Tendinopathy

Question 1

Describe tendinopathy

Answer 1

• Repetitive overload: structural injury to microscopic collagen fibrils
• Clinical signs: pain at tendon, swelling at tendon, decreased function to tendon

Question 2

Intrinsic risk factors for tendinopathy

Answer 2

• Systemic diseases
• Family history
• Obesity
• Age
• Limited or excessive joint mobility
• Muscle weaknesses
• Deficits in neuromuscular control
• Tendinosis & altered tendon structure

Question 3

Extrinsic risk factors for tendinopathy

Answer 3

• Overuse
• Sudden increase in activity or intensity of activity
• Initiation of new activities
• Lack of adequate recovery
• Highly repetitive movement
• Poor workplace ergonomics
• Medications: Fluoroquinolones and Hormone replacement therapy
• Statins

Question 4

Describe the prostaglandin mediated inflammation of an acute soft tissue injury

Answer 4

• Vasodilation
• Vascular permeability
• Pain receptors become sensitized
• Immune response
• Vascularity good

Question 5

Describe the healing of a tendinopathy

Answer 5

• Heal by “cell to cell’ communication: tendon cells are mechanoresponsive
• Cytokines response to overload or underload: stimulate matrix remodeling (degradatin or synthesis)
• Tenocytes maintain the extracellular matrix & are influenced by tendon load & biochemical stimulus (respond to cytokines)
• Vascularity bad

Question 6

Describe mechanotransduction

Answer 6

• Refers to the process by which the body converts mechanical loading into cellular responses
• Mechanical trigger or catalyst
• Communication throughout a tissue to distribute the loading message
• Response at the cellular level to effect the response

Question 7

Describe mechanotherapy

Answer 7

• Therapeutic exercise is prescribed to promote the repair or remodeling of injured tissue

Question 8

Epidemiology of tendinopathy

Answer 8

• More common than OA
• LE > UE
• Athletes > general population
• 18-65 y/o (women more common than men)
• <18 y/o (boys more common than girls)

Question 9

Typical history for a tendinopathy

Answer 9

• Early: stiffness, gets better with activity, worse at cool down
• Injury history, especially if “deloaded”
• Intrinsic/extrinsic factors, family factors
• Causes: overuse and/or overload

Question 10

Examination and imaging for proper diagnosis for tendinopathy

Answer 10

• Focal pain, not diffuse, possible swelling, but not inflammatory
• Compressive or tensile load reproduces pain, goes away when load is removed
• Imaging: poor correlation between structure & pain, limited role

Question 11

Treatment goals for tendinopathy

Answer 11

• Education (process will take a long time)
• Reduce symptoms and promote tendon healing
• Improve capacity of the tendon & muscle to manage load
• Improve patient function

Question 12

Treatment techniques for tendinopathy

Answer 12

• Passive: pharmacy, injection, extracorporeal shockwave therapy, therapeutic ultrasonography, low level laser
• Active: tendon loading exercise, education, load management

Question 13

Exercise based strategies for tendinopathy

Answer 13

• Tendon loading exercises
• Eccentrics
• Isometrics
• Heavy Slow Resistance (HSR)
• Progressive individualized strengthening program
• Key concept the patient needs to be aware of: exercise duration >12 wks likely 1 yr for results and tendons take 6-12 months to fully heal

Question 14

Foundations of exercise programming do not change with tendinopathy which includes

Answer 14

• Restore motion: manual therapy including mobilization & manipulation
• Restore motor control & coordination
• Restore tissue tolerance (muscle performance): train all muscles for vascularity except the impaired tendon
• Maintain/improve conditioning
• Activity modification: stay active 7 address equipment and/or biomechanical concerns

Question 15

What should you NOT do for tendinopathy

Answer 15

• RICE
• Static stretching: dynamic stretching & neurodynamics are OK
• Immobilization
• Heat: no therapeutic ultrasound
• Continue to overuse tendon
• Patient factors: avoid smoking, antibiotics, & NSAIDs

Question 16

Equipment considerations for tendinopathy

Answer 16

• Free weights/barbells/pulley/weight machines & single limb stance work
• NO bands, isokinetic equipment, dynamic surface, & bilateral work

Question 17

Loading considerations for tendinopathy

Answer 17

• 55% of 1RM up to 90% 1RM
• Must be heavy
• Use pain as a guide as there may be some pain but it should not greatly impact motor control

Question 18

Rep considerations for tendinopathy

Answer 18

• > 9 reps: increase micro trauma, work past creep phase into plastic phase, goal to increase load, not reps
• 3x15 vs 1x10
• Goal 5-10 minutes of stress, 6 hours of rest, AM and PM sessions

Question 19

Time principle for tendinopathy

Answer 19

• Time: 5-10 minutes of stress (use timer)
• Frequency: 6 hours minimum b/w sets
• Speed: musculotedinous = eccentric, slow (>7 sec), 1 set of 10-15 reps; tendon osseous = isometric, 30 seconds, 4 reps, 2 minute rest
• Load: heavy as pain free & coordinated (55-90% 1RM)

Question 20

Which tendons are eccentric based versus isometric based

Answer 20

• Eccentric based = quadriceps & Achilles tendons
• Isometric based = patellar & supraspinatus tendon