Contractile Tissues (tendinopathy) Flashcards
What is tendinopathy?
Pain and dysfunction associated with any tendon
-opathy = disease or disorder
What are the common lower limb areas affected by tendinopathy?
What is the most common?
Glutes
Patella
Achilles
Tibalis post.
Hamstrings
Peroneals
Plantar fasciopathy - fascia rather than tendon
Most common - glutes
Common upper limb areas affected by tendinopathy:
Most common =
Rotator cuff
Long head biceps
Lateral epicondyalgia
Medial epicondyalgia
De quervains - APL and EPB tendons
Most common - rotator cuff
Pathophysiology of tendinopathy
Types of load that may cause it:
Generally is triggered by overload of a tendon, but changes can also occur with underload
Tensil load - longitudinal direction eg stretching/ contracting muscle that tendon attaches to
Compressive load - force perpendicular to the collagen fibres, often at insertion point of the tendon
Does tendinopathy have both degenerative and inflammatory components?
Yes
How does the tendon cell population alter when tendinopathy occurs?
Increased number of tenocytes
Increased tenocyte metabolism
Increased immature tenocytes (therefore they don’t produce collagen)
Increased rate of apoptosis - cell death
Immune reactive cells
Tendinopathy pathophysiology
Collagen:
Collagen becomes disorganised due to the fact that immature tenocytes cannot produce it
Reduced number of type 1 fibres - continuous healthy tendon fibres
Increased type 3 fibres
Higher concentration of immature collagen bundles
Tendinopathy pathophysiology
Ground substance changes -
Increased proteoglycans which leads to increased water content - this causes an increased cross section of the tendon, breaks down cross fibres between collagen therefore making the tendon weaker
Chemical alterations - increased substance P, glutamate and lactate
Tendinopathy pathophysiology
Neovascularization -
Influx of blood vessels and nerves in growing into the tendon therefore making it more sensitive
Cook and Purdum model, 3 stages tendinopathy:
1) reactive tendinopathy -
First stage, non-inflammatory proliferative response in cell matrix
Result of compressive or tensile overload
Collagen integrity maintained
Tendon will thicken to reduce stress and increase stiffness
Tendon can revert back to normal
Cook and purdum model, tendinopathy stages:
2) tendon dysrepair -
Continuation of increased protein production which results in separation of collagen and disorganisation within cell matrix
Now visible on MRI
Difficult to diagnose, emphasis on thorough history taking
Developed by frequently overloading the tendon in phase 1
Cook and purdum model, tendinopathy stages:
3) degenerative tendinopathy -
Poor prognosis for the tendon and changes are now irreversible
Areas of cell death, trauma and tenocyte exhaustion
Tendon thickened and present with modular sections on palpation
Present in older individuals with on going issues or younger individuals who has continued to overload
Why is it also not effective to just rest the tendon?/be sedentary?
If there is significant underload, the normal movement of functional activities will become too much for the tendon
This now means that what should be ‘normal’ activity is now overloading the tendon
Therefore it is important to get a balance between overload and underload
What influences tendon repair ?
(Risk factors)
Tendon structure
Age - more common athlete 40+ and sedentary 60+
Previous injury
Increased BMI - increased adipose tissue results in increased inflammation therefore influencing tendons ability to heal
As well as lower limb tendons having to take more load
Diabetes - affects recover time
Medications - steroids and stations
Genetic factors
What will the impact be if an athlete is constantly not recovering after exercise on there net sysnthesis ?
Exercise produces both protein sysnthesis and protein degradation
The net sysnthesis within the first 24hours is more in protein degradation
If proper recovery is not prioritised net degradation will build up over time
This will results in net loss of collagen and can lead to an overuse injury
Clinical signs and symptoms of tendinopathy
Pain
Weakness
Decreased function
Swelling
Physiotherapy management of tendinopathy
Education
Exercise
Load modification/ management
- eccentric loading
- isometric loading
Stretches
Shockwave
Manual therapy
What has isometric loading been shown to do to aid tendinopathy symptoms?
