Tendinopathy Flashcards
Function of Tendon
Transmit forces from muscle to bone
Energy conservation (spring)
Protect muscle from injury
Tendon Composition
Highly organized, parallel collagen fiber bundles
fibers are oriented in one direction because force is mostly coming from one direction
what is the main type of collogen fiber found in tendons
type 1
what kind of force does type one fiber resist the best
Resist tensile force well
where do Tenocytes (tendon cells) sit
sit between collagen fibers
Tendon are good resisting what kind of force
tensile
tendons are bad at what what kind of forces
compression
shearing
what is shearing important for
loading - adapting to loads
what kind of structure is a tendon (elastic wise)
Viscoelastic structure
Response to loading (function) is dependent on magnitude AND rate of loading
The faster we load a tendon the more stiff it acts
Silly putty
what does load trigger in tendons
biological response
what does it mean - Tendons are metabolically active
Respond to changes in their loading environment
Tenocytes experience shear and compression forces during loading > remodeling
Overload + Inadequate Recovery leads to
injury
what is important for tendon recovery
time
after heavy loading tendons can take 72 hours to repair
what is Overuse in a tendon
imbalance in use and recovery
what does Degenerative mean
failed healing response
tendinopathy
Separation of collagen fibers
Increase in Type III collagen, thinner Type I collagen
III is not as strong
Greater proteoglycan (protein) and water content
Neovascularization (blood vessel ingrowth)
Accompanied by nerves (contributor to pain?)
Altered stiffness/viscoelastic properties
Tendinosis
= Imaging diagnosis of degenerated tendon
Clinical Presentation
Isolated tendon/enthesis pain
Load dependent: ↑ load = ↑ pain
(+) Palpatory tenderness
(+/-) Palpable thickening (superficial tendons)
Achilles tendon mostly
(+) Sensation of stiffness (AM, prolonged sitting)
Enthesis
Enthesis: where then tendon is attaching into the bone
Progression of symptoms
Early: Pain/stiffness after activity
Middle: Pain/stiffness at onset of activity, improves after warm-up, may return after prolonged activity (warm-up effect)
Late: Pain at rest, does not improve with warm-up
what is tendinopathy normally proceeded by
change in activity level
Treatment for tendiopathy
Mechanotherapy, or tendon loading, is the best supported treatment for lower extremity tendinopathy
Activity modification is considered a core component of mechanotherapy
Loading =
strengthening
what does Mechanotherapy/tendon loading promote
Promotes tendon remodeling
Improved tendon function, viscoelastic properties, structure, and pain
Tendon appears to respond most favorably (more remodeling) that is
Higher loads, up to a point (90% MVC better than 55% MVC)
Slower speeds/longer duration (more time under tension)
Dynamic vs static contractions
tendons respond to different contraction types
Tendon does not respond differently to different contraction types
4 phases of Tendinopathies
Symptom-Management and Load Reduction Phase
Recovery Phase
Rebuilding Phase
Return-to-Sport Phase
Goals in the symptom mangment phase
Halt abusive loading
Manage symptoms and initiate loading
Establish/manage expectations
Establish baseline (outcome measures!)
Initiate training diary
pt status in the symptom mangement phase
pain at rest or with ADLs
Goals in the symptom mangment phase
Halt abusive loading
Manage symptoms and initiate loading
Establish/manage expectations
Establish baseline (outcome measures!)
Initiate training diary
Treatment
Daily exercises
Progress loading up to 100% body weight
If highly irritable, may need to begin with isometric, aquatic therapy, or some form of bodyweight support
Begin addressing other impairments & risk factors (proximal and distal joint ROM, strength, endurance)
Interventions to reduce pain
what si the Continued Exercise program
Followed the pain-monitoring model
- get to a certain level of pain with a activity then change it
this is showing that you do not need to stop working out
what does compression do to recovery in tendiopathy
may delay or prolong recovery
manage expectations
Tendinopathy takes longer to fully recover than many other overuse injuries
with tendinopathy the the tendon often rupture
While possible, that vast majority of patients with painful tendons do not rupture
Tendon loading exercises may be protective against rupture
what does a partial or interstitial tear mean in the MRI
Partial or interstitial tears are common MRI findings consistent with tendinopathy, generally not the same as a rupture – Check with physician if any concerns!
pain with tendinopathy reecovery
need to tolerate some level of pain to get maximum benefit from loading exercises
what level of pain is not really a concern
Transient (<24 hours) increases in pain are generally not a concern
why are Training Diaries important
Help patients manage symptoms, track recovery
Assist clinician in modifying treatment/training
what is included in training dairies
Loading exercises performed
Other activity
Pain in the morning, highest and lowest pain during day
Recovery Phase Goals
Regain strength/endurance
Improve tendon’s tolerance to load
Recovery Phase Patient Status
Pain with exercise
morning stiffness
pain when performing loading exercises
Recovery Phase Treatment
Continue/progress loading exercises
If previously performing isometric exercises, progress to dynamic
Add external resistance
Increase speed
Light energy storage activities (plyometrics)
Prepare tendon for demands of sport
Rebuilding Phase Goals
Progress to heavy loading
Promote energy storage ability
Rebuilding Phase pt status
Tolerates the recovery phase exercises well
Possibly decreased or increased morning stiffness
Rebuilding Phase treatment
Add additional external resistance
Consider reducing loading to 3x/week
Must be heavy
Increase movement speeds of plyometric activities
Return-to-Sport Goals
Return patient to full participation
Continue to improve tendon and lower extremity function
Return-to-Sport pt status
Pain-free during daily activities and minimal pain during loading activities
Return-to-Sport treatment
Continue to progress loading exercises
Initiate return-to-sport
Focus on previously aggravating activities (e.g. running/jumping)
Sport specific training
loads and activities in recovery
Better to perform heavy loading/sports activities on same day with adequate time for recovery
Recovery days are critical
does absencee of pain = full recovery
no
Continue HEP loading activities for at least 1 yr after symptoms resolve
