1
Q
Tendons are _____________________.
A
Dense connective tissues
2
Q
Tendons are mostly made up of __________ collagen fibres.
A
Type I
3
Q
Tendons are a longitudinal array of ____________.
A
Tenocytes
4
Q
Tendons sense and respond to ________________.
A
Tensile loading
5
Q
Define “tendon laceration”.
A
A cut through the tendon
6
Q
What are the classifications of tendon lacerations?
A
1) Acute vs chronic
2) Complete or partial
3) Open or closed
4) Simple, or complex (with associated injuries)
5) With or without tendon retraction
7
Q
What is tendon retraction?
A
- When the muscle pulls on the lacerated tendon, leaving a large gap that needs to be surgically repaired.
8
Q
What happens to retracted tendons?
A
- Start to degenerate if not re-attached immediately
- Requires loading = mechanotransduction
9
Q
Where do tendon lacerations most commonly occur?
A
Hand/Wrist
10
Q
What is the most common population for tendon lacerations?
A
Males, Average mid 30s
11
Q
What are some risk factors for tendon lacerations?
A
1) Occupational injuries and assaults are the most
common risk factors
2) Workers using cutting tools are most at risk
12
Q
What are the most common mechanism of injury for tendon lacerations?
A
1) sharp object - incision
2) animal or human bites
3) crush injury
4) deep abrasions
13
Q
What is the pathophysiology of tendon lacerations?
A
- Rupture of tendon fibres, sheath, and associated blood vessels leads to inflammation of tendon and para-tendon, and loss of function
- Tendon may become retracted due to unopposed muscle tension
14
Q
What are the diagnostic tests associated with tendon lacerations?
A
1) Active and passive ROM and strength
2) US may be used to visualize the extent of injury, especially for CLOSED injuries
3) X-ray may be used to rule out injury to associated structures
15
Q
High sensitivity of a study means:
A
Great for ruling out a condition (SNOUT)
16
Q
High specificity of a study means:
A
Great for ruling in a condition (SPIN)
17
Q
** What is the treatment protocol for distal laceration of finger extensor tendons? **
A
Splint immobilization for several weeks (2 weeks?)
18
Q
T/F:
Most, but not all, tendon lacerations require surgery.
A
True
19
Q
What is the typical treatment of tendon lacerations?
A
1) wound debridement
2) early tendon repair
3) early ROM
4) pain or anti-inflammatory meds may be prescribed by physician
20
Q
Tendons heal by ___________.
A
scarring
21
Q
What are the properties of healed tendon?
A
1) Decreased type I collagen
2) Increased type III collagen
3) Increased water content
4) Increased vessels/nerves
22
Q
Remodeling of tendon is ongoing for ____________
following injury, and normal structure is __________ restored.
A
years, never
23
Q
What factors influence the rehabilitation protocols following a tendon laceration?
A
1) size of tendon
2) extent of injury
3) timing of suture removal
4) surgeon’s assessment of patients ability to comply
24
Q
How long should a distal extensor tendon be immobilized following a laceration?
A
2 weeks
25
How long should an achilles tendon be immobilized following a laceration?
10-12 weeks
26
What are the overall goals of therapy for tendon laceration?
1) Ensure compliance with post-op restrictions
2) Stimulate tissue repair by gradually increasing the load through the tendon
3) Maintain ROM and strength of associated joints and muscles
4) Maintain tendon gliding without damaging it further
5) Pain control
6) Monitoring incision
27
What are the complications of tendon lacerations?
1) Reduced ROM
2) Adhesions, loss of gliding function
3) Joint stiffness
4) Risk of joint capsule fibrosis is proportional to time of immobilization
5) Treated with early ROM, stretching, and tenolysis if necessary
28
Cartilage get their nutrients through the _____________ of the joint.
Pumping action
29
What are the classifications of achilles tendon rupture?
1) Acute or chronic
(occult/neglected)
2) Size of gap
3) Partial (< 50%) or
complete
30
What age group is most likely to be affected by achilles tendon rupture?
30-40 years
31
What is the male to female ratio of achilles tendon rupture?
5 to 1
32
What are the risk factors for achilles tendon ruptures?
