Therapeutic exercise approach for tendinopathy Flashcards

week 3

1
Q

what are tendons and what do they do?

A

noncontractile soft tissue
- primarily type I collagen
- some elastic
- serves as an attachment point from muscle to bone
transmit (muscle) forces t o(skeletal) levers to facilitate movement (store and release energy)

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2
Q

What properties comprise healthy tendons?

A
  • stiffer than muscle
  • has greater tensile strength than muscle
  • can withstand large loads w/ minimal deformation

these properiteis enable tendons to transmit muscle forces efficiently while minimizing energy loss from tendon strain

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3
Q

when is strain a bad thing?

A

during activities requiring efficient force transmission i.e. jumping (want tendon stiff)

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4
Q

what is tendon stiffness?

A

isn’t: hypomobility your reduced ROM
IS: resistance to deformation strain under load

how we minimize energy loss is stiff tendons

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5
Q

what is tendon elasticity?

A

the ability of your spring to recoil ( and a stiff tendon recoils faster)

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6
Q

when is strain a “good” thing?

A

Muscle Fiber Damage:
When you lift weights or perform other physically strenuous activities, muscle fibers tear slightly.
Repair and Growth:
The body then repairs these microscopic tears, and in doing so, the muscle fibers grow back stronger and larger than before, leading to increased muscle mass and strength

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7
Q

What is tendinopathy?

A

a general term that refers to tendon (microtraumatic) injury affected by mecnanimcal loading
- pain and dysfunction in the tendon

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8
Q

tendinopathy is most reported in what areas?

A
  • achillies
  • patellar
  • lateral elbow
  • rotator cuff
  • hip

can affect any muscle-tendon unit in the body but most commonly seen in these places

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9
Q

pathophysiology of tendinopathy

A

pathogenesis is unclear but
- tendinopathy is commonly preceded by a change in activity
- too rapid a progression without adequate recovery
- attempted return to PLOF following forced relative rest
- renders tendon susceptible to pathological changes and degradation

prior level of function = PLOF

load accumulation disease

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10
Q

tendinopathy is now widely considered to be degenerative and NOT ?

A

a classic inflammatory response
- why we say tendinopathy now vs. tendinitis

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11
Q

tendinopathy can be classified across a continuum consisting of what 3 stages

A
  1. reactive tendinopathy
  2. tendon disrepair
  3. degenerative tendinopathy
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12
Q

How does reactive tendinopathy occur?
what is going on at the cellular matrix and collagen level?

A

typically results from acute bout of overload
- changes in the cellular matrix
- collagen integrity is largely maintained
- potential to normalize

changes only to cellular matrix - collagen still good (important bc there is potential for reversability)

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13
Q

disrepair tendinopathy?
cellular matrix and collagen?

A
  • chronically overloaded tendon
  • changes in the cellular AND collagen matrix
  • collagen becomes disorganized
  • some reversibility possible

changes to both cellular matrix and collagen - same as degenerative tendinopathy

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14
Q

degenerative tendinopathy?
cellular matrix and collagen?

A
  • chronically overloaded tendon
  • changes in the cellular AND collagen matrix
  • progressive
    disorganization, breakdown, and less collagen
  • little if any capcaity for reversibility
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15
Q

what will be occuring at the cellular level in a tendinopathy?

A
  • rounded fibroblasts unevely distributed throughout the tissue
  • increased ground substance
  • capillary ingrowth
  • disorganzied type I and III collagen fibrils
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16
Q

a healthy tendon remains even in the ________ or __________ tendon

A

“disrepair” or “ degenerative”

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17
Q

tendinopathy management considerations in brief

A
  • DOES NOT improve with absolute rest (relative rest is better)
  • modifying load is imporatnt to reduce tendon pain
  • exercise is the most evidence based treatment
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18
Q

because tendon pain is directly liked to ________ _______, the body learns how to avoid load to the tendon

A

tendon loading

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19
Q

since the body is good at compenstating and avoiding loading the tendon - tendinopahties are very often accompained by?

A
  • muscle dysfunction (reduced muscle capacity, atrophy)
  • kinetic chain dysfunction
20
Q

why is therapeutic exericse good for tendinopathies?

A
  • modulate pain
  • restore structural integrity in the unhealthy tendon
    no go for degenerative, have low expectations for disrepair
  • improve tendon load capacity in the halthy tendon
  • optimize tendon function for performance
21
Q

how does therapeutic exercise improve tendon load capacity?

think train the strain

A

train the strain
- in teh presence of appropriately dosed stress (load) the tissue will respond strain
- tenocytes respond to that strain
- tissue adaptation follows:
- increased collagen synthesis
- normalized collagen morphology (type, organization)

22
Q

how does therapeutic exercise improve tendon function for performance?

