Tendinopathies

Question 1

What is a tendinopathy

Answer 1

it is a failed healing response of the tendon, associated with overuse in and around tendons

Question 2

Definitions: tendinopathy, tendonitis, tendinosis

Answer 2

1. General term that describes tendon degeneration
2. refers to a painful tendon with histological signs of inflammation within the tenon
3. is a localised intrinsic degeneration of unknown aetiology, usually characterised by localised swollen tendon nodes

Question 3

Load types of tendinopathy: Compressive

Answer 3

A tendon can be squashed against a bone (e.g. proximal hamstring tendon against ischial tuberosity)

Question 4

Load types of tendinopathy: shear and friction

Answer 4

movement of the tendon sheath on the tendon can cause sheath irritation, e.g. AT sheath moves with repeated DF/PF

Question 5

Load types of tendinopathy: tensile

Answer 5

store and release energy like a a spring for power

Question 6

Load types of tendinopathy: combination

Answer 6

A combination of compressive, tensile and shear/friction.
e.g. hockey platers running in hip flex have a combination of loads on their proximal hams tendon

Question 7

first stage of tendinopathy continuum: Reactive tendinopathy

Answer 7

Non-inflammatory proliferative response in cell matrix. Due to compressive or tensile overload.
Cell changes shape-> more cytoplasmic organelles=increase protein function,
collagen integrity maintained, short-term adaptations- thickens the tendon to reduce stress and increase stiffness, the potential to revert back to normal tendon

Question 8

second stage of tendinopathy continuum- Tendon disrepair

Answer 8

Chronic overload of RT.
Increased protein production- separation of collagen and disorganisation within cell matrix
great breakdown physiologically
Visible on MRI & US
May be increase vascularity and neural ingrowth in tendon
Reversibility possible with correct load and management

Question 9

third stage of tendinopathy continuum- Degenerative tendinopathy

Answer 9

Areas of cell death due to apoptosis, trauma, tenocyte exhaustion
Large areas of matrix-disordered and vessels, matrix breakdown and little collagen
little capacity for reversibility
focal swelling and pain
high risk of rupture
clinically this is present in older individuals with ongoing problems with tendinopathy or younger individuals who have continued to overload

Question 10

fourth stage of tendinopathy continuum- reactive on degnerative

Answer 10

hybrid of reactive and degenerative pathology
Structually (normal) part of the tend may drift in and out reactive phase
degenerative portion: unable to transmit tensile load
manage as a reactive tendon

Question 11

what does the tendinopathy continuum mean clinically

Answer 11

Interventions should be tailored to the stage of pathology
exercise and load management fundamental to management
if correct stage not identified= symptoms may get worse

Question 12

clinical presentations of tendinopathies: reactive

Answer 12

rapid onset, load substantially exceed previous exposure, easily aggravated by exercise and slow to settle
Painful and less common

Question 13

clinical presentations of tendinopathies: reactive on degenerative

Answer 13

old adult (50-60)
past history of load related excaerbation
onset after overload
variable swelling
less irritable
painful and common

Question 14

clinical presentations of tendinopathies: degenerative

Answer 14

older (30-60)
long history of minimal symptoms
variable swelling and lumps/bumps
unloading strategies
Not painful

Question 15

concepts to consider with tendinoapathies

Answer 15

tendon don’t like compression or too much stretch-shortening cycles
tendons are highly responsive to mechanical loading
chronic, habitual tendon loading needed for adaptations
Effective training program should apply high loading intensity over long duration (>12/52)

Question 16

Treatment: education

Answer 16

pain doesnt= harm
restore the balance between load and tissue capacity
important for compliance
kinesiophobia
manage expectations
slow to settle but quick to aggravate

Question 17

Patient advise- RC tendinoapthy

Answer 17

avoid excessive, unaccustomed activity above shoulder height, take regular breaks from repetitive shoulder movement, pillow under arm and behind patient to prevent them rolling on that side at night

Question 18

Patient advise- Tennis elbow

Answer 18

when gripping/lifting try and keep palm facing upwards
modify movement/activities that bring on pain

Question 19

Patient advise- hamstring

Answer 19

avoid excessive hip flexion
avoid repeated stretching of hamstring

Question 20

Patient advise- gluteal

Answer 20

avoid sitting with legs crossed, avoid standing with weight on one leg, avoid laying on it at night
sleep position advise- duvet folded over under patient, pillow between leg

Question 21

Patient advise- patella

Answer 21

avoid excessive running or jumping movements intially, initially reduce load on the knee in flexed position (squat)

Question 22

Patient advise- achilles

Answer 22

In insertional: avoid excessive DF to prevent compressive load
Avoid plyometric movements to reduce SSC/Tensile load, but continue running at a tolerable level
Put more weight through heel so not using PF
Orthotics- limited benefit however AFO can be useful in longitudinal tears in early phases of rehab

Question 23

pain management

Answer 23

Reduced motor responses, more severe in reactive phase, manage the load on the tendon- avoid compressive load i.e. stretching, cut out activities involving SSC
anti-inflammatory to regulate tenocyte activity
isometric exercise

Question 24

treatment: isometrics

Answer 24

5X45 sec hold with 1 min rest
significant reduction in acute pain 45 mins as compared with isotonic
well tolerated- can be tailored to patients preferred ROM
Useful for reactive tendons

Question 25

treatment:Alfredson protocol

Answer 25

3X15 reps, unilateral, 3 sec contraction
2 min rest between sets
5 min rest between exercises
2 exercises: heel drops of step with straight and bent knee
twice daily
12 weeks
limitations: lots of reps, very time consuming, often poor compliance

Question 26

treatment: Heavy slow resistence

Answer 26

• 3 x a week
• 3 second concentric and eccentric (6s total)
  contraction
• 2-3 min rest between sets
• RPE of 8 on last 2 reps
  Protocol:
• Week 1: 3 x 15 RM
• Week 2-3: 3 x 12 RM
• Week 4-5: 4 x 10 RM
• Week 6-8: 4 x 8 RM
• Week 9-12: 4 x 6 RM
  3 exercises:
• Resisted seated heel raise
• Straight leg heel raise
• Straight leg heel raise in standing with barbell and
  forefoot on weight

Question 27

Treatment: monitoring load and progression

Answer 27

symptoms led number of reps, >12 reps= add external load, education RE normal pain, pain monitoring model by Silbernagel

Question 28

Sedentary people

Answer 28

 Heavy external loads may be less appropriate
 Greater structural changes – correlated to
functional ability
 Tend to respond faster
 If progressing to HRT – rest days should be
incorporated