WEEK 10 - TENDINOPATHY Flashcards
(16 cards)
Biochemically driven vs biomechanically driven?
Biochemically driven
- Tendon pain = consequence of pro – inflammatory, tendon sensitising lifestyle factors
- Overweight, sedentary, potentially diabetic population
- Small increases in load lead to large pain response
- Due to systemic drivers often multi-site.
Biomechanically driven
- Often more athletic middle aged population
- Usually linked to training load error - underload or overload (or both sequentially)
- Often other underlying biomechanical factor
- More likely to be single site
Factors that affect tendinopathy risk?
loss of tendon stiffness due to
- body composition
- obesity (adipokines and hormones)
- mechanical loading demand that exceeds capacity (fatigue-related damage)
- genetics
- gender
- perimenopausal
- alcohol intake
- age - increased cell senesence
differential diagnoses - achilles region
- mid portion achilles tendinopathy
- insertional achilles tendinopathy
- plantaris tendinopathy
- achilles peritendinopathy
- tibialis posterior/FHL tendinopathy
- superficial bursa
- sural nerve
differential diagnoses - patella tendinopathy
- patella-femoral pain syndrome
- osgood schlatters syndrome
- quadricep tendinopathy
- infra-patella fat pad syndrome
- PFJ instability
differential diagnosis - priximal hamstring tendinoapthy
- pubic bone stress injury
- femoral neck bone stress injury
- sciatic nerve irritation
- SIJ disorder
- hip joint
- lumbar spine referral
- deep gluteal syndrome
differential diagnoses - gluteal tendinopathy
- trochanteric bursitis
- hip joint
- femoral bone stress stress injury
- lumbar spine referral
Key physical examination for diagnosis of tendinopathy
-
Palpation:
- Careful palpation along the length and insertion of the suspected sensitized tendon
-
Load tolerance:
- Contract it – localized specific contraction of muscle tendon unit – local pain response expected.
- If irritability is low it may require higher intensity - eg jumping/hopping
- +/- Stretch it – targeted lengthening of the muscle tendon unit to increase tensile and compressive load.
Achilles exercises - increasing load
- slow DL heel raise
- slow SL heel raise
- continuous DL jumps
- continuous SL leg hops
- forward hops
Patellar tendinopathy exercises - increasing load
- DL squats (decline board)
- SL squats (decline board)
- DL jumps
- SL jumps
- stop jump
Hamstring tendinopathy - increased load
- DL slow bending forward (RDL)
- SL slow bending forward (RDL)
- DL fast bend forward
- SL leg fast bend forward
- fast single leg changes of direction with hip flexion
adductor tendinopathy - increased load
- adductor squeeze with bent knees
- standing adduction against resistance
- copenhagen - adductor exercise
- change of direction
- kicking
Key physical examination to guide care - tendinopathy
- Functional Assessment - looking for adaptive V maladaptive changes.
- Capacity of the local muscle system
- +/-mobility of the local system
- Capacity of the global muscle system
- How the tendon functions as a spring (jump,skip,hop) (May have crossover with functional assessment in some people). Key Considerations:
- Irritability
- Safety
- Functional demands of the person!!
Prescribe a care plan for people diagnosed with common tendinopathies - 4 stages
Diagnostic clarity
- Diff Dx
- Screening for background medical conditions and contributors
Primary Mx
- education and advice
- graded return to aggravating activities
- rehab - address local and kinetic chain
- MD care - exercise physiology or dietetics, psychology
Adjunct therapies
- MT
- SWT
- Orthoses
Recovery
- RTS, STP, RTW
Rehab summary - 7 phases
Phase 1 - pain dominant phase
Aim - reduce pain
Mx strategies:
- educate
- trial isometrics mid-inner range
- modify loading (reduce compressive load and SSC)
- NSAIDs (ibuprofen) if reactive
Phase 2 - load dominant phase
Aim: improve base strength (locally and globally)
Mx strategies
- heavy, slowish tendon loading program (TLP) (avoid compression, especially if insertional)
Phase 3:
aim: build functional strength (locally and globally)
Mx strategies
- progress loading to include functional/compound exercises
- TLP through ROM
Phase 4:
aim: increase power
Mx strategies
- TLP = reduce reps but increase speed
Phase 5
Aim - develop SSC abilities
Mx strategies
- introduce graduated plyometrics (+/- graded return to running)
Phase 6
Aim - sport-specific training
Mx strategies
- add sports-specific drills
Phase 7 - RTS phase
Aim - maintain optimal tendon health
Mx strategies
- maintain base strength and power (and slowly progress)
- maintain SSC training
- monitor training errors and recovery
Heavy-loading programs - High-load eccentric vs high slow resistance
High load eccentric
- 7 days per week
- 3 x 15 slow repetitions of eccentric unilateral loading
- 3 min rest per set
High slow resistance
- 3/4 sessions pw for 12/52
- 12-15RM reducing to 6-8RM at 6-12 weeks
- 3-4/sets/exercise/session
- 2-3 min rest w 5 min rest between exercises
Pain monitoring model (4)
- the pain is allowed to reach 5 the NPRS during the activity
- the pain after completion of the acitvity is allowed to reach 5
- the pain the monitoring after the activity should not exceed a 5
- pain and stiffness is not allowed to increase from week to week
Ideally keep within 3-4/10.
