Contractile Tissues (tendinopathy)

Question 1

What is tendinopathy?

Answer 1

Pain and dysfunction associated with any tendon
-opathy = disease or disorder

Question 2

What are the common lower limb areas affected by tendinopathy?
What is the most common?

Answer 2

Glutes
Patella
Achilles
Tibalis post.
Hamstrings
Peroneals
Plantar fasciopathy - fascia rather than tendon

Most common - glutes

Question 3

Common upper limb areas affected by tendinopathy:
Most common =

Answer 3

Rotator cuff
Long head biceps
Lateral epicondyalgia
Medial epicondyalgia
De quervains - APL and EPB tendons

Most common - rotator cuff

Question 5

Pathophysiology of tendinopathy
Types of load that may cause it:

Answer 5

Generally is triggered by overload of a tendon, but changes can also occur with underload
Tensil load - longitudinal direction eg stretching/ contracting muscle that tendon attaches to
Compressive load - force perpendicular to the collagen fibres, often at insertion point of the tendon

Question 6

Does tendinopathy have both degenerative and inflammatory components?

Answer 6

Yes

Question 7

How does the tendon cell population alter when tendinopathy occurs?

Answer 7

Increased number of tenocytes
Increased tenocyte metabolism
Increased immature tenocytes (therefore they don’t produce collagen)
Increased rate of apoptosis - cell death
Immune reactive cells

Question 8

Tendinopathy pathophysiology
Collagen:

Answer 8

Collagen becomes disorganised due to the fact that immature tenocytes cannot produce it
Reduced number of type 1 fibres - continuous healthy tendon fibres
Increased type 3 fibres
Higher concentration of immature collagen bundles

Question 9

Tendinopathy pathophysiology
Ground substance changes -

Answer 9

Increased proteoglycans which leads to increased water content - this causes an increased cross section of the tendon, breaks down cross fibres between collagen therefore making the tendon weaker
Chemical alterations - increased substance P, glutamate and lactate

Question 10

Tendinopathy pathophysiology
Neovascularization -

Answer 10

Influx of blood vessels and nerves in growing into the tendon therefore making it more sensitive

Question 11

Cook and Purdum model, 3 stages tendinopathy:
1) reactive tendinopathy -

Answer 11

First stage, non-inflammatory proliferative response in cell matrix
Result of compressive or tensile overload
Collagen integrity maintained
Tendon will thicken to reduce stress and increase stiffness
Tendon can revert back to normal

Question 12

Cook and purdum model, tendinopathy stages:
2) tendon dysrepair -

Answer 12

Continuation of increased protein production which results in separation of collagen and disorganisation within cell matrix
Now visible on MRI
Difficult to diagnose, emphasis on thorough history taking
Developed by frequently overloading the tendon in phase 1

Question 13

Cook and purdum model, tendinopathy stages:
3) degenerative tendinopathy -

Answer 13

Poor prognosis for the tendon and changes are now irreversible
Areas of cell death, trauma and tenocyte exhaustion
Tendon thickened and present with modular sections on palpation
Present in older individuals with on going issues or younger individuals who has continued to overload

Question 14

Why is it also not effective to just rest the tendon?/be sedentary?

Answer 14

If there is significant underload, the normal movement of functional activities will become too much for the tendon
This now means that what should be ‘normal’ activity is now overloading the tendon
Therefore it is important to get a balance between overload and underload

Question 15

What influences tendon repair ?
(Risk factors)

Answer 15

Tendon structure
Age - more common athlete 40+ and sedentary 60+
Previous injury
Increased BMI - increased adipose tissue results in increased inflammation therefore influencing tendons ability to heal
As well as lower limb tendons having to take more load
Diabetes - affects recover time
Medications - steroids and stations
Genetic factors

Question 16

What will the impact be if an athlete is constantly not recovering after exercise on there net sysnthesis ?

Answer 16

Exercise produces both protein sysnthesis and protein degradation
The net sysnthesis within the first 24hours is more in protein degradation
If proper recovery is not prioritised net degradation will build up over time
This will results in net loss of collagen and can lead to an overuse injury

Question 17

Clinical signs and symptoms of tendinopathy

Answer 17

Pain
Weakness
Decreased function
Swelling

Question 18

Physiotherapy management of tendinopathy

Answer 18

Education
Exercise
Load modification/ management
- eccentric loading
- isometric loading
Stretches
Shockwave
Manual therapy

Question 19

What has isometric loading been shown to do to aid tendinopathy symptoms?