A

bring the spring (plyos) - work on tendon load capacity before the performance.

train the strain then bring the spring

23
Q

the brain with exercise and tendinopathies:
cortical inhibition reduces - motor excitability increases

A

in the presence of tendon pain, cortical inhibitoin increases and thereby reduces and or delays motor output to the dysfunctional tendon

24
Q

ther ex for tendinopathy:
frequently and should include resistance training - what types?

A

resistance training
- isometric
- dynamic muscle contraction (eccentric)
- heavy slow resistance

at presesnt no single protocol appears to have demostracted superiority

25
Q

what is occuring when we start working on therapuetic exercise?

A
  • the tendon becomes stiffer and store energy better
  • the muscle gets stronger
  • kinetic chain dysfunction resolves
  • the brain increases in motor excitability (its okay to move)
26
Q

what is isometrics? how is it beneficial for tendinopathy?

A

static muscle activation
- may be beneficial for temporary pain relief (great “buy” in strategy)
- can help maintain muscle mass during relative rest
- can help to reestsabilsh and or promote neuromuscular control

27
Q

according to the research (rio. et al, and clifford et al.) isometrics were found to be?

A

beneficial as part of a progressive loading program

  • isometric were found to decrease pain immediately short term
28
Q

what was the isometric protocol performed by rio et. al?

A

5 X 45 seconds @ 70% MVIC

if this perameter doesn’t work play with both time and intensity

29
Q

what is the why behind isometrics?

A

modulate pain “ tame the pain”
- mitigate muscle atrophy/maintain muscle mass during relative rest
- reestablish and/or promote neuromuscular control

30
Q

dynamic muscle contraction (not so accurately) aka isotonic

A

technicially not synonymous but they are still used interchangabely…but why? what is similar ? what is different?

31
Q

eccentrics

A
  • dynamic muscle activation with lengthening
  • greater external loads can be attenuated w/ eccentric vs concentric exercise
32
Q

eccentric:
adaptation is proprtional to workload and

A

strain
- higher workloads are comparately more effective than lower workloads
- this may likley be a rationale for utilizing eccentric vs concentric

33
Q

what is the protocol for alfredson et al. stufy for eccentric loading for chronic ankle tendinopathy?

A

two eccentric heel raises:
knee straight, knee bent
3x15 eac, 2x/day, 7 days wek x 12 wks

34
Q

eccentrics by to the “why”

A
  • greater external loads result in tissue deformation and thereby adaptation
  • increase tendon load capacity - “train the strain”
35
Q

heavy slow resistance training

A

repeated slow contractions through concentric, isometric and eccentric phases against a heavy load
- HSR has become more widely accepted due t oits ability to
moderate rate of loading AND provide sufficient load

traditional emphasis on eccentric loading may not be necessary

36
Q

several parameters must be considered with targeted exercise Rx to address tendinopahty

A
  • intensity
  • relative submaximal lifting capacity
  • rate of loading
  • time under tension
37
Q

HSR considerations: intensity i.e. the “heavy”

what is intensity? what does the lit say for protocol?

A

the amount of exgernal resistance omprosed onteh contracting muscle during each repetition of an exercise
> 70% of 1 RM is a “good starting bet” to achieve necessary tendon strain and thereby adaptation

38
Q

HSR considerations - relative submaximal lifting capacity
what is the rep range?

A

> 12 reps can be completed with a given load it is highly likely that this laod will be less than 70% of 1 RM intensity

39
Q

HSR considerations - rate of loading the “slow”

waht is rate of loading?

A

the time interval from onset of movement to peack force - how quickly the force is generated

time under tension!!

40
Q

HSR considerations - TUT the “slow”
is determined by?

A

total reps
- the speed of each rep aka tempo
- a slower tempo has been found to
reduce RSLC
reduce intensity

41
Q

HSR needs to be both _____ and ______ to achieve strain and tehreby adaptation

A

heavy and slow

  • heavy >70% 1RM
  • slow, but not too slow
42
Q

what is the flow chart framework to rehab tendinopathy has outlined by de Vos RJ et al. 2021

A

tame the pain
train the strain
bring the spring

pain 24 hrs later you may want to scale back

43
Q

what is the framework outline by malliaras et all. 2015 for patellar tendinopathy?

44
Q

what is pt edu look like for tendinopathy

A
  1. explanation of condition
  2. explanation about the prognosis
    - takes a while but if diligent really good outcomes
  3. pain education
45
Q

treatment- what is loading advice for tendinopathy?

A
  1. temp stop to pain provoking activities
  2. repalce w/ nonpainful activities
  3. gradually increase activity load
  4. monitor using pain scale
  5. maintain consistent laod for the long run