FMC Test 2 *Tendon Healing & Tendinopathy*

Question 1

What is the function of a Tendon?

Answer 1

Attach muscle to bone
- Transmits force between muscle to bone

Serves as a dynamic stabilizer of joints
- Via muscle-tendon unit

Question 2

The tendon can be divided into three main sections, what are they?

Answer 2

• Muscle-Tendon Junction
• Bone-Tendon Junction
• Tendon Mid Substance

Question 3

What is the composition of a Tendon?

Answer 3

Similar to ligament make up but muscle attachment create a transfer of loads

-They are dense connective tissue
- Specialized fibroblastic cells called tenocytes

Question 4

The Midsubstance of the Tendons is composed of?
(3 connective tissues)

Answer 4

Peratenon
Epitenon
Endotenon

Question 5

In the Midsubstance of the tendons, what is Peratenon?

Answer 5

Loose areolar connective tissue composed of mainly type 1 and type 3 collagen, elastin and synovial cells
- It is a Tendinous sheath that may be filled with synovial fluid (tenosynovium) in tendons subject to friction. (For ex. tendons passing under retinaculums in wrist and ankle)
- The Peratenon is also attached loosely to the Epitenon

Question 6

In the Midsubstance of the tendons, what is Epitenon?

Answer 6

The Epitenon is directly under the Peratenon.
- Its a fine sheath of connective tissue the envelopes the entire tendon

Question 7

In the Midsubstance of the tendons, what is Endotenon?

Answer 7

Endotenon is deep within the tendon, it forms a network of connective tissue around the subfascicle, fascicle, and fiber bundles of tendon tissue
- Organizes, orients, and provides gliding surfaces for the tendon fibers.
- Holds nerve, lymphatics and Blood vessels

Question 8

What is Myotendinous Junction (Muscle-tendon Junction)?

Answer 8

• Numerous interdigitations between muscle cells and collagen fibers
  (These interdigitations enhance the connection between muscle and tendon, allowing for efficient transmission of forces generated by muscle contractions to the skeletal system)
• Infoldings increase the surface area to distribute stress, (this ensures the junctions are loaded in shear rather than tension to provide friction to minimize are of stress concentration)

Question 9

What are muscle cells surrounded by?

Answer 9

Muscle cells are surrounded by collagenous tissue so that the entire surface of the muscle fiber can transfer tension across cell membrane to the tendon.

Question 10

What are tendons responsible for and whats their mechanisms of injury?

Answer 10

Tendons are responsible for tensile loads transmitted from muscle to bone for movement

• If the tensile load is Greater then the tensile strength this can lead to Micro-Failure/Partial Tearing (which is most commonly found by PTs), and/or Macro-failure/Full Rupture (Can be seen in bicep brachii long-head, achilles t., and RTC)

Question 11

What are the 3 sources of blood supply of Tendon?

Answer 11

• Bone-Tendon Junction
• Muscle-Tendon Junction
• Peratenon and intra-tendinous vascular network

Question 12

Where does the Bone-Tendon Junction supply blood to?

Answer 12

• Typically supplies the lower/distal 1/3 of tendon
  
  • Because of the fibrocartilage barrier between bone and tendon tissue, it offers NO vascular supply to midsubstance tendon

Question 13

Where does the Muscle-Tendon Junction supply blood to?

Answer 13

• The proximal 1/3 of tendon
  
  • Vascularity of the muscle is evident with only a sparse network of vessels at this junction

Question 14

Where does the Peratenon and intra-tendinous vascular network supply blood to?

Answer 14

Supplies midsubstance of the tendon

Question 15

In terms of Tendon Nutrition, what is the difference between Intrinsic and extrinsic mechanism?

Answer 15

• All tendons have intrinsic blood supply, direct blood flow is supplied by the vessels of the region or by the vincula. (Intrinsic)
• Tendons surrounded by tendon sheath have POOR blood supply and require additional method so they can receive nutrition, this extrinsic method of receiving nutrients to keep the tendon healthy comes from diffusion which is enhanced by motion. (Extrinsic)

Question 16

What type of healing do Tendons have?