1) Age - tendons start losing tensile strength and flexibility with aging
2) Male
3) Increased BMI - increased adiposity
4) Diabetes
5) antibiotics -Fluoroquinolones (e.g. ciprofloxacin)
33
How does diabetes contribute to achilles tendon rupture as a risk factor?
- High blood sugar leads to advanced glycation end product
- Accumulate in tendons and reduce their energy absorption properties and make them more brittle.
34
How do certain antibiotics contribute to achilles tendon rupture as a risk factor?
- inhibit glucosamine and glycan synthesis
- leads to dehydration of tendon
35
What is the pathophysiology of achilles tendon rupture?
1) Achilles tendon must withstand large loads (e.g. 12 times body weight)
2) Muscle-tendon unit crosses two joints
3) In younger individuals, rupture usually occurs during sudden (high velocity) movements
4) In older individuals, rupture can also occur during normal movements --> eccentric activity
36
What are some signs and symptoms of achilles tendon rupture?
1) Sudden onset Achilles pain and weakness
2) May be a popping sensation
3) Cardinal signs
4) Abnormal resting position of foot
37
What are some diagnostic tests associated with achilles tendon rupture?
1) Calf-squeeze test
– May still be some active PF through
long flexor muscles
2) US may be used
if the diagnosis is
uncertain
38
Which tendon can confusion the picture and cause false negatives on the calf-squeeze test?
Plantaris tendon
39
What is the treatment overview of achilles tendon rupture?
1) Surgical repair and immobilization (10-12 weeks) is the typical management
2) Conservative management (immobilization) may be
used in riskier/older or sedentary patients
3) Surgeons may prescribe a short course of post-op NSAIDs, or analgesics
40
What are the different surgical repair methods for achilles tendon ruptures?
1) small gap - suture end to end
2) larger gap - tendon graft
3) chronic - release retracted gastrocs
41
Define "tendinopathy".
- A clinical syndrome defined by persistent tendon pain and reduced load-bearing function, usually accompanied by structural change in the tendon.
- Mostly chronic but also can present acute as well
42
What is the failed healing model of tendinopathy?
1) Repetitive mechanical loading of a tendon and its attachments
2) Cellular-matrix response (Adaptation)
3) Continued loading outside the window that our body can cope
4) Overuse injury
43
What does continued loading of a tendon outside of its coping capacity lead to?
1) Microinjury to collagen / tenocytes
2) Injury of biomechanical weakpoints (attachments)
3) Low level activation of inflammatory paths
4) Accumulation of inferior repair tissue (scar tissue)
44
What are biomechanical weakpoints?
1) muscle-tendon junction
2) tendon-bone junction
45
What are some signs and symptoms of tendon overuse injury?
1) Pain on palpation and with loading
2) Thickening
3) Weakness
4) Altered movement patterns
46
For the same amount of load, tendinopathic tendon tends to _________ more.
Strain
47
Tendinopathic tendon becomes _________, therefore cannot store much energy and can snap under load.
Stiff
48
Tendons adapt to the ____________ they experience.
Amount of load
49
How well does the tendon respond to loading?
1) High intensities are more potent (MVC >70%)
2) Mode of muscle activity does NOT matter (eccentric, concentric, isometric)
3) Longer duration (e.g. 7s) is better than short duration (3s or plyometrics)
50
In treatment of patellar tendinopthy, which of the following seems to result in the best outcomes?
A) Corticosteroid injection
B) Eccentric decline squat training
C) Heavy slow resistance training
C) Heavy slow resistance training
51
Resistance training results in production of new ___________ fibres in the tendon.
Collagen
52
What is the recommended PT treatment paradigm for tendinopathy?
1) Education / BPS model
2) Biomechanical assessment /intervention
- Static, dynamic
3) Progressive rehab, graded exposure
- Muscle recruitment
- Range of motion
- Strength, power
- Skill / function
4) Load management (tissue, pain)
53
Define "tendinitis".
Inflammation of the tendon or its linings (usually following an acute event, e.g. partial rupture, or acute bout of loading)
54
Define "tendinopathy".
Refers to the clinical syndrome of tendon pain and thickening
55
Define "tendinosis
an older term, referring to the underlying pathology (i.e. biopsy, imaging): "angiofibroblastic tendinosis”
56
What are the classifications of achilles tendinopathy?
