thoracic today. They will come, they will have that awareness. But for other teams that I just sporadically work with, like in a short period of time, they don't understand that.

Yeah.

So it really takes time and yeah, it takes time and education for them to understand what chiropractic is, to be honest.

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