Tendinopathy Flashcards
Describe the clinical presentation of tendinopathy
- Gradual onset
- Localised pain
- Worse with activity, maybe disappears after warm up, may return during cool down
- Can usually continue training
Tenderness/thicking
Swelling/crepitus
Define tendinosis vs tendinitis
Tendinitis = inflammatory condition of the tendon
Tendinosis = degenerative mucoid condition characterized by increased ground substance + vascular tissue and NO inflammatory markers
Describe the pathophysiology of tendinosis (Cook’s 3 stages)
When tendons loaded appropriated they increase in STIFFNESS - not by thickening
- can unload a tendon as well - if you unload too much you create a STRESS SHIELDED tendon whereby the superficial fibres take too much stress and the deep fibres too little - can progress to reactive tendinosis with normal or excessive load; can also progress to reactive if excessive load on normal tendon
Stage 1: Reactive tendinopathy
- acute tensile stress or compressive overload
- tendon cells react and cause thickening/swelling
- allows for SHORT TERM reduction in stress
*this stage usually in younger more athletic pop with hx of tendon overload; so must try to ID overload and reduce it!
Stage 2: Dysrepair
- after the initial SHORT TERM stress reduction, body starts to break down
- tendon cells become more rounded+prominent
- myofibroblasts proliferate - they’re good for healing but they lay down too much tissue! more proteoglycans/collagen which causes matrix disruption
- neovascularization on nerves - thats why pain?
- might see changes on MRI/US?
- can reverse if loading is modified/controlled
Stage 3: Degenerative
- this is the end stage - hopefully your pt doesn’t get here and you’re trying to prevent them from getting here
- cell death in affected portion of tendon
- matrix+cell changes
- disorganized matrix
*this stage can occur in anyone - young, middle aged, old (unlike Stage 1)
How does management differ based on what stage you’re in?
Stage 1+early Stage 2:
- reduce the load!
- reduce frequency/intensity of the load
Late Stage 2+Stage 3:
- exercise (eccentrics?)
- ESWT
- friction/US
What are the benefits of eccentric exercises for tendinopathy?
- reduces pain (4-6wks)
- more collagen production in affected tendon + improved tendon structure
- reduces tendon vessels
Whats the difference between Alfredson and Curwin+Stanish protocols for strengthening?
Alfredson:
- patella+achilles
- can exercise with pain
- eccentric only
- 12 wks, 3x/day, 3x15
Curwin+Stanish
- patella
- exercise with no pain only
- 6 wks, 1x/day, 3x10
- slow, med, fast speeds
Risk factors for Achilles Tendinopathy
- sudden increase in volume/intensity of work
- change in surface/footwear
- excessive pronation
- weak PFs
- short gastrocs/soleus
- reduced subtalar joint/midfoot motion
- proximal weakness (glutes/quads)
What is the management for AT?
- address causative factors (gastroc length, load, pronation)
- heel lift to offload the achilles
- EPA, STW
- exercise
Extensor tendinopathy
- overload
- rearfoot pronation (too many toes sign)
- pain near med mall, navicular
- +ve inversion test
Management:
- taping
- relative rest
- EPA
- orthoses
- mm control training
- NSAIDS
Patellar tendinopathy risk factors?
Weight Waist:Hip ratio LLI Quad strength Quads/hams flexibility Arch height V jump performance
Management of tendinopathies in the groin
Pain free exercise
Strengthen lumbopelvic region and local musculature (add)
Reduce load
Graded increase in load
Management of RC tendinopathy
- Control symptoms
- Strengthen (mm weakness/tightness; scapulothoracic joint; technique)
Low evidence:
Laser/Massage/NSAIDs/US/IFS
Evidence ‘present’:
Reduce load/ice/GTN/corticosteroid
Evidence for strengthening for RC tendinopathy
- evidence mainly of external rotators (eccentric ex?)
- stretching post capsule
- correcting biomechanics
Surgery for RCT
- surgery (acromioplasty/bursectomy) no more effective than exercise
Clincal signs/tests for Lateral elbow pain
- mostly ECRB (but can be ED/ECU as well)
- seen a lot in gripping activities/sports
- mainly in 40-50 yrs
- can be gradual or sudden onset
- palpation - sensitive on insertion; if mid-substance then 1-2 cm distal
Tests:
IMT - wrist extension; middle finger extension
Cx screen
Neurodynamic tests
