Lecture 8, 9 And 10 Flashcards
What is a tendon
Organization of Collagen fibres
• Connects muscle to bone
• Transfer force from muscles
into skeletal system
• Excellent tensile properties
Enthesis
• Junction between a
tendon and a bone
• Fibrocartilage
Myotendinous
Junction (MTJ)
• Connection between
tendon and muscle
• Susceptible for
injury
Tendon
Stress-Strain Curve
• Relationship between
stress and deformation
of tendons is the same
as for ligaments
Adaptation to Training in tendons
Tendons adapt to training by increasing cross-sectional area
Tendon loading every 2-3 days; problematic to jumping sport not too much time for recovery; problematic to jumping sport not too much time for recovery
Compared to muscles, it takes longer time to gain tendon strength
Tendon Injury Types
Overuse tendon injuries
• Enthesopathy
• Tendinopathy
Acute tendon injuries
• Direct trauma
• Rupture
Enthesopathy
• Injury or disorder affecting the enthesis
• Cause/mechanism
• Overuse (most common); repetitive loading
• Trauma (direct blow)
• Characterized by inflammation,
degeneration, or calcification of the
attachment point
• Pain and dysfunction
Enthesopathy:
Diagnosis and
Treatment
• History
• Inspection & Palpation
• Imaging (rarely used): US, MRI
Treatment
• Rest from offending activity
• Pain control: Ice, NSAIDS
• Orthoses
• Physiotherapy: progressive strength training
• Mild cases (4-6 weeks); moderate to severe
cases (3-6 months)
mechanism of tendinopathy
Repetitive tensile (or compressive) loading (e.g.,
sprinting, jumping, changing direction) → repetitive
microtraumas
• Inadequate recovery between loadings
Tendon Pathology:
Cook–Purdam Model
• Reactive tendinopathy
• Non-inflammatory, structural
changes & thickening of stressed
tendon area
• Tendon disrepair
• Worsening tendon pathology,
tendon structure becomes
disorganized
• Degenerative tendinopathy
• Chronic stage
when athlete does jump training and there is insufficient recivery it results in tendinopathy true or false
True
healthy tendon is highly organized and when we start to feel pain it becomes disorganized , the structure does not act like a healthy tendon anymore true or false
True
Intrinsic risk factors for tendinopathy
• Older age
• Male sex
• Menopause
• Genetics
• Systemic conditions
• Medications
• Biomechanics
• Previous injury
Extrinsic risk factors in tendinopathy
• Training load
• Spikes in loads
• Periods of deconditioning
• Biomechanical change
What does biomechanics mean when referring to intrinsic risk factors to tendinopathy
biomechanists refer to how you land, directional changes and landing
What is bio mechanical change when referring to extrinsic risk factors with tendinopathy
biomechanical change; change in movement patterns, different tendons engaged and leads to tendinopathy
Diagnosis of tendon injury
• History: Symptoms often progress
• First pain after exercise
• Then pain at the start of
an activity
• Finally pain both during
and after activity
• Physical Examination
• Palpation → tenderness
• Imaging: US, MRI
Management of tendinopathy
Education of patients
Load monitoring
Pain monitoring
Exercise based progressive
rehabilitation program
What is the stages of exercise based rehabilitation programs for lower limb tendinopathy
Stage 1 Isometric exercises: every day, multiple times a day (relieves pain)
Stage 2 Isotonic & Heavy slow resistance exercises, alternate days
(improves tendon stiffness and strength), continue doing isometric exercises
Stage 3 Increase in speed and energy storage exercises: single jumps
continue doing isometric and isotonic exercises
Stage 4 Energy storage and release & Sport specific exercises: repeated jumps
(This replaces stage 3) direction changes, continue doing isometric and isotonic exercises
Rotator Cuff
Tendinopathy
And associated pain
-Subacromial pain syndrome
(SPS)
-Rotator-cuff related shoulder
pain
Rotator Cuff Tendinopathy Diagnosis
• History
• Inspection, palpation, ROM, Pain provocation tests
• Imaging
• Treatment
• Progressive exercise therapy 6-12 weeks
• Surgery and rehabilitation 6-7 months
Other Treatments for tendinopathy