Been shown to have an anagesic effect (reduces pain)
Information about gluteal tendinopathy -
Most prevalent lower limb tendinopathy
Occurs mostly in mid-life
Females > males - this is because females have a bigger Q angle, and normally sit in increased adduction naturally
23.5% females and 8.5% males between ages 59-70
Combination of excessive compression and high load
Gluteal tendinopathy, the involvement of glute medius and minimus -
Med and min tendons are involved
This means opposite side of pelvis may drop, this therefore leads to increased hip adduction of the weak side
As a result gluteal tendons are compressed on the greater trochanter by the ITB band
Gluteal tendinopathy
Clinical signs and symptoms -
Lateral hip pain / tenderness around greater trochanter
Pain on walking / standing on one leg / getting up from sitting / side lying
Gluteal tendinopathy
Physiotherapy management -
Other management -
Physio - education
Load management
Avoid compressive exercises in early stages is suggested
Other - shockwave therapy, corticosteroid injection, surgical intervention
Patella tendinopathy information
Where is it most seen?
What are the risk factors?
High prevalence in jumping sports
Risk factors - weight, BMI, leg length difference, height of food arch, quads flexibility/strength, hamstring flexibility , vertical jump performance
Patella tendinopathy
What are the theories on how it occurs?
Vascular, mechanical, impingement related and neurological theories
Impingement = patella impinges on patella tendon
Chronic overload is the most commonly proposed theory
Underlying pathology is normally degenerative
Patella tendinopathy
Clinical signs and symptoms -
Anterior knee pain
Decreased function eg stairs up/down, hills and kneeling
Patella tendinopathy
Physio management -
Other management -
Physio - education
load management
Exercise - eccentric loading is more effective here than concentric in some studies
A decline board (slope downwards) has also shown improvements
Taping - short term symptom reduction
Other - corticosteroids, shockwave and surgical intervention
Achilles tendinopathy
Most likely effects -
What influences it? And where does it affect?
Lifetime incidence in elite runners of 7-9%
Also common in other athletes
1/3 of cases are non athletes
Biomechanical factors - overpronation of foot, footwear, training surfaces
Overload/underload
Can be insertional (tendon to bone) or mid potion of the Achilles
Achilles tendinopathy
Clinical signs and symptoms -
Pain and swelling in and around tendon
Pain often at its worst at start and end of training session
Tender, nodular swelling usually present in chronic areas (can palpate this)
Achilles tendinopathy
Physio management -
Other management -
Physio - education
Load management eg progressive return to sport
Exercise
Taping - short term symptom reduction
Other - surgery (has poor outcomes), shockwave and injections
Plantar fasciopathy
Commonly effects -
1 in 10 people will suffer in their lifetime
Peak between 45-65
90% resolve within 12 months of conservative treatment
No difference between men and women
Increased risk with increased BMI
Plantar fasciopathy
Risk factors -
Overpronated foot, reduced gastroc length, serve hallux valgus (big toe deviates from norm angles towards 2nd toe)
Both thickening and degernative changes are more common than inflammatory changes
Plantar fasciopathy
Clinical signs and symptoms -
Pain at proximal insertion of plantar fascia (inf. aspect calcaneous) especially with big toe extension and ankle dorsiflexion
Often painful first thing in moring and after activities/at end of day.
Plantar fasciopathy
Physio management -
Other management -
Physio - education
Load management
Exercise - stretching/strengthening
Eg. Calve raises (but to increase load of plantar fascia can place ball of foot on a block for example rather than doing them on the floor)
Other - orthotics
Steroid injections, shockwave and surgery
Rotator cuff related shoulder pain
What are the 3 sub categories ?
What are some of the causes?