Answer 19

Been shown to have an anagesic effect (reduces pain)

Question 20

Information about gluteal tendinopathy -

Answer 20

Most prevalent lower limb tendinopathy
Occurs mostly in mid-life
Females > males - this is because females have a bigger Q angle, and normally sit in increased adduction naturally
23.5% females and 8.5% males between ages 59-70
Combination of excessive compression and high load

Question 21

Gluteal tendinopathy, the involvement of glute medius and minimus -

Answer 21

Med and min tendons are involved
This means opposite side of pelvis may drop, this therefore leads to increased hip adduction of the weak side
As a result gluteal tendons are compressed on the greater trochanter by the ITB band

Question 22

Gluteal tendinopathy
Clinical signs and symptoms -

Answer 22

Lateral hip pain / tenderness around greater trochanter
Pain on walking / standing on one leg / getting up from sitting / side lying

Question 23

Gluteal tendinopathy
Physiotherapy management -
Other management -

Answer 23

Physio - education
Load management
Avoid compressive exercises in early stages is suggested
Other - shockwave therapy, corticosteroid injection, surgical intervention

Question 24

Patella tendinopathy information
Where is it most seen?
What are the risk factors?

Answer 24

High prevalence in jumping sports

Risk factors - weight, BMI, leg length difference, height of food arch, quads flexibility/strength, hamstring flexibility , vertical jump performance

Question 25

Patella tendinopathy What are the theories on how it occurs?

Answer 25

Vascular, mechanical, impingement related and neurological theories Impingement = patella impinges on patella tendon Chronic overload is the most commonly proposed theory Underlying pathology is normally degenerative

Question 26

Patella tendinopathy Clinical signs and symptoms -

Answer 26

Anterior knee pain Decreased function eg stairs up/down, hills and kneeling

Question 27

Patella tendinopathy Physio management - Other management -

Answer 27

Physio - education load management Exercise - eccentric loading is more effective here than concentric in some studies A decline board (slope downwards) has also shown improvements Taping - short term symptom reduction Other - corticosteroids, shockwave and surgical intervention

Question 28

Achilles tendinopathy Most likely effects - What influences it? And where does it affect?

Answer 28

Lifetime incidence in elite runners of 7-9% Also common in other athletes 1/3 of cases are non athletes Biomechanical factors - overpronation of foot, footwear, training surfaces Overload/underload Can be insertional (tendon to bone) or mid potion of the Achilles

Question 29

Achilles tendinopathy Clinical signs and symptoms -

Answer 29

Pain and swelling in and around tendon Pain often at its worst at start and end of training session Tender, nodular swelling usually present in chronic areas (can palpate this)

Question 30

Achilles tendinopathy Physio management - Other management -

Answer 30

Physio - education Load management eg progressive return to sport Exercise Taping - short term symptom reduction Other - surgery (has poor outcomes), shockwave and injections

Question 31

Plantar fasciopathy Commonly effects -

Answer 31

1 in 10 people will suffer in their lifetime Peak between 45-65 90% resolve within 12 months of conservative treatment No difference between men and women Increased risk with increased BMI

Question 32

Plantar fasciopathy Risk factors -

Answer 32

Overpronated foot, reduced gastroc length, serve hallux valgus (big toe deviates from norm angles towards 2nd toe) Both thickening and degernative changes are more common than inflammatory changes

Question 33

Plantar fasciopathy Clinical signs and symptoms -

Answer 33

Pain at proximal insertion of plantar fascia (inf. aspect calcaneous) especially with big toe extension and ankle dorsiflexion Often painful first thing in moring and after activities/at end of day.

Question 34

Plantar fasciopathy Physio management - Other management -

Answer 34

Physio - education Load management Exercise - stretching/strengthening Eg. Calve raises (but to increase load of plantar fascia can place ball of foot on a block for example rather than doing them on the floor) Other - orthotics Steroid injections, shockwave and surgery

Question 35

Rotator cuff related shoulder pain What are the 3 sub categories ? What are some of the causes?

