Lecture 6: Tendinopathy cont. Flashcards
Peritendinitis
Paratenonitis
– Marked inflammatory changes of the
peritendinous structures surrounding the tendon
Peritendinitis causes and where can it occur
– Causes may include injury, overuse or infection
– Can occur anywhere along the length of the
tendon
Long term peritendinitis leads to
– Long term inflammation can lead to intra- tendinous change (wrist, hands, feet commonly affected)
How did the paratendon relate to how antiinflammatories are not effective for tendinopathy?
Paratendon is the one going through inflammation. So if you take antiinflammatories, you feel better because the inflammation of the paratendon goes down. This is dangerous because the person will decide then to run again and the tendon will not have time to heal.
Enthesis organ: Key features (3)
1) Tendon inserts into the
bone at an angle after a
boney prominence
2) There is often a bursa
between the tendon and
bone
3) Fibrocartilage is
expressed to absorb the
compression of the
tendon against the bone
Compressive strain drives tissue change from
fibrous tissue to fibrocartilage
Enthesis Organ includes
Summation of the insertion + the additional
surrounding structures = the enthesis organ
Enthesis Organ functions to (2)
Functions to: 1) Decrease tensile load at the insertion 2) Confirm mechanical advantage to the muscle tendon unit
Enthesopathy
Consists of most tendinopathy and also called insertional tendinopathy!
Nearly all clinical tendinopathy occurs at, or adjacent to
the bone-tendon junction i.e. the enthesis
Anatomical site of compression, position of compression: Achilles tendon
Superior calcaneus
Dorsiflexion
Anatomical site of compression, position of compression: Tibialis posterior
Medial Malleolus
Anatomically permanent pivot
Anatomical site of compression, position of compression: biceps long head
bicipital groove
shoulder extension
Anatomical site of compression, position of compression: supraspinatus
greater tuberosity
Adduction
Anatomical site of compression, position of compression: hamstring (upper)
ischial tuberosity
hip flexion
Anatomical site of compression, position of compression: glute med and min
greater trochanter
hip adduction
Anatomical site of compression, position of compression: adductor longus/rectus
pubic ramus
hip abduction/extension
Anatomical site of compression, position of compression: peroneal tendons
lateral malleolus
anatomically permanent pivot
Anatomical site of compression, position of compression: quadriceps
femoral condyles
deep knee flexion
Where does the pain come from?: Surrounding
Structures
- Paratendon (nearby tendon looks like enthesis)
- Bursae
- Fat pad
Where does the pain come from?: Chemicals in the
Environment
• Nociceptive
substances
- Neuro-transmitters
- Lactate
Where does the pain come from?: Changes of the Tendon
- Neovascularization
* Neural ingrowth
What are the clinical features of
tendinopathy (4)
- Dose dependent / Hx of increased load
- Well localized to tendon or enthesis
- Increased pain with increased load
- Pain at start of activity, decreased pain with warm up, return of pain post activity (common story of tendinopathy)*
Lower Limb Tendinopathy History: Glute med
Gluteus Medius Pain with sidelying, lateral hip pain. Mostly menopausal women
Lower Limb Tendinopathy History: Hip adductor
Hip Adductor Pain with landing from lateral hop.
Sprinting/kicking sports, increased change of direction
Lower Limb Tendinopathy History: Hamstring
Hamstring Pain with sitting (hard surface). Deep buttock pain.
Sprinters and speed walkers
Lower Limb Tendinopathy History: Patella
Patellar Pain with prolonged sitting, jumping. Jumping athletes (volleyball, basketball)
Lower Limb Tendinopathy History: Achilles tendon
Achilles Body of tendon, or above insertion. Morning stiffness.
Young sprinters, older distance runners,
court sports
Lower Limb Tendinopathy History: Tib posterior
Tibialis Posterior Prolonged eversion (speed skating, running on banked curves).
Change in footwear.
Overpronation in older women
Lower Limb Tendinopathy Physical Exam (4 steps)
- Observation
– Early: generally swollen Late: Lumpy/thickened [Achilles] - Functional Tests
a. Do they have sound biomechanical form?
b. How much load can the tendon tolerate?* - Strength Tests
- Range of Motion
- Special Tests
- Differential Palpation (last!)*
How much load can the tendon tolerate?*
Low load concentric → High load concentric →
dynamic (energy storage/release)
At each step of tendinopathy exam assess:
a) The presence of pain
b) The quality of the movement
Reactive pathology: Definition, goals (2), treatment, PAIN=, how long to rest
1 st time flare up, acutely overloaded tendon, direct trauma to the tendon, usually in the young person.
GOAL:
1) Decrease sensitivity of tenocytes (via relative decrease in loading)
2) Increase tendon tolerance to load (based on their needs)
Tx: Deload, Maintain, Rebuild
PAIN=IRRITABLE
Rest 24-72 hours
Degenerative pathology: definition, goals (1), treatment, PAIN=
Repeated bouts of pain/recovery, quick to recover, middle age to older patient with history of intense use of tendon (high school sprinter), focal tendon swelling.
GOAL:
1) Remodel the matrix (via appropriate loading)
Tx: Maintain, Rebuild (because pain is stable)
PAIN= STABLE
Treatment
Where do you start?
❑Stage of Tendinopathy
❑How much load their tendon can tolerate
❑If there’s a compressive component involved
How to increase load*
Isometric load → Low load concentric → High load concentric
Eccentric load → dynamic (energy storage/release) → Sports specific
How to increase load from light to moderate to highest: Patella
Lightest: flat or decline squats
moderate: split squats/lunge
highest load: forward hopping
A note on Eccentric Exercise*
• PT’s love eccentric exercise for Tendinopathy!!!
– High load exercise
– Could be detrimental if used incorrectly
• Provocative for reactive tendons, compressive component
– Can be effective as part of a program, but not
necessary to do in isolation
1 Tendinopathy is a load based problem
resulting in
degenerative changes in the tendon.
2 Tendons don’t like
rest or change (they need time to adapt)
3 Slow loading program is best, with
one variable change at a time
4 Don’t forget the big picture – consider (3) in the kinetic chain
muscle strength
motor control
biomechanics
