Therapeutic exercise approach for tendinopathy Flashcards
week 3
what are tendons and what do they do?
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)
What properties comprise healthy tendons?
- 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
when is strain a bad thing?
during activities requiring efficient force transmission i.e. jumping (want tendon stiff)
what is tendon stiffness?
isn’t: hypomobility your reduced ROM
IS: resistance to deformation strain under load
how we minimize energy loss is stiff tendons
what is tendon elasticity?
the ability of your spring to recoil ( and a stiff tendon recoils faster)
when is strain a “good” thing?
What is tendinopathy?
a general term that refers to tendon (microtraumatic) injury affected by mecnanimcal loading
- pain and dysfunction in the tendon
tendinopathy is most reported in what areas?
- achillies
- patellar
- lateral elbow
- rotator cuff
- hip
can affect any muscle-tendon unit in the body but most commonly seen in these places
pathophysiology of tendinopathy
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
tendinopathy is now widely considered to be degenerative and NOT ?
a classic inflammatory response
- why we say tendinopathy now vs. tendinitis
tendinopathy can be classified across a continuum consisting of what 3 stages
- reactive tendinopathy
- tendon disrepair
- degenerative tendinopathy
How does reactive tendinopathy occur?
what is going on at the cellular matrix and collagen level?
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)
disrepair tendinopathy?
cellular matrix and collagen?
- 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
degenerative tendinopathy?
cellular matrix and collagen?
- chronically overloaded tendon
- changes in the cellular AND collagen matrix
- progressive
disorganization, breakdown, and less collagen - little if any capcaity for reversibility
what will be occuring at the cellular level in a tendinopathy?
- rounded fibroblasts unevely distributed throughout the tissue
- increased ground substance
- capillary ingrowth
- disorganzied type I and III collagen fibrils
a healthy tendon remains even in the ________ or __________ tendon
“disrepair” or “ degenerative”
tendinopathy management considerations in brief
- 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
because tendon pain is directly liked to ________ _______, the body learns how to avoid load to the tendon
tendon loading
since the body is good at compenstating and avoiding loading the tendon - tendinopahties are very often accompained by?
- muscle dysfunction (reduced muscle capacity, atrophy)
- kinetic chain dysfunction
why is therapeutic exericse good for tendinopathies?
- 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
how does therapeutic exercise improve tendon load capacity?
think train the strain
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)
how does therapeutic exercise improve tendon function for performance?
bring the spring (plyos) - work on tendon load capacity before the performance.
train the strain then bring the spring
the brain with exercise and tendinopathies:
cortical inhibition reduces - motor excitability increases
in the presence of tendon pain, cortical inhibitoin increases and thereby reduces and or delays motor output to the dysfunctional tendon
ther ex for tendinopathy:
frequently and should include resistance training - what types?
resistance training
- isometric
- dynamic muscle contraction (eccentric)
- heavy slow resistance
at presesnt no single protocol appears to have demostracted superiority
what is occuring when we start working on therapuetic exercise?
- 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)
what is isometrics? how is it beneficial for tendinopathy?
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
according to the research (rio. et al, and clifford et al.) isometrics were found to be?
beneficial as part of a progressive loading program
- isometric were found to decrease pain immediately short term
what was the isometric protocol performed by rio et. al?
5 X 45 seconds @ 70% MVIC
if this perameter doesn’t work play with both time and intensity
what is the why behind isometrics?
modulate pain “ tame the pain”
- mitigate muscle atrophy/maintain muscle mass during relative rest
- reestablish and/or promote neuromuscular control
dynamic muscle contraction (not so accurately) aka isotonic
technicially not synonymous but they are still used interchangabely…but why? what is similar ? what is different?
eccentrics
- dynamic muscle activation with lengthening
- greater external loads can be attenuated w/ eccentric vs concentric exercise
eccentric:
adaptation is proprtional to workload and
strain
- higher workloads are comparately more effective than lower workloads
- this may likley be a rationale for utilizing eccentric vs concentric
what is the protocol for alfredson et al. stufy for eccentric loading for chronic ankle tendinopathy?
two eccentric heel raises:
knee straight, knee bent
3x15 eac, 2x/day, 7 days wek x 12 wks
eccentrics by to the “why”
- greater external loads result in tissue deformation and thereby adaptation
- increase tendon load capacity - “train the strain”
heavy slow resistance training
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
several parameters must be considered with targeted exercise Rx to address tendinopahty
- intensity
- relative submaximal lifting capacity
- rate of loading
- time under tension
HSR considerations: intensity i.e. the “heavy”
what is intensity? what does the lit say for protocol?
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
HSR considerations - relative submaximal lifting capacity
what is the rep range?
> 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
HSR considerations - rate of loading the “slow”
waht is rate of loading?
the time interval from onset of movement to peack force - how quickly the force is generated
time under tension!!
HSR considerations - TUT the “slow”
is determined by?
total reps
- the speed of each rep aka tempo
- a slower tempo has been found to
reduce RSLC
reduce intensity
HSR needs to be both _____ and ______ to achieve strain and tehreby adaptation
heavy and slow
- heavy >70% 1RM
- slow, but not too slow
what is the flow chart framework to rehab tendinopathy has outlined by de Vos RJ et al. 2021
tame the pain
train the strain
bring the spring
pain 24 hrs later you may want to scale back
what is the framework outline by malliaras et all. 2015 for patellar tendinopathy?
what is pt edu look like for tendinopathy
- explanation of condition
- explanation about the prognosis
- takes a while but if diligent really good outcomes - pain education
treatment- what is loading advice for tendinopathy?
- temp stop to pain provoking activities
- repalce w/ nonpainful activities
- gradually increase activity load
- monitor using pain scale
- maintain consistent laod for the long run