Answer 16

They have Intrinsic and Extrinsic Mechanisms of healing.

• They can heal spontaneously from the formation of tenocytes, fibroblast and vascular inflammatory response mechanisms from adjacent tissue.

Question 17

What does the degree of healing depend on for tendons? (3)

Answer 17

• Degree of injury
• Need for surgical repair or not
• Amount of immobilization after injury
  –Need for controlled stress to develop tensile strength of the tendon

Question 18

Where are tendons innervated?

Answer 18

• Primarily innervated at the musculotendinous junction
  –Little innervation at midsubstance

Question 19

What are the different types of sensory Mechanoreceptors for tendons?

Answer 19

• Pressure and stretch receptors (Ruffini corpuscles) ~slow rate of response
• Movement receptors {Acceleration/Deceleration movements} (Pacinian Corpuscles) ~rapid response
• Proprioceptive receptors (Golgi tendon organs) ~gives input on position, active muscle contraction, and passive stretch
• Free nerve endings (C Fibers)
  –Response to pain

Question 20

What is Acute Tendinitis depicted by?

Answer 20

Pain, functional loss, and signs of inflammation from repetitive activity before 1-7 days before seeking treatment.

Question 21

How does Tendinosis develop?

Answer 21

Develops after a tendon fails to heal

Question 22

Chronic Tendinopathy is depicted by?

Answer 22

Is when the tendon lacks inflammatory signs that is commonly seen in the achilles, quad. tendon, and suprasinatus tendon.

Question 23

If a patient has a tendon rupture, what do they usually require?

Answer 23

They usually require surgery

Question 24

Other than poor tendon health, other factors can contribute to injury, such as: autoimmune disease, infection, tumors, etc. How can this affect a tendon?

Answer 24

They can all lead to poor tendon healing that can lead to micro and macro injuries to tendons.

PT must do a thorough review of symptoms to see if the patient has an underlying condition that is leading to tendon dysfunction.

Question 25

In tendon healing, what is the Acute (Inflammatory) stage?

Answer 25

Trauma incites a complex series of chemical events

• This is the inflammatory phase of healing
• Causes Hemostasis (the mechanism that leads to cessation of bleeding from a blood vessel)

Question 26

In tendon healing, what is the Subacute (Proliferative/repair) stage?

Answer 26

Gradual removal of cellular waste from the injured site
–Accumulation of fibroblast and myofibroblasts signal the initiation of the proliferative stage
–Neoangiogenesis or capillary budding is a characteristic of this phase
–Starts with Type 3 Collagen then Type 1 Collagen

• Repair and Healing

Question 27

In tendon healing, what is the Chronic (Remodeling) stage?

Answer 27

• Maturation and remodeling phase
• Density of tendon collagen is almost exclusively Type 1 Collagen
• This stage may last greater than or equal to 1 year depending on extent of initial injury

Question 28

What is the Safe Load Bearing Progression for Conservative (For mallet or central slip avulsion) tendon? (Inflammatory phase, repair phase, and remodeling)

Answer 28

Inflammatory phase:
- RICE
- Avoid stresses/motion to involved tissue (restriction devices used for 6-8 weeks)

Repair phase:
- Avoid stresses/motion to involved tissue (restriction devices used for 6-8 weeks)

Remodeling:
- Progressive load bearing as long as no joint lag is noted

Question 29

What is the difference between Minor tendon injuries and Major tendon injuries?

Answer 29

• Minor tendon injures (incomplete) have the potential to heal without surgical intervention
• Major tendon injuries may require surgical repair
  -Suture repair of tendon
  -Helps minimize scar formation by closing the gap
  between tendons

Question 30

How long does it take for a tendon to regain strength?

