Tendon, Ligament and Cartilage Pathologies

Question 1

Acute/Sudden Onset Injuries - Tendon, Ligament and Cartilage

Answer 1

Tendon: Tear, Rupture
Ligament: Tear (sprain)
Cartilage: Osteochondral lesion, acute tear (meniscal, IVD disc herniation)

Question 2

Overuse/Gradual Onset Injuries - Tendon, Ligament and Cartilage

Answer 2

Tendon: Tendinopathy (paratenonitis, tenosynovitis, tendinosis, tendinitis)
Cartilage: Chondropathy, degenerative tear (meniscus, IVD)
Ligament: Inflammation (rare)

Question 3

Phases of Healing (3)

Answer 3

1. Inflammation
2. Proliferation/repair
3. Consolidation/remodeling

Question 4

Tendon Tear/Rupture - Phase of Healing: Inflammation

Answer 4

↑ Vascularization
↑ Platelets
↑ Neutrophils
↑ Monocytes
↑ Erythrocytes
↑ Mesenchymal stem cells
Swelling
↑ Growth factors (4)

Question 5

Tendon Tear/Rupture - Phase of Healing: Proliferation

Answer 5

↑ Extracellular matrix production
↑ Collagen type III production
↑ Tenoblast activity
↑ Proliferation of nerve cells and blood vessels

Question 6

Tendon Tear/Rupture - Phase of Healing: Consolidation/Remodeling

Answer 6

↓ Extracellular matrix production
↓ Collagen type III production
↑ Collagen type I production
(type III turns into type I)

Question 7

Tendinopathy - Cause & Recovery

Answer 7

Tendon cells are mechanoresponsive, they adapt according to mechanical load: remodeling. When there is not given enough time for remodeling, collagen fibers become disorganized, which creates a thickening of the tendon (not inflammation).
Cause: Incorrect loading.
Recovery: Correct loading.

Question 8

Tendinopathy - Model of Continuum

Answer 8

Normal tendon
↓
Reactive tendinopathy
↓
Tendon dysrepair
↓
Degenerative tendinopathy

Question 9

Reactive Tendinopathy - Characteristics (2)

Answer 9

Short term adaptation to overload. Reverts to normal if overload is reduced or sufficient time given between sessions.

Question 10

Tendon Dysrepair - Characteristics (3)

Answer 10

Attempt of tendon healing ECM breakdown.
Cell proliferation resulting in disorganized ECM.
Start of nerve and vessel ingrowth.

Question 11

Degenerative Tendinopathy - Characteristics (3)

Answer 11

Areas of apoptosis, large ECM areas disorganized, large vessels.
High risk of rupture.
Very difficult to heal.

Question 12

Tendinopathy - Clinical Presentation (3)

Answer 12

Pain after training (not during unless it’s degenerative), or following morning.
Local tenderness and/or thickening.
Crepitation may be present (usually in tenosynovitis)

Question 13

Ligament Tear/Sprain - Grade 1 (5)

Answer 13

Minor nr. of fibers affected.
Minimal tenderness on palpation.
Minimal swelling.
Normal end-feel.
Minimal functional deficit.

Question 14

Ligament Tear/Sprain - Grade 2 (5)

Answer 14

Considerable nr. of fibers affected.
Significant tenderness on palpation.
Significant swelling.
Increased laxity but end point present.
Moderate functional deficit.

Question 15

Ligament Tear/Sprain - Grade 3 (5)

Answer 15

Complete disruption of fibers.
Immediate pain but reduces quickly.
Immediate and significant swelling.
Abnormal ROM, no end point.
Significant functional deficit.

Question 16

Ligament Tear/Sprain - Phases of Healing: Inflammation (7)

Answer 16

48-72h
Hemorrhage
Clotting
↑ Growth factors
↑ Neutrophils
↑ Monocytes
↑ Mesenchymal stem cells
Swelling

Question 17

Ligament Tear/Sprain - Phases of Healing: Proliferation/Repair (7)

Answer 17

4-8 weeks.
↑ Fibroblasts
↑ Proteoglycans
↑ Glycoproteins
↑ Collagen type III production
↑ ECM turnover
Scar tissue formed

Question 18

Ligament Tear/Sprain - Phases of Healing: Consolidation/Remodeling

Answer 18

Months/years
↓ ECM turnover
↓ Collagen type III production
↑ Collagen type I production
Ongoing remodeling of scar tissue.

Question 19

When does return to sport occur after ligament tear/sprain?

Answer 19

Before tissue healing has completed.
3-6 weeks for mild injuries.
8-12 weeks for moderate to severe injuries (ACL excluded).

Question 20

Generalized Ligament Laxity: Hypermobility - Beighton Scale (5)

Answer 20

Hyperlaxity is normal.
5th finger passive extension >90°
Thumb passive dorsiflexion to flexor aspect of forearm.
Elbow hyperextension >10°
Knee hyperextension >10°
Trunk flexion w/ knee extension, palms flat on floor.
Adults ≥ 4/9
Children ≥ 7/9
Always compare sides!

Question 21

Acute Injury of Articular Cartilage - Types (2) and Common Sites

Answer 21

Usually result of acute trauma.
Chondral Injury: only cartilage affected.
Osteochondral injury: cartilage and subchondral bone affected.
Most common sites: femur condyles, talus, patella.

Question 22

Acute Injury of Articular Cartilage - Repair

Answer 22

Limited repair and regeneration due to poor vascularization.
Risk factor for early OA.

Question 23

Knee Menisci Tear - Clinical Presentation and Healing

Answer 23

Acute or degenerative.
Pain at the time of injury.
Swelling (can be delayed)
↓ ROM
↓ Joint stability
Popping/clocking sound
Loss of function
Healing (migration of cells from synovial membrane) depends on blood supply (type of tear).