Sub-acromial pain syndrome (impingement)
Rotator cuff tendinopathy
Rotator cuff tears
Causes - tendon compression: extrinsic and intrinsic factors
Tendon overuse/underuse
Rotator cuff related shoulder pain
Clinical signs and symptoms -
Pain and impairment of shoulder movement and function, using during shoulder elevation (flex/abd of GHJ, not SG elevation)
And lateral rotation
Painful to lie on affected side
Rotator cuff related shoulder pain
Physio management -
Other management -
Physio - education
Exercise
Symptom modification - trying different things to reduce symptoms, then incorporating into treatment plan
Other - steroid injections
Surgery - results of this show not much difference between this and physio
Therefore patients should always be encouraged to try physio first
Lateral epicondylalgia/tennis elbow
What and who does it effect?
Most common overuse syndrome in the elbow
Tendinopathy involving extensor muscles of the forearm
Affects 1-3% of population
Male and female equal
More common 40/50’s
Prognosis - most cases are self limiting
Smoking and obesity are risk factors as they effect tendon repair
ECRB most commonly effected
Supinator, ECRL, ED, EDM and ECU
What causes lateral epicondylalgia ?
Excessive or repetitive use can cause it - musicians, computer users, manual works and racquet sports
Lateral epicondylalgia
Clinical signs and symptoms -
Pain located (+on palpation) around lateral epicondyle of elbow, usually radiating in line with the extensors
Variable pain reported - intermittent/continuous and varying severity
Aggravated by wrist/finger extension and forearm supination
Stretching tendon can reduce symptoms as well as gripping
Lateral epicondylalgia
Physio management -
Other management -
Physio - education
Load management
Exercise
Brace/taping
Other - NSAID’s, corticosteroid injection, shockwave, surgery
Medial epicondylalgia/golfers elbow
What and who does it effect?
Overuse tendinopathy, similar to tennis elbow but affecting common origin of flexors and pronators
Less common than tennis elbow
Age 40-60
Prevalence 0.3-1.1% female>male
Associated with golf, manual workers
Involves pronator teres and FCR
Medial epicondylalgia
Clinical signs and symptoms -
Pain on medial aspect elbow - tender to palpate
Aggravated by reissued/repetitive wrist flexion or pronation, valgus stress, stretching
Aggravated by throwing/gripping
Reduced grip strength
Can involve ulnar nerve (20%) as it passes through head of pronator teres
Medial epicondylalgia
Physio management -
Other managent -
Physio - education
Load management
Exercise
Brace/taping
Other - NSAIDs, corticosteroid injection, shockwave and surgery
De quervains, what is it?
Inflammation of the synovial sheaths of EPB and APL
Swelling leads to eventual thickening of the sheaths
Adhesions may develop between the tendon and the sheath which restricts normal tendon movement
Enclosed tendons may become constricted
De quervains
Who does it effect and how?
More common in women
Often reported in new mothers
Age most commonly 40-50’s
May occur spontaneously (idiopathic) or can be initiated by overuse of the thumb
Overuse may involve eccentric lowering of the wrist into ulnar deviation with load
De quervains
Clinical signs and symptoms
Pain on radial side of the wrist that can be referred to the thumb
Aggravated by resisted thumb extension / abduction or by stretching the affected tendons (finkelstein test)
Pain on palpation of affected tendons
De quervains
Physio management -
Other management -
Physio - education
Load management - difficult as its hand, esp for new mothers who have to pick up their baby
Exercise
Splinting (offloading)
Other - NSAID’s, corticosteroid injection,shockwave and surgery
Aspects of muscle strains/tears -
Involves over contacting or lengthening a muscle causing tearing of collagen
Grade I, II or III
* make sure to know aspects and differences of each of these from pathophysiology 1
Two joint muscles
Eccentric contractions (deceleration phase)
Muscles with higher percentage of type II fibres are mor commonly affected
Physio management of strains/tears -
(Depends on severity of strain)
POLICE/PRICE
Mobilisation - asap
Strength/loading
Proprioception
Endurance training
Other - surgery