Answer 30

• The tendon is weakest 7-10 days
• Regains strength at 21-28 days
• Near full strength at 6 months

Question 31

Treatment guidelines for tendon (and Ligament) injuries guide us through decisions regarding… (4)

Answer 31

• Protection of the joint structure during healing
• Early protected motion after injury/repair
• Progressive therapeutic exercises and functional activities
• Encourage weight bearing and progressive function as soon as the tissue tolerates

Question 32

What is the Safe Load Bearing Progression for Post-surgical tendons? (Inflammatory phase, repair phase, and remodeling)

Answer 32

Inflammatory Phase: Focus on protecting newly repaired tendons and mange edema
- PRICE
- Avoid AROM focus on PROM

Repair Phase:
- Continue PROM; work towards AAROM/AROM (Usually 3 1/2 to 4 weeks)
- Avoid strengthening of involved muscular
–Avoid co-contractions
–until remodeling phase

Remodeling Phase:
- Progress resistance slowly with guidance of surgeon

Question 33

What is Tendinitis associated with?

Answer 33

Inflammation

Question 34

What is Tendinosis associated with?

Answer 34

Degeneration

Question 35

What is Tendinopathy?

Answer 35

Basic def.: Pain in the tendon

Considered to be a degenerative cascade that may occur in tendons
- Encompasses all conditions related to micro-injury of tendon

Question 36

What are the 4 stages associated with Tendinopathy?

Answer 36

Stage 1: Associated with inflammation
Stage 2: Poorly developed vasculature and disorganized collagen bundles
Stage 3: Microscopic failure of the tendon
Stage 4: Tissue fibrosis (scarring)

Question 37

What is the Safe Load Bearing Progression for tendons with micro-trauma, Inflammatory Phase?

Answer 37

RICE (Relative rest/education)
Limit painful motions
Avoid strengthening of involved musculature
–Assess entire kinetic chain for impairments that
may be related

Question 38

What is the Safe Load Bearing Progression for tendons with Micro-Trauma, Repair Phase?

Answer 38

Remain within pain-free range
Isometric progression to eccentric/isotonic strengthening
–Address entire kinetic chain impairments

Question 39

What is the Safe Load Bearing Progression for tendons with Micro-Trauma, Remodeling Phase?

Answer 39

Continue education and strategies to avoid re-irritation

Question 40

What is the Safe Load Bearing Progression for Tendinopathy? (7-steps)

Answer 40

We can load pathologic tendons without fear

1. Ensure the tendon is the source of pain
2. Assess existing muscle and tendon capacity and function
3. Establish what patient wants to achieve, the capacity and function required
4. Slowly build from one to another
   -Decrease loads enough to eliminate pain
5. Unload the tendon where the problem began
6. Exercises to reduce pain - loaded isometrics
7. Adress comorbidites

Question 41

A 40 year old firefighter presents to your clinic 2 weeks following distal bicep repair. What stage of healing is he most likely in?

A) Inflammatory/Fibroblastic
B) Fibroblastic/Remodeling
C) Remodeling/Maturation

Answer 41

B) Fibroblastic/Remodeling

Question 42

A 40 year old firefighter presents to your clinic 2 weeks following distal bicep repair. What is mostly likely to be happening primarily on a cellular level?

A) Fibroblast proliferation and synthesis of the extracellular matrix
B) Type 3 Collagen is being replaced by Type 1 Collagen
C) Cross link formation increases as a response to stress
D) Bradykinin triggers the release of prostaglandins (yellow)

Answer 42

B) Type 3 Collagen is being replaced by Type 1 Collagen

Question 43

A 40 year old firefighter presents to your clinic 2 weeks following distal bicep repair. Based on your knowledge of tendon healing what is the BEST treatment intervention?

A) An orthotic to immobilize the elbow at 90
B) Rest, Ice, Compression, and Elevation
C) Hinge elbow brace to allow controlled motion
D) Initiation of strengthening (Yellow)

Answer 43

C) Hinge elbow brace to allow controlled motion

Question 44

A 40 year old firefighter presents to your clinic 2 weeks following distal bicep repair. When performing PROM of the elbow, the therapist should avoid:

A) Full Extension of the elbow
B) Full Flexion of the elbow

Answer 44

A) Full Extension of the elbow