Week 7 Tendinopathy Flashcards
types of tendons
-
energy storage tendon
- high injury risk
- relatively compliant -
positional tendon
- low injury risk
- relatively stiff
how do you adapt a tendon?
exam question:
principle of stiffness –> good thing for sprinters
>70% maximal voluntary contraction/ 1 repetitions maximum-
any contraction type(eccentric, concentric, isometric) slow
size generally does not change so stiffness and modulus increase
continuum model of tendinopathy
normal tendon –> optimised load –> adaptation –> strengthen –> normal tendon…
a cycle
change in stretch shorten cycle load
拉伸縮短循環負荷的變化
good question adding it to interview
- starting hills or speed sessions
- streting to train for marathon or event
- changing surface
- transition to flat shoes or spikes
- starting preseason after break
- buying a sports watch or fitbit
development or persistence of tendinopathy symptoms
肌腱病症狀的發展或持續
biopsychosocial factors
bio:
- age
- obesity
- strength
- horomones
- genetics
- elevated cholesterol
- family or past history
psycho:
- emotions
- pain catastrophising
- past failed treatments
- mixed messages
social:
- life trauma
- work or home stress
- sleep
- activity level
diagnosis of tendinopathy
- pain location
- pain during activity (SSC)
- tests that provoke pain 引起疼痛
- palpation to assess pain
what about imaging for diagnosis
Not necessary
mainly ultrasound & MRI
what is acceptable pain? (numeric pain rating scale)
safe zone – 0-2 (mild)
acceptable – 2-5 (moderate)
high risk zone – 5-10 (severe)
if it is more than mild, we are going to avoid or modify that activity until the pain is better with some of the other things that we do
assess load tolerance 評估負載耐受性 (2 steps)
exam questions
step 1:
- how much pain with daily activities?
- at the start or end or both?
- does it stop them?
- how long (hours, days) does it last for after?
step 2
- how much pain with a graded loading progression?
- stop when you reproduce moderate-severe pain
load management gradient adjuncts 輔助物
useful for initial pain reduction
- NSAID - reduce inflammation
- massage - modify 減輕 pain in the short term
- dry needling - modify pain in the ST
- tape, heel wedges, orthotics - modify loads and pain
- shockwave therapy - modify pain the ST, potential for tendon healing
- injections (eg: PRP, steroid) - reduce inflammation/ aid 幫助 tendon healing
4 stages of rehabilitation tendinopathy
- isometric loading (muscle length does not change)
- isotonic loading
- energy-storage loading
- return to sport
stage 1: isometric – indications
- develop load tolerance
- start here if not load tolerant to other loads 如果不能承受其他負載，請從這裡開始
stage 1: isometric – implementation 執行
- 45-60 seconds hold
- 5 repetitions
- can do a few times per day if they can short term pain response
stage 1: isometric – considerations 考慮因素
- most likely in mid range out of compression
- seated calf raise is a good option for people who are too painful to sustain their bodyweight load through the calf
- seated calf raise also targets soleus
- avoid bouncing - needs to be static 靜態
stage 2: isotonic – indications
- develop load tolerance
- develop hypertrophy 肌肉增長 and strength
- progress to/start here when load tolerant to these loads
stage 2: isotonic – implementation 執行
4 sets x 6-8 repetition maximum (RM 最大重複次數) (maximal strength)
4x8-12 (hypertrophy)
4x15-20 (endurance)
Slow Metronome Every second day Unilateral 慢速節拍器 每隔一天 單邊
stage 2: isotonic – considerations 考慮因素
- Care with compressive end range positions
- Hamstring→limit to 90 degrees hip flexion
- Patellar → limit to ** 90 degrees knee flexion**
- Gluteal → care with end range adduction
- Achilles → care with end range dorsiflexion
- Ensure slow and good technique
- Consider using a metronome 速節拍器
what is the ideal zone in OMNI scale?
6-8/10
when patient rate below 6 (eg: four sets of 6), so increase the load session next week
stage 3: stretch shorten cycle – indications
- develop load tolerance to SSC
- develop confidence and power
- pain criterion 標準: mild pain and pain should be minimal during execution
- strength criterion 標準: start when strength impairments minimal
stage 3: stretch shorten cycle – implementation
every 2-3 days
maintain stage 2
stage 3: stretch shorten cycle – considerations 考慮因素
- change 1 thing at a time
- increase volume gradually, then consider intensity
- eg: running, walking, submaximal hopping program
stage 4: sport specific – indications
- progressive and maximal SSC to replicate sport specific loads requirements
- Key to establish workload i.e. the intensity and the volume required for that sport 確定運動量的關鍵，即該運動所需的強度和運動量
- pain criterion: Start when load tolerant and progressed through stage 3 SSC exercises
- strength criterion: Start when strength with stage 2 is recovered
stage 4: sport specific – implementation
every 2-3 days
maintain stage 2
stage 4: sport specific – considerations 考慮因素
- change 1 thing at a time
- high speed running program (eg: soccer, hockey)
- jumping progression (eg: volleyball, basketball)
load tests of achilles, patellar, proximal hamstring, gluteal, lateral elbow
achilles - submaximal hop/ calf raise
patellar - single leg decline squat
proximal hamstring - long lever bridge
gluteal - step up
lateral elbow - grip strength at pain onset and maximal
recommended initial care for every patient:
- exercise
- education and advice
- activity modification
activity modification (load management) principles (walking, running/sport, upper limb function)
- Walking
Step 1: Reduce by 50% via step count data (eg: 20000 steps –> 10000 steps)
Step 2: Reduce by 100% with crutches or boot if severely intolerant - Running or sport
Step 1: Reduce or remove intensity eg: speed sessions or hills
Step 1 to 2: Also reduce volume by 50-100% depending in how load intolerant - Upper limb function
Step 1: Reduce by 50% of volume e.g. lifting or housework
Step 2: Reduce by 100% (Severely intolerant)
tendinopathy education to patients
exam question: list at least three key principles of education for tendinopathy
what is it? (reassure)
- pathology stable
- pathology may not completely heal
- pain does not mean damage
what can i do? (empower)
- load management
- acceptable pain –> mild pain is acceptable
- how to monitor pain –> stop exercise when pain is greater than moderate
how long? (set expectations)
- pain will fluctuate
- will take months
things must know about tendinopathy
-
rest does not improve tendinopathy
–> pain may settle, but will be back when returning to activity, as rest does not increase the tolerance of the tendon to load exercise is the top treatment for tendinopathy-
modifying load is very important
–> tendons need to be loaded progressively, so they can develop greater tolerance to the loads that an inidividual needs to endure in their day-to-day life -
tendinopathy rarely improves long term with only passive treatments
–> such as massage, shock wave therapy, injections etc -
pathology on imaging does not equal pain
–> ‘severe pathology’ or ‘tears’ does not necessarily mean will not get better or have a poorer outcome