• Shock wave therapy, laser, and
ultrasound
• Medications
• Injectable therapies
• Passive treatments
• Experimental treatments
• Surgery
prevention of tendinopathy
• Progressive training
• Enough rest
• Education of athletes and coaches
• Correct movement technique
• Offseason continue strength training
Main reason for tendon rupture
tendon rupture Main reason is tendinopathy and the structural changes associated, common
In older adults
Tendon
Rupture
• Acute rupture of a normal and healthy tendon is rare
• Commonly occur in athletes and recreational exercisers aged
30-50 years
True or false within Tendon
Rupture it is caused by Eccentric force generation in Mid-tendon area causing a Partial or Complete
rupture
True
Achillies tendon rupture Mechanism
• Strong contracture of the
lower leg musculature,
with simultaneous
extension
• ECCENTRIC LOADING of
the tendon
Diagnosis TENDON RUPTURE
Acute, intense pain
Audible ‘SNAP’
Reduced power in plantar flexion
‘Gap’ in the tendon tissue
Bruise and swelling
Ultrasound/MRI
Treatment and Rehabilitation for tendon rupture
Conservative (exercise program interventions) vs. Surgical repair
(end-to-end suture)
Cast
Rehabilitation
Return to Sport
Patellar Tendon Rupture: Treatment
• Partial rupture
• Conservative treatment: Cast 4 weeks, physiotherapy &
progressive training
• Surgery
• RTS 4-6 weeks
• Complete rupture
• Surgery
• End-to-end repair or Transsosseus repair
• Tendon reconstruction (severe degenerative tissue changes)
• Post-operative rehabilitation
• Running after 6-15 months
• RTS after 8-18 months
prevention of tendon rupture
• Strengthening exercises when approached with tendon tightness
• Heavy lifting (healthy tendons need heavy lifting)
• stay active
• Proper recovery
Prevention of shoulder
problems in overhead sports: caused us to use what program
OSTRC
Shoulder Program
28% decrease in problems
Exercises to treat tendinopathy (2)
Single jump, load tendons but don’t release energy ( increase in speed and energy storage)
And then
Repeated jumps, energy storage and release as well as sport specific exercises
Muscle function
Generate power
Muscle actions
- isometric; during contraction, muscle length does not change, static muscle generates force
- isotonic; tension,contraction and change in muscle length
- concentric; shortening of muscle; tension is present
- eccentric; lengthening of muscle when muscle is extended
Muscle adaptation to training
-rapid response to training, changes in strength within a few weeks
- neural factors (early stages), changes are due to new role adaptation improvements in muscle strength to neuromuscular adaptation
- muscular factors (prolonged training)
- muscle fibres increase their cross sectional area (hypertrophy)
Muscle injury types
- Direct muscle injury;contusion and laceration
- Indirect muscle injury disorder; muscle strain, fatigue- induced muscle disorder, DOMS, Neuromuscular muscle disorders
- Other; muscle cramps, chronic compartment syndrome
What is muscle contusion common in
Contact sport, caused by a direct blow
Muscle contusion
Muscle bruise (hematoma)
- caused by external force
- contact sports, team ball sports
- most common site is the quadriceps
- mild, moderate or severe
Muscle contusion diagnosis and treatment
- history (mechanism), physical examination (introspection, palpitation, function tests (active ROM)
- Imaging
- Progressive physiotherapy; gentle active and passive pain free muscle stretching, stretching, isometric strength, functional and sport specific movements once ROM achieved
- RTS for mild contusion (5-7 days), RTS for moderate and severe (4-6 weeks)
Compression is important in the first few days with having a muscle contusion TRUE OR FALSE
True
Muscle contusion complications
- acute compartment syndrome
- myostitis ossificans- formation of bone inside muscle tissue, rare
- muscle fibrosis- scar tissue not functioning properly limited range of motion due to improper rehab
- chronic pain and weakness- improper rehab
- recurrent injury
Muscle strain
- tensile forces
- usually close to myotendinous junction
