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ANAT2012 > Tendons and Ligaments L3: Pathology and rehabilitation of tendons and ligaments > Flashcards

Tendons and Ligaments L3: Pathology and rehabilitation of tendons and ligaments Flashcards

1
Q

Combination of structure-combination-function on tendons and ligaments

A
  • Tendon & ligament can change their structure and/or composition (and thus their function) in response to changes physiology (maturation, ageing), injury or other disease processes
  • If one structure at joint is affected, the total function of the joint will be disrupted
  • Rehabilitation should consider behaviour of all the affected structures/ induce adaptation in each structure.
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2
Q

What are the 2 functions of ligaments?

A
  • Strong enough to provide stability
  • Flexible enough to permit joint motion
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3
Q

What are the mechanics of injury of ligaments?

A
  • Ligaments fail when tensile loads exceeds capacity
  • Often awkward position of landing
  • Joint dislocation is often associated with ligament damage
  • Abnormal motion between bony articulation predisposes to articular damage ¥ Eg. lateral ankle is common
  • Sublaxation = partial dislocation often strain (not torn) ligament
  • Collagen fails progressively (ligament) vs rapidly (tendon)
    • Grade 1: damage to some collagen fibres
      • Ev/inv tears
    • Grade 2: more extensive number of fibres damaged
    • Grade 3: complete rupture
      • More laxity, end feel not from ligament
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4
Q

What are the 3 grades of failure of ligaments?

A
  1. Grade 1: damage to some collagen fibres
    • Ev/inv tears
  2. Grade 2: more extensive number of fibres damaged
  3. Grade 3: complete rupture
    • More laxity, end feel not from ligament
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5
Q

Ligament healing is a continuous process? True or false?

A

True

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6
Q

What are the 3 phases (triphasic) of ligament healing?

A
  1. Inflammation
    • Swelling
  2. Proliferation
    • Layng down new tissue
  3. Remodelling
    • Collagen fibres in direction of stress
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7
Q

What are the 3 mechanical properties of ligament healing?

A
  1. Decreased stiffness (lower slopes)
  2. Decreased load at failure (all times)
  3. Altered site of failure (entire ligament is weakened)
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8
Q

What are the 3 morphology properties of ligament healing?

A
  1. Increased cross-sectional area (all times)
  2. Progressive decrease in CSA from 3-14wks
  3. Increased laxity at 3, 6, and 40wk
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9
Q

When should extra-articular ligament (outside capsule) be operated on?

A
  • High healing capacity
  • Often treating conservatively
  • Eg. ankle, collateral ligaments of knee/elbow
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10
Q

When should intra-articular ligament (inside joint) be operated on?

A
  • Lower healing capacity
  • Often require surgery
  • Eg. ACL, PCL , scapholunate ligament (wrist)
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11
Q

Ligaments are associated with…

A
  • Instability (increased ROM)
  • Bony bruising (bone on bone interaction)
  • Osteoarthritis (if ligament damage remains, or ligament not healed properly)
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12
Q

What are 3 questions that should be asked in regards to rehabilitation?

A
  1. What structure is damaged & to what extent? (grade level)
  2. What is the timeframe of healing response?
  3. What are the priorities at this timepoint?
    • Inflammation?
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13
Q

What are 4 characteristics of a normal ligament?

A
  1. Hypocellular ( decreased cell density)
  2. Hypovascular ( decreased blood)
  3. Highly organised
  4. Dense collagen structure
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14
Q

What are processes that occur during injury, on a time line?

A
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15
Q

What are processes that occur during injury, at 10 days?

A

Defect filled with vascular inflammatory tissue

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16
Q

What are processes that occur during injury, at 3 weeks?

A

inflammatory cells subsided and active fibroblasts dominated

17
Q

What are processes that occur during injury, at 6 weeks?

A

decrease in number and size of fibroblasts + some evidence of longitudinal alignment of nuclei (along long axis of ligament)

18
Q

What are processes that occur during injury, at 14 weeks?

A

remodelling – increased realignment and decreased cell numbers

19
Q

What are processes that occur during injury, at 14-40 weeks?

A

few changes noted; cells remained larger and more numerous

20
Q

What are the 3 mechanical properties of ligament healing?

A
  1. Mechanical properties of healing MCL substance remain inferior to normal ligament (sham surgery) for up to one year
  2. MCL may increase stiffness by increasing CSA of healing ligament by as much as 2 ½ times normal size
  3. Healed ligaments are generally more bulky and not as strong as native tissue
21
Q

What are the 3 functions of tendons?

A
  • Transmit tensile forces
    • Mechanical properties of tendon affect muscle function (force generating capacity + muscle length-tension relationship)
  • Storage & release of energy for efficiency
  • Buffering, amplifying role
22
Q

What are 11 mechanism for tendon injury?

