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Peripheral Musculoskeletal Science > Tendinopathy > Flashcards

Tendinopathy Flashcards

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1
Q

What is a tendon made up of

A

❖ 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

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2
Q

what is the function of the enthesis organ

A

➢ 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

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3
Q

what is the SSC

A

-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

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4
Q

what is the spring function in the LL

A

➢ Runners use Achilles as a spring

➢ More dynamic stuff–>use the knee as a spring

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5
Q

what is the tendon’s response to load at 24hrs

A

net catabolic–> normal

LOOK AT GRAPH

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6
Q

what determines whether it is an overload and development tendinopathy

A

fluctuations of greater than 10% in tendon response to load–> considered a pathology

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7
Q

what is the histopathology of tendinopathy

A 
❖ 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
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8
Q

what is the histopathology of

the extracellular matrix in tendinopathy

A

➢ Loss of collagen organisation
➢ Fibrocartilaginous change
➢ Glycosaminoglycan deposition

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9
Q

what is the histopathology of

chronic inflammation in tendinopathy

A
  • 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
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10
Q

what is the histopathology of

poor colagen fibril structure in tendinopathy

A

➢ 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

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11
Q

Why does tendon thickening occur

A

❖ Thickening of the tendon as a result of trying to repair itself but not doing a very good job

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12
Q

what is the presentation of reactive tendinopathy

A

➢ Acute severe pain
➢ Significant loss of function
➢ Thickening of tendon
➢ No hyperechoic areas on US or increased signal on MRI

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13
Q

What is the presentation of degenerative tendinopathy

A

➢ 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

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14
Q

what is the presentation of reactive-on-degenerative tendinopathy

A

an acute flare in pain with history of mild to moderate ‘grumbly’ Achilles tendon pain

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15
Q

what factors affect load sensitivity

A

❖ Genetics
❖ Gender
❖ Metabolic syndrome/diabetes
❖ Antibiotics

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16
Q

how does genetics affect load sensitivity

A

❖ COL5A1 gene mutation increases type 5 collagen

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17
Q

how does gender affect load sensitivity

A

❖ 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

18
Q

how does metabolic syndrome affect load sensitivity

A

❖ Insulin resistance = fatty infiltration in muscle tension
❖ Pain associated with fatty infiltration in tendon
❖ Waist circumference associated with tendinopathy

19
Q

how does antibiotics affect load sensitivity

A

❖ Ciprofloxacin and levofloxacin were most commonly implicated fluoroquinolones
❖ Mean time of onset of symptoms was 16days following first FQ dose

20
Q

What are the common subjective features of achilles tendinopathy

A

❖ 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

21
Q

What are some objective features of achilles tendinopathy

A

-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

22
Q

What are the common subjective features of patella tendinopathy

A

❖ 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

23
Q

What are some objective features of patella tendinopathy

A

❖ 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

24
Q

what is the pathogenesis of PHT

A
  • 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
25
Q

What are the common subjective features of PHT

A

❖ 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

26
Q

What are some objective features of PHT

A

❖ 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

27
Q

What is the function of hip abductors during gait and hence the affect of gluteal tendinopathy on gait

A

keep the pelvis level, preventing Trendelenburg gait

28
Q

What are the subjective features of gluteal tendinopathy

A

❖ 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

29
Q

What are the objective features of gluteal tendinopathy

A

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

30
Q

how do you manage an achillies tendinopathy

A

❖ Load the local muscle
❖ Load rest of leg
❖ Retrain the spring
❖ Isometrics

31
Q

what is the role of isometric exercises and the parameters

A

➢ A pain relieving modality not a strength training exercise
➢ Must be sustained and hard
➢ 5 x 45sec isometric holds
➢ 2 min rests

32
Q

what would be the strength training for tendinopathy and the parameters

A

❖ 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)

33
Q

how do you manage patella tendinopathy

A

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)

34
Q

isometric exercises for patella tendinopathy

A

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

35
Q

Management of PHT

A

Reduce compression
❖ Load in non-compressive positions–>hip flexion as minimal as possible
❖ Progress as pain allows

36
Q

what are some PHT strength exercises

A

➢ Double leg isometric glute bridge–>or SL
➢ Hip thrusts with load
➢ Hamstring curls prone
➢ Plank with leg lift

37
Q

management of gluteal tendinopathy

A

-stop compressing and get strong

38
Q

Gluteal tendinopathy exercises

A 
❖ Bridge
❖ Offset bridge
❖ Bridge march
❖ SL stance
❖ Side lying with single leg raise
❖ Jumping and land--> more progressive
39
Q

how do you reduce compression of glutes in gluteal tendinopathy

A 
❖ 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
40
Q

how is management different for insertional tendinopathy

A

❖ 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

Peripheral Musculoskeletal Science (3 decks)

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