Rotator Cuff and Tendonopathy Flashcards
What is the standard structure of a tendon like?
-Dense, regularly arranged tissue that connects muscle to bone.
-Highest tensile strength of all connective tissue as it has:
High proportion of collagen and a closely packed paralell arrangement in the direction of force.
What are 3 components in and aroun tendons?
- Tendon itself
- Bone insertion
- Muscle tendon junction
What is the composition of tendons like?
- 20% cellular (fibroblasts/tenocytes)
- 80% ECM (70% H2O, 30% solids such as collagen 1 and 3, ground substance and elastin).
What is vascularisation of tendons like?
- Sparsely vascularised
- In rotator cuff, early stages of healing there is neovascularisation
What is the difference betwenn intrinsic and extrinsic processes in tendon healing?
- Extrinsic- cells from outwith tendon come in to help (eg. inflammatory cells)
- Intrinsic- internal cellular structure aids repair mechanisms
What 3 phases can tendon healing be put into and what are their rough timescales?
- Inflammation (day 0-7)
- Repair (day 3-60)
- Organisation (day 28-180)
What molecules control tendon healing?
-Cytokines and other mediators such as PDGF (chemotaxis) and TGFB (collagen type).
Describe the process of inflammation in tendon healing?
-Inflammation cells migrate from:
Epitendinous tissues (sheath, periosteum, soft tissue)
Epitendon and endotendon
-Defect rapidly filled with granulation tissue, haematoma and tissue debris.
-Matrix proteins laid down as scaffolding for collagen synthesis.
Describe the repair phase of tendon healing?
- Fibroblast/tenocyte migrate to zone of injury and begin to synthesise collagen by day 5.
- Initially collagen 3 produced and laid down in random orientation.
- During 4th week intrinsic fibroblasts proliferate and these cells take over the healing process both by synthesising and reabsorbing collage. (Tendon Callus)
- Switch to production of type 1 collagen, is increasingly orientated along line of force.
- Vascular ingrowth via collagen/fibroconectin scaffolding.
Describe organisation phase of tendon healing?
-Final stability acquired during this phase by the normal physiological use of tendon.
-Accompanied by cross linking between fibrils, further increasing tendon tensile strength.
-Complete regeneration never acheived:
defect remains hypercellular
thinner collagen fibrils
What do tendons do:?
- Connect muscle to bone
- Transmit force
Why is early controlled mobilisation important for muscle/tendon damage?
- Reduce scar adhesions
- Facilitate healing by stimulating remodelling.
What will excessive loading do during tissue repair?
-Disrupt tissue repair
What does optimal healing depend on?
- Surgical apposition and mechanical stabilisation
- Minimal sot tissue damage
- Optimal mechanical environment for healing
What does patient rehab time often depend on?
-Anatomical area
What are some causes of rotator cuff tears?
- Age, more common in >65
- Multifactorial
- Bone spurs
- Acromion shape (bigliani)
- Trauma (mostly acute)
- Genetic
- Repetitive overloading
- Tendinopathy leading to tears
What are some intrinsic risk factors of tendiopathy?
- Systemic diseases (diabetes, obesity)
- Family history
- Age
- Muscle weakness
What are some extrinsic factors of tendinopathy?
- Overuse
- Sudden increase in activity or intensity of activity
- Lack of adequate recovery
- Medications (HRT)
- Poor workplace ergonomics
What are some potential treatments of tendinopathy?
- Non-operative: -physio
- Injection (steroid/local) for pain
- Operative: -repair tendon to bone
- Arthroscopic surgery/open surgery
- Platelet rich plasma injection
Compare the surgery options for tendonopathy?
- Arthroscopic: -less invasive, faster recovery, visualise whole joint
- Open: -more invasive, still good long term results
Describe the pathophysiology of tendinopathy?
- Disregulation of ECM
- Causes immune responses, stromal responses
- Failure of normal homeostatic responses eventually leads to early tendinopathy with influx of immune cells, stromal cell dysfunction, apoptosis, oxidative stress and matrix dysfunction.
What does dysregulation of repair mechanisms lead to in tendonopathy?
-Established/chronic tendinopathy with clinical features of poor function, pain and load capacity.
How can tendinopathy be diagnosed, discuss symptoms and examination?
- Symptoms/signs: localised pain
- Pain provoking tests specific for tendon involved eg. single leg hopping for achilles tendonopathy.
What are the common sites for tendinopathy?
- Shoulder: rotator cuff tendons
- Hip: gluteal tendons
- Knee: patellar tendons
- Foot/ankle: achilles tendon
- Peroneal or posterior tibial tendons
- Elbow: common extensor origin, common flexor origin
What is the differential diagnosis test for tendinopathy and AC joint pain?
-Examine AC joint for instability and labral tests
What is the differential diagnosis test for tendinopathy and biceps tendon pain?
Speeds and yergassons test.
What is the differential diagnosis test for tendinopathy and superior labral anterior to posterior tear?
Obriens sign
What is the differential diagnosis test for tendinopathy and shoulder instability or glenoid labral tears?
-Apprehension test, sulcus signs
Describe management process for tendinopathy patients?
- Early diagnosis is key
- 1st line treatment: individualised tailored loading programme, (presicion tendinopathy management plan).
- Patient engagement and reevaluation within 3 month period crucial to dtermine progression.
- Surgical intervention may be considered after failed response after 12 months of personalised loading problem.
What are some more diagnostic tests for tendinopathy?
-Palpation: oatient complains of pain on palpation
-Empty can test
-Hawkins test
-Jobe test
The last 3 all test certain movements and are positive if patient experiences pain in it.