A
  1. Excessive force
  2. Repeated overload
  3. Normal forces applied to weakened tendon
  4. Stress-shielding
    • Even if whole tendon is exposed to normal mechanical loading, some fibres may be underloaded (stress-shielded) and other fibres over-loaded
    • Eg: Lower strain in proximal posterior part of healthy patellar tendons
  5. Forces applied in alternative direction o Tendon compression frequently contributes to insertional tendinopathy
    • eg: Achilles or Gluteus medius tendons
  6. Ageing
  7. Adiposity
    • mechanical loads + systemic effects
  8. Physical activity levels
    • spikes in acute load relative to chronic loads
  9. Diseases
    • e.g. diabetes, rheumatoid arthritis
  10. Medications
    • e.g. corticosteroids - suppresses fibroblastic reaction and inhibits growth
  11. Alcohol
    • inhibits fibroblast proliferation
  • Degenerative changes may weaken the tendon’s mechanical properties predisposing to injury
  • 97% of ruptured Achilles tendons had asymptomatic (didn’t feel) degenerative changes
23
Q

Where are the 3 places that overuse tendinopathy can occur?

A
  1. Midsubstance (red) (e.g. Achilles)
  2. Insertional (blue) (e.g. Achilles, lateral elbow (tennis elbow), patellar tendinopathy
  3. Musculotendinous junction (e.g. hamstrings, quadriceps tendon)
24
Q

What are characteristics of an overuse tendinopathy?

A
  • Grey and amorphous to naked eye
  • Disorganised collagen (separation, fragmentation, disorientation)
  • Inflammatory & immune cells absent
  • cellularity
  • Hypervascularity
  • proteoglycans and water content
25
Q

What are characteristics of a normal tendon?

A
  • Highly organised, relatively few cells
  • Glistening white
26
Q

What are some changes in mechanical properties in tendons?

A
  • Reduced Achilles tendon stiffness in Achilles tendinopathy
27
Q

Why would ultrasound imaging be used in tendinopathy?

A
  • Demonstrates tendon thickening, hypoechoic areas, tears (B-mode)
  • Neovessels (Doppler)
28
Q

___ sensitivity and ____ specificity for diagnosis of tendinopathy = negative ultrasound = useful to rule out tendinopathy

A

High; low

29
Q

There is a limited correlation with pain severity in tendinopathy? True or false

A

True

30
Q

What are some changes in elastic properties?

A
  • A and P tendinopathy subject had lower Achilles tendon elastic modulus and higher patellar tendon elastic modulus.
  • General rule- higher velocity = increased stiffness
31
Q

What is one of the most critical components of rehabilitation for tendinopathy?

A

Exercise

32
Q

Why is exercise a critical rehab option for tendinopathy?

A
  • Isometric exercise possibly superior ?
  • Improve function
  • Progressive loading to remodel tendon
  • Avoid compressive loading, especially if insertional
  • (eg: prox hamstrings)
  • Considerations…
  • What is the loading history ?
  • Gradual progression of loads
  • Address stability/coordination
  • No quick fixes (slow turnover)
33
Q

What is paratendinitis?

A
  • Occurs where a tendon rubs over a bony protuberance
    • De Quervains (APL, EPL)
    • FHL (near medial maleolus)
  • Acute oedema, hyperaemia of paratenon
  • Inflammatory cells
  • Tendon itself minimally involved
  • Crepitis (fibrinous exudate fills shealth)
34
Q

What is a tendon rupture?

A
  • Can occur in normal tendon if loads are sufficiently large
  • Common tendons
    • Rotator cuff (older adults)
    • Achilles (young, active adults)
  • More commonly occurs in tendon weakened by pre-existing degenerative change (diabetes, alcohol)
35
Q

How to assess tendon pathology?

A
36
Q

What are the effects of immobolisation on tendons and ligaments?

A
  • decreased structural properties of tendons/ligaments
    • Immature, weaker, disorganized collagen
    • decreased tissue stiffness up to 50% after 8 weeks of immobilisation
    • Tissue deterioration is less if immobilised in some tension
37
Q

What are the effects of remobilisation and recovery?

A
  • Re-establishment of normal stresses can reverse effects, but …
  • Tendons/ligaments are relatively hypovascular + hypocellular
  • Healing is slow - takes many months and may never attain past characteristics
  • Insertion sites are more resistant to recovery
38
Q

What are some exercise training concepts to understand as rehabilitation?

A
  • Progressive loading to improve tendon “capacity”
  • Increased strength = increased energy storage = store and release

ANAT2012 (31 decks)

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