Tendinopathy Flashcards
What is a tendon made up of
❖ Made up of collagen
❖ Collagen have a ‘wave-like’ appearance
❖ That configuration allows it to stretch and re-coil
❖ ‘Mid Portion’ can be a trouble portion or the origin
what is the function of the enthesis organ
➢ Compression of the tendon against the bone
reduces tensile load on insertion–>there is a wedge between the tendon and bone which gets pressed when tendon is pulled on which is normal, however when it occurs repeated times, causes a problem
➢ Confers a mechanical advantage to the muscle-tendon unit
what is the SSC
-Stretch -shortening cycle
❖ Tendon gets elongated–>stores potential energy/elastic energy and then releases this energy
❖ Function of muscle is intrinsically related to function of tendon
❖ Muscle contribute half of the passive extensibility of the MTU
what is the spring function in the LL
➢ Runners use Achilles as a spring
➢ More dynamic stuff–>use the knee as a spring
what is the tendon’s response to load at 24hrs
net catabolic–> normal
LOOK AT GRAPH
what determines whether it is an overload and development tendinopathy
fluctuations of greater than 10% in tendon response to load–> considered a pathology
what is the histopathology of tendinopathy
❖ Loss of fine fibre structure ❖ Loss of parallel fibre arrangement ❖ Reduction in tenocyte numbers, with rounded nuclei, more resemblant of chondrocytes ❖ Increased cellularity ❖ Increased vascularity ❖ Absence of inflammatory cells
what is the histopathology of
the extracellular matrix in tendinopathy
➢ Loss of collagen organisation
➢ Fibrocartilaginous change
➢ Glycosaminoglycan deposition
what is the histopathology of
chronic inflammation in tendinopathy
- higher levels of inflammatory cells in tendinopathic tissue v/s healthy control tendons
- tissue and cells derived from tendinopathic and ruptured achilles tendons show evidence of chronic inflammation
what is the histopathology of
poor colagen fibril structure in tendinopathy
➢ Poor collagen fibril structure of the tendon causes the pain and dysfunction
➢ Disorganisation of collagen is related to worsening clinical status
➢ Pain and function significantly improve with loading programs
➢ Tendon structure and dimensions remain unchanged
Why does tendon thickening occur
❖ Thickening of the tendon as a result of trying to repair itself but not doing a very good job
what is the presentation of reactive tendinopathy
➢ Acute severe pain
➢ Significant loss of function
➢ Thickening of tendon
➢ No hyperechoic areas on US or increased signal on MRI
What is the presentation of degenerative tendinopathy
➢ Mild to moderate pain
➢ Mild/moderate loss of function
➢ Thickening
➢ Hyperechoic regions on US and abnormally increased signal on MRI
➢ Often managing to run/walk for a long time with symptoms
➢ Pain is local
➢ Pain ‘warms up’–>The ability for it to warm up during exercise is a tendinopathy sign
➢ Pain and stiffness next morning
what is the presentation of reactive-on-degenerative tendinopathy
an acute flare in pain with history of mild to moderate ‘grumbly’ Achilles tendon pain
what factors affect load sensitivity
❖ Genetics
❖ Gender
❖ Metabolic syndrome/diabetes
❖ Antibiotics
how does genetics affect load sensitivity
❖ COL5A1 gene mutation increases type 5 collagen
how does gender affect load sensitivity
❖ Post menopausal women are equal to the male risk of tendinopathy
❖ Active women have higher incidence of tendon abnormality and thicker tendons than healthy inactive women
how does metabolic syndrome affect load sensitivity
❖ Insulin resistance = fatty infiltration in muscle tension
❖ Pain associated with fatty infiltration in tendon
❖ Waist circumference associated with tendinopathy
how does antibiotics affect load sensitivity
❖ Ciprofloxacin and levofloxacin were most commonly implicated fluoroquinolones
❖ Mean time of onset of symptoms was 16days following first FQ dose
What are the common subjective features of achilles tendinopathy
❖ HPC
➢ Gradual onset of symptoms
➢ Preceded by ‘increase’ in training (volume/intensity/nature)
➢ May be long-standing
❖ Relevant history intermittent over many years
❖ Symptom behaviour
➢ Aggravated by SSC activities–>warms up
➢ Morning stiffness
❖ Local muscle atrophy–> atrophy of PF muscles
What are some objective features of achilles tendinopathy
-PROM–> VISA-A
❖ Different diagnosis tests–> can be ligaments, joints or other muscle soft tissue that could be the problem, so need to cancel that out
❖ Palpate
➢ Achilles tendinopathy–>mid-portion, 2-4cm proximal to calcaneus
❖ Assess spring (carefully)–> what is their ability to so SSC
❖ Assess local muscle strength look at gastrocnemius for achillies (calf raise)
❖ Assess strength through the rest of leg (leg press)
❖ Assess spring maximal hop test
What are the common subjective features of patella tendinopathy
❖ HPC
➢ Gradual onset of symptoms
➢ Preceded by ‘increase’ in training (volume/intensity/nature)
➢ May be long-standing
❖ Relevant history–>intermittent over many years