- hamstrings,quads, gastrocnemius
- pop,bump,swelling
- pain on active contraction and passive stretch reduced contraction strength, decreased ROM and loss of function
Myotendinous junction
- common injury site
- region where muscle fibres fibres connect to tendon
- transfer of contraction force from muscle to tendon and skeletal system
- high stress during jumping and sprinting
Clinical grading of muscle strains
- Mild, “few fibre” injury, minimal loss of strength and motion
- Moderate, tissue damage decreased ability to contract and decreased ROM
- Severe complete tear, complete loss of muscle function
Two types of hamstring rupture
Type 1- Sprinting related hamstring strain (bicep femoris)
Type 2- Stretching-related hamstring strain (semimembranosus)
Type 1 diagnosis
-history, physical examination; mechanism, palpation and spinal examination
- imaging MRI
Type 2 diagnosis
- history and physical examination mechanism, palpitation and spinal examination
-MRI
Neuromuscular muscle disorder
- spinal or spinal nerve-related
- neuromuscular end plate-related
Spinal or spinal nerve related
- nerve damage in the spine, nerve root plexus lead to increased muscle tone, pain, tinging, numbness, weakness
Neuromuscular endplate related
- muscle fatigue leads to dysfunctional neuromuscular control leading to increased alpha motor neuron activity leading to increased muscle tone, over contraction
Assessment of hamstring injury should include a thorough
- spinal examination, lumbar spine, pelvis, sacrum
- neural testing
- biomechanical evaluation
Muscle injury healing phases
- Destructive phase (Hemostasis and inflammation)
- Repair phase (proliferation)
- Maturation phase (remodelling)
Muscle strain rehab if a patient can do jogging 2 days after injury can return to sport after
2 weeks
Muscle strength rehab if it takes more than 5 days return to sport after a
Month
Muscle strain rehab
- mobilization
- progressive strengthening
- functional exercises (running programs)
- other body region exercises
Prevention of hamstring strains
Stretching
Nordic eccentric exercise
Hip and core exercise programs prevents running related overuse injuries T or F
true
Run RCT aim
- aim investigate which intervention was effective in prevention of running related injuries (hip and core exercise program)
Nordic hamstring exercise
- used in high risk sports
DOMS is related to what structure
Muscle
Overuse injury types
Chronic injuries that develop over time due to repetitive strain
Overuse bone injury
Stress fractures, apophysitis, ostetits
Overuse tendon injury
- tendinopathy
Overuse joint/ligament injury
- labrum overuse
- ligament degeneration
- synovitis
Overuse muscle/fascia injuries
- DOMS
- Fasciitis
- chronic compartment syndrome
Low back pain in adult athlete prevalence
Lifetime prevalence in athletes can lead to time loss from sport and reduced quality of life
adult athletes non specific low back pain
- caused by intrinsic (spine structure, past injury) and extrinsic (technique and stress) factors
Degenerative disc disease
- symptoms; stiffness, reduced ROM, radiating pain
- treatment- physiotherapy focusing on core strength and flexibility (conservative treatment)
Avulsion
- tendon or ligament pulls a piece of bone off attachment point
- common sites- ASIS, ischial tuberosity
- causes- common in high risk sports
- symptoms- sudden pain, popping sound, swelling
- treatment- conservative (physiotherapy), or surgical
Ankle sprain (3 types)
- Lateral ankle sprain
- Medial ankle sprain
- High ankle sprain
Lateral Ankle Sprain:
Mechanism: Excessive inversion or supination.
Involved Structures: ATF, PTF, CF ligaments.
Grades:
Grade I: Partial rupture of one ligament.
Grade II: Complete rupture of one ligament or partial rupture of two.
Grade III: Complete rupture of two or more ligaments.
Treatment: Bracing, taping, progressive exercise.
Medial Ankle Sprain:
Mechanism: Excessive eversion.
Involved Structures: Deltoid ligament, sometimes malleolar fractures or syndesmosis.
Treatment: Bracing, arch support, functional treatment, physiotherapy (longer recovery compared to lateral sprains).
