Week 7 Tendinopathy

Question 1

diagnosis of tendinopathy

Answer 1

1. localised pain (not always for shoulder, elbow, hamstring, gluteal)
2. onset following change in activity (usually) 活動變化後發作
3. start up pain (eg: morning stiffness)
4. pain for hours or days when provoked (usually by SSC activity) 受到刺激時疼痛持續數小時或數天
5. proportional load-pain relationship

Question 2

what about imaging for diagnosis

Answer 2

Not necessary

Question 3

what is acceptable pain? (numeric pain rating scale)

Answer 3

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

Question 4

assess load tolerance 評估負載耐受性 (2 steps)

Answer 4

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

Question 5

load management gradient adjuncts 輔助物

Answer 5

1. NSAID - reduce inflammation
2. massage - modify 減輕 pain in the short term
3. dry needling - modify pain in the ST
4. tape, heel wedges, orthotics - modify loads and pain
5. shockwave therapy - modify pain the ST, potential for tendon healing
6. injections (eg: PRP, steroid) - reduce inflammation/ aid 幫助 tendon healing

Question 6

4 steps of loading programs

Answer 6

1. progressive (eg: intensity)
2. regular progression
3. monitor load tolerance
4. 12 weeks or longer

Question 7

4 stages of rehabilitation tendinopathy

Answer 7

1. isometric loading (muscle length does not change)
2. isotonic loading
3. energy-storage loading
4. return to sport

Question 8

stage 1: isometric – indications

Answer 8

• 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

Question 9

stage 1: isometric – implementation 執行

Answer 9

• 45-60 seconds hold
• 5 repetitions
• can do a few times per day if they can short term pain response

Question 10

stage 1: isometric – considerations 考慮因素

Answer 10

• 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

Question 11

stage 2: isotonic – indications

Answer 11

• develop load tolerance
• develop hypertrophy 肌肉增長 and strength
• progress to/start here when load tolerant to these loads

Question 12

stage 2: isotonic – implementation 執行

Answer 12

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

Question 13

stage 2: isotonic – considerations 考慮因素

Answer 13

• 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

Question 14

what is the ideal zone in OMNI scale?

Answer 14

6-8/10

when patient rate below 6 (eg: four sets of 6), so increase the load session next week

Question 15

stage 3: stretch shorten cycle – indications

Answer 15

• 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

Question 16

stage 3: stretch shorten cycle – implementation

Answer 16

every 2-3 days
maintain stage 2

Question 17

stage 3: stretch shorten cycle – considerations 考慮因素

Answer 17

• change 1 thing at a time
• increase volume gradually, then consider intensity
• eg: running, walking, submaximal hopping program

Question 18

stage 4: sport specific – indications

Answer 18

• 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

Question 19

stage 4: sport specific – implementation

Answer 19

every 2-3 days
maintain stage 2

Question 20

stage 4: sport specific – considerations 考慮因素

Answer 20

• change 1 thing at a time
• high speed running program (eg: soccer, hockey)
• jumping progression (eg: volleyball, basketball)

Question 21

load tests of achilles, patellar, proximal hamstring, gluteal, lateral elbow

Answer 21

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

Question 22

recommended initial care for every patient:

Answer 22

1. exercise
2. education and advice
3. activity modification

Question 23

activity modification (load management) principles (walking, running/sport, upper limb function)

Answer 23

1. 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
2. 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
3. Upper limb function
   Step 1: Reduce by 50% of volume e.g. lifting or housework
   Step 2: Reduce by 100% (Severely intolerant)

Question 24

tendinopathy education to patients

Answer 24

what is it?
- pathology stable, may not completely heal, pain does not mean damage

what can i do?
- load management, acceptable pain, how to monitor pain

how long?
- pain will fluctuate, will take months