Answer 35

Sub-acromial pain syndrome (impingement) Rotator cuff tendinopathy Rotator cuff tears Causes - tendon compression: extrinsic and intrinsic factors Tendon overuse/underuse

Question 36

Rotator cuff related shoulder pain Clinical signs and symptoms -

Answer 36

Pain and impairment of shoulder movement and function, using during shoulder elevation (flex/abd of GHJ, not SG elevation) And lateral rotation Painful to lie on affected side

Question 37

Rotator cuff related shoulder pain Physio management - Other management -

Answer 37

Physio - education Exercise Symptom modification - trying different things to reduce symptoms, then incorporating into treatment plan Other - steroid injections Surgery - results of this show not much difference between this and physio Therefore patients should always be encouraged to try physio first

Question 38

Lateral epicondylalgia/tennis elbow What and who does it effect?

Answer 38

Most common overuse syndrome in the elbow Tendinopathy involving extensor muscles of the forearm Affects 1-3% of population Male and female equal More common 40/50’s Prognosis - most cases are self limiting Smoking and obesity are risk factors as they effect tendon repair ECRB most commonly effected Supinator, ECRL, ED, EDM and ECU

Question 39

What causes lateral epicondylalgia ?

Answer 39

Excessive or repetitive use can cause it - musicians, computer users, manual works and racquet sports

Question 40

Lateral epicondylalgia Clinical signs and symptoms -

Answer 40

Pain located (+on palpation) around lateral epicondyle of elbow, usually radiating in line with the extensors Variable pain reported - intermittent/continuous and varying severity Aggravated by wrist/finger extension and forearm supination Stretching tendon can reduce symptoms as well as gripping

Question 41

Lateral epicondylalgia Physio management - Other management -

Answer 41

Physio - education Load management Exercise Brace/taping Other - NSAID’s, corticosteroid injection, shockwave, surgery

Question 42

Medial epicondylalgia/golfers elbow What and who does it effect?

Answer 42

Overuse tendinopathy, similar to tennis elbow but affecting common origin of flexors and pronators Less common than tennis elbow Age 40-60 Prevalence 0.3-1.1% female>male Associated with golf, manual workers Involves pronator teres and FCR

Question 43

Medial epicondylalgia Clinical signs and symptoms -

Answer 43

Pain on medial aspect elbow - tender to palpate Aggravated by reissued/repetitive wrist flexion or pronation, valgus stress, stretching Aggravated by throwing/gripping Reduced grip strength Can involve ulnar nerve (20%) as it passes through head of pronator teres

Question 44

Medial epicondylalgia Physio management - Other managent -

Answer 44

Physio - education Load management Exercise Brace/taping Other - NSAIDs, corticosteroid injection, shockwave and surgery

Question 45

De quervains, what is it?

Answer 45

Inflammation of the synovial sheaths of EPB and APL Swelling leads to eventual thickening of the sheaths Adhesions may develop between the tendon and the sheath which restricts normal tendon movement Enclosed tendons may become constricted

Question 46

De quervains Who does it effect and how?

Answer 46

More common in women Often reported in new mothers Age most commonly 40-50’s May occur spontaneously (idiopathic) or can be initiated by overuse of the thumb Overuse may involve eccentric lowering of the wrist into ulnar deviation with load

Question 47

De quervains Clinical signs and symptoms

Answer 47

Pain on radial side of the wrist that can be referred to the thumb Aggravated by resisted thumb extension / abduction or by stretching the affected tendons (finkelstein test) Pain on palpation of affected tendons

Question 48

De quervains Physio management - Other management -

Answer 48

Physio - education Load management - difficult as its hand, esp for new mothers who have to pick up their baby Exercise Splinting (offloading) Other - NSAID’s, corticosteroid injection,shockwave and surgery

Question 49

Aspects of muscle strains/tears -

Answer 49

Involves over contacting or lengthening a muscle causing tearing of collagen Grade I, II or III * make sure to know aspects and differences of each of these from pathophysiology 1 Two joint muscles Eccentric contractions (deceleration phase) Muscles with higher percentage of type II fibres are mor commonly affected

Question 50

Physio management of strains/tears -

Answer 50

(Depends on severity of strain) POLICE/PRICE Mobilisation - asap Strength/loading Proprioception Endurance training Other - surgery