❖ Symptom behaviour
➢ Aggravated by SSC activities–>warms up
➢ Morning stiffness
What are some objective features of patella tendinopathy
❖ Subjective history including factors influencing load sensitivity (Tendon Q)
❖ PROM–> VISA-A
❖ Different diagnosis tests
❖ Palpate
❖ Assess spring (carefully) what is their ability to so SSC
❖ Assess local muscle strength look at gastrocnemius for achillies
❖ Assess strength through the rest of leg (leg press)
❖ Provocation testing pain at inferior pole of patella
what is the pathogenesis of PHT
- Excessive compression of hamstring tendon in hip flexed positions
- internal compression= repeated hip flexion
- external compression = lots of sitting time
- relative increase in load in hip flexed positions
- degenerative changes occur at under surface of hamstring/ pain
What are the common subjective features of PHT
❖ Symptom behaviour during:
➢ Hip flexion positions squat, leaning forward, running up hill
➢ Direct compression sitting
❖ No difficulty standing still
❖ Pain at ischial tuberosity
❖ Referral into posterior thigh, to popliteal fossa
❖ No neurological symptoms
What are some objective features of PHT
❖ Subjective history including factors influencing load sensitivity (Tendon Q)
❖ PROM VISA-A
❖ Different diagnosis tests sciatic nerve: want to rule out stress # of ischium
❖ Palpate
❖ Assess spring (carefully)–> what is their ability to so SSC
❖ Assess local muscle strength
❖ Assess strength through the rest of leg (leg press)
❖ PHT provocation testing/cluster
What is the function of hip abductors during gait and hence the affect of gluteal tendinopathy on gait
keep the pelvis level, preventing Trendelenburg gait
What are the subjective features of gluteal tendinopathy
❖ Demographics–> females > 40yo and variable activity levels
❖ HPC: insidious onset, chronic and episodic
❖ PMH–> peri-menopausal
❖ Symptom behaviour:
➢ SI loading (walking, stairs, running etc.)
➢ Direct compression (sleeping)
-Factors affecing load sensitivitty
What are the objective features of gluteal tendinopathy
PROM–>VISA-A
❖ Different diagnosis tests–>sciatic nerve: want to rule out stress # of ischium
❖ Palpate
❖ Assess spring (carefully)–>what is their ability to so SSC
❖ Assess local muscle strength
❖ Assess strength through the rest of leg
❖ Gluteal provocation testing
how do you manage an achillies tendinopathy
❖ Load the local muscle
❖ Load rest of leg
❖ Retrain the spring
❖ Isometrics
what is the role of isometric exercises and the parameters
➢ A pain relieving modality not a strength training exercise
➢ Must be sustained and hard
➢ 5 x 45sec isometric holds
➢ 2 min rests
what would be the strength training for tendinopathy and the parameters
❖ 3 sets of 15 progressing to 3x6 by week 12
❖ Want high intensity on the first day of strength training
❖ Want low load between 24-48 hours of the strength training–>as it is net catabolic to anabolic phase hence don’t want to break down what is building
❖ 48-72 hours post exercise–>want medium load of tendon as it in net anabolic and is settling down
❖ Repeat to strengthen tendon
❖ Starting load–> pt will usually give you a starting load
❖ Pain and stiffness should not worsen or increase week to week
❖ The pain during activity after completion and morning after is allowed to reach 5 on the NPRS (Numerical Pain Rating Scale)
how do you manage patella tendinopathy
Load local muscle
❖ Load rest of leg
❖ Retrain the spring
➢ Build program around more jumping exercises
➢ 3 x 10 (2 min recovery)/ 3 x 10 (3 min recovery)
isometric exercises for patella tendinopathy
wall squats
➢ With patella can load local muscle and address the rest of the leg at the same time with step-ups on box with load/leg press
Management of PHT
Reduce compression
❖ Load in non-compressive positions–>hip flexion as minimal as possible
❖ Progress as pain allows
what are some PHT strength exercises
➢ Double leg isometric glute bridge–>or SL
➢ Hip thrusts with load
➢ Hamstring curls prone
➢ Plank with leg lift
management of gluteal tendinopathy
-stop compressing and get strong
Gluteal tendinopathy exercises
❖ Bridge ❖ Offset bridge ❖ Bridge march ❖ SL stance ❖ Side lying with single leg raise ❖ Jumping and land--> more progressive
how do you reduce compression of glutes in gluteal tendinopathy
❖ DON’T STRETCH/ROLL ❖ Day-time postures repetitive or sustained positions of (loaded) hip abduction ➢ Hanging on 1 hip ➢ Standing with legs crossed ➢ Sitting with knee crossed ➢ Sitting with knees together ❖ Day-time activities ➢ Avoid hills ➢ Shorten stride length ➢ Use handrail with stairs ❖ Night-time postures ➢ Avoid side lying as it will compress both tendons ➢ Supine with pillow under knees is good ➢ Side-lying with pillow between knees is good
how is management different for insertional tendinopathy
❖ Reduce compression
➢ DF increases compression of achilles tendon on calcaneus
➢ Hence encourage high heels (females) or shoe elevation
❖ Load local muscle
❖ Load rest of leg
❖ Retrain the spring