High Ankle Sprain (Syndesmosis):
Mechanism: Forced external rotation. Excessive
Involved Structures: Syndesmotic ligaments connecting tibia and fibula.
Treatment: Walking boot (partial rupture, conservative treatment, 2 weeks) or surgery for severe cases.(complete rupture )
Complications: High re-injury rate, risk of chronic instability, and potential arthritis.
Difference in Back Pain between Youth and Adult Athletes
Youth: More likely due to growth plate injuries, apophysitis.
Adults: Degenerative conditions (e.g., DDD), higher risk of chronic pain.
characteristics of over use injury Gradual Onset:
Athletes may not notice symptoms initially; the injury develops over time.
Chronic in Nature: These injuries are persistent and may worsen without intervention.
Alternative Names:
Chronic injury
Repetitive strain injury (RSI)
Cumulative trauma disorder
Sports disease
Growth plate= growth cartiliage T or F
T
Epiphysis located vs where apophysis located and are they both resistant to receptive loading
At the end of the bone
Site where tendons/ligaments attach the bone
No they are less resistant to repetitive loading leading to increased risk of injury
Apophysitis definition
Apophysitis: A traction injury that occurs when there is repeated stress on the apophysis (the growth plate at the site where tendons and ligaments attach to bones).
Apophysitis cause and symptoms
Causes: Repetitive motion or stress on the growth plates during periods of rapid growth.
Symptoms: Pain, swelling, and tenderness at the affected site.
Common Types of Apophysitis:
Sever’s Disease:
Location: At the heel bone (calcaneus).
Age group: Common in children aged 8-14 years.
Symptoms: Pain in the heel, especially during running or jumping.
Osgood-Schlatter Disease:
Location: At the tibial tuberosity (just below the knee cap).
Age group: Typically affects children aged 10-15 years.
Symptoms: Knee pain, particularly during activities that involve running, jumping, or kneeling.
Little League Elbow:
Location: At the medial epicondyle of the elbow.
Age group: Affects children between 8-15 years, often baseball players.
Symptoms: Pain on the inside of the elbow, especially during throwing motions
treatment of synovitis of knee is load modification, physiotherapy and nsaids treatment of chondromalacia patella is correcting valgus movement true or false
True
Plantar Fasciitis: def, cause, symptoms
Definition: Inflammation of the plantar fascia,
Causes: Overuse or repetitive stress (e.g., running, prolonged standing).
Improper footwear lacking proper arch support. Biomechanical issues like flat feet or high arches.
Symptoms: Heel pain, especially with the first steps in the morning or after periods of inactivity.
Treatment: Conservative Treatment: Rest and load reduction. Proper footwear or orthotics for support.
Stretching exercises
Risk Factors for Overuse Injury: intrinsic
Intrinsic Factors:
Previous Injury
Malalignment: Structural imbalances in the body.
Leg Length Discrepancy
Muscle Imbalance or Weakness
Lack of Flexibility
Sex: Certain injuries may affect men and women differently.
Body Composition
Genetic Factors
Risk Factors for Overuse Injury: Extrinsic Factors:
Extrinsic Factors:
Training Load Errors: Increasing intensity or volume too quickly.
Surfaces: Hard or uneven training surfaces.
Shoes: Inadequate or worn-out footwear.
Equipment: Improper or poorly fitting gear.
Environmental Conditions: Extreme temperatures or poor weather conditions.
Inadequate Nutrition
Osteochondral Fractures and Chondral Injuries:
Definition: Damage to the cartilage and underlying bone, usually associated with ankle sprains.
Symptoms: Recurrent pain, stiffness, or joint locking.
Diagnosis: MRI to assess the extent of cartilage and bone damage.
Treatment: Conservative: Cast/brace for 6-8 weeks, followed by rehabilitation.
Surgery: May be required if symptoms persist or damage is extensive.
Complication: Can lead to ankle joint osteoarthritis if not treated properly.
Sprained ankle complications
- Increased risk for recurrent injury
- Unstable joint (chronic ankle instability)
- Ankle joint osteoarthritis
- Persistent pain
Treatment of chronic ankle instability
- brace
- balance and strength
- surgery
