Tendons and Healing Flashcards
Describe dense regular connective tissue.
- Type 1 collagen (resists tension: dense connective tissue)
- Low elastin
- Fibrocytes
- Parallel fibers for more unidirectional loads
Tendons resist what?
Tension and releases energy with muscle action
More stiffness (beneficial for tendon) will give you what kind of transmission or potential energy?
Better force transmission for storing of potential energy
What is the structure of a tendon (connects muscle to bone)?
Smallest:
- Collagen Fibril
- Collagen Fiber
- Primary Fiber Bundle (sub-fascicle)
- Secondary Fiber Bundle (fascicle)
- Tertiary Fiber Bundle
- Tendon
Largest:
Is the mid portion of a tendon hypo or hyper vascular and hypo or hyper neural?
- Hypovascular
- Hyponeural
Is the insertion of a tendon hypo or hyper vascular and hypo or hyper neural?
- Hypervascular
- Hyperneural
What is the prevalence of a tendinopathy?
- 30% of general musculoskeletal injuries
- 30-50% of sport injuries
Is tendinitis common or uncommon?
Uncommon
What is tendinitis?
Inflammation of a tendon without structural changes due to overuse
What are signs and symptoms of tendinitis?
- Typically acute and classic presentation
- TTP (tender to palpation)
- Pain and limitation with lengthening
- Pain with resisted testing and MMT, particularly in a lengthened position - may be weak
What kind of tendinopathy is the most common?
Tendinosis
What is tendinosis?
Degenerative changes with some inflammation
What is tendinosis due to?
- Repetitive stress and tendinitis
- Impingement pathomechanics
- Neural/ vascular insufficiency
- Exercise induced hyperthermia
- Older age
- Hormonal fluctuations
If a tendinosis is acutely irritated what signs and symptoms present? (big picture… it presents like what other tendinopathy)
Tendinitis Signs and Symptoms
What are specific tendinosis symptoms?
- Persistent (> 4-6 weeks) often with previously failed PT
- Decreasing tendon tolerances
- Often mislabeled as tendinitis and treated as such
What are specific tendinosis signs?
- Observation: enlarged tendon may be visible
- Acts like tendinitis if acutely inflamed
- Otherwise … ROM and resistance testing and MMT likely WNL
- No convincing association between strength deficits and tendinopathy
What are you going to see with palpation and tendinosis?
- TTP with decreased pain thresholds
- Increased in-growth of vessels and nerves
- Elevated pain neurotransmitters
What are the special tests specific to for tendinosis?
(+) special tests specific to tendon, etiologies, and pathomechanics
What amount of inflammation is there with tendinosis?
Little to no inflammation
What kind of fiber changes do you see on imaging with tendinosis?
- Degeneration and disorganization that also may be present prior to symptoms
- Weakened and greater likelihood of overload
- Increased non-collagen matrix
- Fatty infiltration
What do corticospinal (voluntary movement) influences do to tendinosis?
- Increased inhibition
- Increased excitability (aberrant/ excessive firing)
- Bilateral influences as well
Are acute tendon tears common or rare?
Rare
Where do you see higher and oblique forces?
During fast eccentric loading
When do you typically get and acute tendon tear?
- With higher and oblique forces during fast eccentric loading
- Prior degeneration or tendinosis
Why are acute tendon tears more likely with age and disuse?
- Elastin and vascularity decrease
- Atrophy and drying
- Shorter smaller tendon is less pliable and durable
When do most tendinitis heal?
- Primarily resolution of inflammation
- At most in 4-6 weeks (sometimes 2 weeks: inflammation phase)
When do most tendinosis and smaller tears heal?
- Primarily proliferating tendon (repair phase)
- Tensile strength initially improves at 3-5 weeks
- Even greater tensile strength when dense fibrous tissue fills in at 8 to 12 weeks
- Gradual and partial tears can improve with PT
Traumatic and full tear tendinosis likely require what?
- Surgery
- 10-12 months to normal strength postoperatively
What kind of patient education should you be doing with patients with tendinitis and tendinosis?
- Load management: optimal loading
- POLICED
NSAIDS should be used for _____ _____ pain relief in acute presentations.
