L5 TENDINOPATHIE FOUNDATION Flashcards
Description of mechanism of tendinopathy
Schema 1
Inflammatory cells in tendinopathy
Inflammatory cells (= cytokines) observed in tendinopathy
- NOT a response to rupture or tear (traditional physiological phases of healing)
- Inflammatory cytokines seen in tendinopathy ( CIX-2, PGE-2, IL-6, IL-1B, TGF-B)
- Changes in inflammatory markers occur as response to cyclic loading (expressed by resident
tenocytes)
- Possibly tendon cell signaling in response to loading, leading to imbalance between synthesis &
degradation & resulting in tendon disorganization
What is tendinitis
= degenerative tendinopathy
Mechanism of tendon injury
- Tensile load (mid portion)
- Compressive load: gluteus medius, achilles insertion, hamstring, adductor
o Compression proximal to bone-tendon junction (enthesopathy)
o Compression from shoes / taping also possible - Friction: between tendon & sheath (PF/DF)
- Combined mechanisms
Pain vs structure vs function
Poor function: unloaded tendon with low capacity (older, post-injury), susceptible to overload resulting in
pathology & pain
Pain: imaging normal painful tendon, rare, differential diagnosis
Pathology: degenerative non painful tendon with good function, can rupture
Pathology + Poor function: degenerative non painful tendon with poor function, can rupture
Pain + Pathology + Poor function: pathology & pain with loss of function (reactive, reactive on
degenerative)
Clinical diagnostic indicators
- Localized pain in tendon (able to localize with one finger)
- Positively associated with load
- Pain aggravated by activity & when all activity removed, pain goes away
- In early phases will ease during activity & be worse on cool down
- Morning pain in day after activity, but eases quickly with movement
- Pain does not spread
Role of imaging in tendinopathies diagnosis
- Inconsistencies between clinical presentation & imaging
- Clinical history should be gold standard
- Can be used for differential diagnoses or staging of tendinopathy
- Ultrasound or MRI
Relationship between pain & tendinopathy
- Hyperalgesia
- Reactive-on-degenerative
- Degenerative structures are mechanically silent (unable to transmit tensile load)
- Peripheral mechanoreceptors exist in/near paratendon
- Deep areas of degeneration may not irritate superficial mechanoreceptors / nociceptors
- Reactive tendinopathy with increased tendon size may compress superficial receptors
Cannot know if it is a tendon or muscle problem, but we don’t care => work on both
What mean “treat doughnut, not the hole”
Degenerative portions may be irreversible
- Treat responsive tissue to support degenerative components (offload)
If you do surgery, risk is getting scar tissue which are not able to support same properties as stretch
- Work eccentric facilitate the adding of load
Treatment based on pain vs structure vs function
In reactive tendinopathy: nothing to reduce pain like manual therapy or massage, but load (interventions addressing poor function & load capacity)
In tendon dysrepair and degenerative tendinopathy: pain management to allow putting load
Reactive-on-degenerative: limited ability to remodel tendon structure
SCHEMA
LL tendinopathy management: name & describe 4 steps
PHASE 1: ISOMETRICS
- To relieve pain before provocative exercises
- To reduce cortical inhibition
- 30-45s x 5 reps
- Progress within a week (usually) => not too long, just allow to put load
=> K-tape depending on patient, ice or heat and extra-corporate electrotherapy
PHASE 2 : HEAVY SLOW RESISTANCE & ISOTONIC EXERCISES
- No effect on cortical inhibition, can continue isometrics
- 4 x 6-8 reps, alternate days
- Address all weak components of kinetic chain
- Can take up to 12 weeks
=> Alternate one day isometric and one day isotonic
PHASE 3: INCREASE IN SPEED & ENERGY STORAGE EXERCISES
- Faster, functional movements 2-3x week
- Isometrics & strength can be continued
- Pain response will determine progression or regression
=> If no pain during & in the next 24h → increase intensity
=> If pain during & in the next 24h → decrease intensity
PHASE 4: ENERGY STORAGE & RELEASE OR SPORT SPECIFIC EXERCISES
- Will replaces phase 3 exercises, but phases 1 & 2 remain 2x week
- 3-day cycle: phase 1, phase 2, phase 4 on one day each
Description of watchful waiting technique
- What happens if we do nothing?
- Natural history of disease
- Elbow tendinopathy: decrease in pain, disability & increase in QoL in 12 weeks with “wait and see”
- Achilles tendinopathy: no pain without treatment at 12weeks
Wait and see technique: effect on pain intensity and physical function
Show positive effect but no statistical difference
Pharmacotherapy in tendinopathy description
- Early use of NSAID’s may inhibit tendon cell migration & proliferation (delayed healing)
- Have little effect due to low number of inflammatory cells
- May be small effect in early stages (allowing patients to continue to load when not
recommended)
name 3 types of pharmacotherapy in tendinopathy
Corticosteroid injection
BMSC (bone marrow stromal cells)
PRP (platelet-rich plasma)