Short term … because they dont address the problem
NSAIDS delay healing if the injury is where?
At the insertion
NSAIDS have poor response and no support in what kind of tendinitis and tendinosis presentations?
Persistent presentations … because they have little to no inflammation at this point
Bracing (neoprene sleeves on the involved muscles) and taping (prn/ straps) decrease what?
The resistance arm
Do modalities have any impact on tendinitis and tendinosis?
Modalities - iontophoresis, ultrasound, phonophoresis, and low-level laser treatment lack sufficient evidence at this time
What should you tell you patient with a tendinosis in regards to their soreness with ADLs and exercise?
It is okay to have mild symptoms during or up to 24 hours after exercise, but no more and no longer
What does manual therapy help with in regards to tendinosis?
Manual therapy helps to restore accessory motion as needed
What should be the primary and ultimate goal for tendinosis MET?
- Tendon proliferation
- Possible spinal stabilization if regional interdependence
When should you implement parameters for tendinosis?
After any acuity settles and for all structural changes in tendon, including tears
Should your parameters have heavy or light loads with tendinosis?
Heavy
What kind of actions should you do with tendinosis parameters?
- Slow eccentrics
- Possibly 3 second muscle actions (concentric, isometric, and eccentric)
Parameters pertaining to actions and ranges for tendinosis are what… (he uses an example with the biceps … shortened position is elbow flexed and shoulder flexed)
- Isometric loading without compression from lengthening - isometrics in a shortened position
- Isotonic loading without compression from lengthening - isotonic from neutral into shortened position
- Isotonic loading with compression from lengthening - isotonic from a lengthened position
- (Isometric loading in weight bearing), I.e., UE weight shifting, planks, push ups, etc
- Plyometric loading, I.e. ball bounces, tosses, throwing, etc.
What kind of position prevents compression?
Shortened
How many sets, reps, and exercises should you give your patient with a tendinosis?
- 2-3 sets of 10-15 reps to fatigue
- 2-3 exercises with involved tendons
What kind of activity response should you see with a tendinosis?
- Mild to moderate increase in pain possibly up to a 5/10
- Timeframe of pain should ease back to baseline levels before repeating exercises 24-48 hours
- Soreness Rule: Mild symptoms during or up to 24 hours after exercise as long as it is no more or no longer
- Most likely can repeat exercises every other day; may increase to daily in higher level patients
How long should your MET program be for a tendinosis?
8-12 weeks
What kind of tendinosis populations should have precautions with heavy loads to fatiguing points?
- Deconditioned populations
- Peri-pubescent population until growth plates are fused
What are the most important areas to watch for growth plate fusions?
- Humeral head epiphysis at the shoulder
- Last growth plates to fuse are the ASIS, ischial tube, and the base of the 5th metatarsal
What muscle attaches to the ASIS?
Sartorious
What muscles attaches to the Ischial tuberosity?
- Big picture: Hamstrings!
- Inferior Gemellus
- Quadratus Femoris
- Adductor Magnus
- Biceps Femoris
- Semitendinosus
- Semimembranosus
What muscles attaches to the base of the 5th metatarsal?
Fibularis Brevis
What is a predisposition patients with tendinosis have? (in regards to healing)
Patients have a predisposition or prevalence for “failed healing response”
Pts with both a tendinosis and obesity are prone to what complication?
Obesity: excessive fat absorbs inflammatory cells away from the tendon
Pts with both a tendinosis and diabetes are prone to what complication?
Diabetes: excessive glucose impairs collagen production and remodeling
Low grade and persistent inflammation is associated with what (in regards to tendinosis).
- Associated with systemic disease(s) and/ or SAD diet
- Limits proliferation and remodeling
Do MD Rx have long term or functional benefits?
No
What kind of benefits do cortisone injections have?
Short term benefits
What kind of benefit do glycerin trinitrate patches have?
Effective by increasing circulation
What do sclerosing injections do?
Stiffen tendons for pain relief
Is surgical debridement the first or last option when it comes to MD Rx?
- Last option
- Expensive
- Modest Success
- This is basically scrapping the tendon to get tendon proliferation
What are future options in regards to MD Rx when it comes to tendinosis?
- Growth factors
- Stem cells