1) Acute or chronic
2) Insertional or mid-portion
3) Unilateral or bilateral
4) +/- bursitis or paratendonitis
57
What is the characteristics and treatment recommendations of insertional achilles tendinopathy?
1) pain located right on the calcaneus
2) avoid early loading in high DF position
3) management through progressive loading
58
Which populations are more likely to have achilles tendinopathy?
- Often in runners
- also in sedentary (older) individuals
59
What is the lifelong incidence of achilles tendinopathy in elite runners?
50%
60
What are some intrinsic risk factors for achilles tendinopathy?
1) Pronation
2) Reduced DF
3) Reduced strength of involved side (hip -> ankle)
4) Tight (or weak) calf
5) Advancing age
6) Diabetes
7) Hypercholesterolemia
61
What are some extrinsic risk factors for achilles tendinopathy?
1) Training errors
2) Poor technique
3) Poor footwear
4) Uneven or hard training surfaces
62
What are some signs and symptoms of achilles tendinopathy?
1) Gradual development of symptoms
2) Pain and morning stiffness after mechanical loading
3) Localized tendon pain
4) Pain improved by gentle movement, or heat
5) Tendon usually appears thickened
6) May be “crepitus” (grating/crackling sound)
associated more with an acute paratendonitis.
63
What are some diagnostic tests associated achilles tendinopathy?
1) Load and palpate tendon to determine location and severity / irritability presence of crepitus
2) US +/- colour doppler
3) MRI
64
What are some history questions needed to be considered when treating achilles tendinopathy?
1) Is pain related to activity?
2) Did it come on gradually?
3) Rule out fluoroquinolones, high cholesterol, spondyloarthropathy
65
What are the Dutch guidelines for achilles tendinopathy?
1) Temporary cessation of provoking activity
2) Replace with non-provocative activity (slow controlled exercise promoting tendon adaptations)
3) Gradual increase
4) Use pain scale to monitor
5) Progressive calf strengthening
6) If not progressing after 3 months, other treatments could be considered but acknowledging lack of certainty of effectiveness
66
How do you set expectations with respect to Dutch guidelines for achilles tendinopathy?
1) Majority recover, 2-3 people out of 10 will continue to have symptoms
2) Majority return to sport (85%), after several months of gradual return
3) Address likely barriers to engaging in rehab
67
What is the JOSPT guideline for achilles tendinopathy?
1) Strongest recommendation is for exercise
2) Recommends iontophoresis for acute AT
3) Also suggests taping, stretching, manual therapy, neuromuscular exercises and needling can be tried
68
What is iontophoresis?
Prescription for topical corticosteriod which is driven into the tendon using electrical stimulation
69
What are the 3 exercise rehab protocols for achilles tendinopathy?
1. Alfredson program
2. Silbernagel program
3. Heavy slow resistance training
70
What is the most effective exercise protocol for achilles tendinopathy?
Heavy slow resistance training
71
How is heavy slow resistance training effecting the rehabiliation of achilles tendinopathy?
- People with tendinopathy have reduced sliding between subtendons
- Heavy slow resistance training improves the sliding
72
Define "Tenosynovitis".
inflammation/fibrosis of a tendon sheath
73
Define "DeQuervain's Tenosynovitis".
Tenosynovitis of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendon sheaths
74
What age population is most prone to De Quervain's tenosynovitis?
40-50 years
75
What population is most prone to DeQuervain's tenosynovitis?
More common in people who use the wrist repetitively (athletes, workers, computer users, musicians)
1) Repetitive movements
2) Forceful movements
3) Radial/ulnar deviation of wrist, abduction of thumb
76
What is the pathophysiology of DeQuervain's tenosynovitis?
1) Excessive friction between the EPB and APL tendons, the sheath, and the styloid process, leads to inflammation
2) Repeated episodes of inflammation can lead to scarring (fibrosis), further impeding the gliding mechanism
3) Inner lining of tendon sheath (synovium) can become worn and frayed
77
What are some signs and symptoms of DeQuervain's tenosynovitis?
1) Thickening of the tendon sheath
2) +/- an active inflammation with cardinal signs
3) Pain, episodes of acute inflammation, usually activity-related
4) Pain when stretching the tendons or compressing them against the styloid process
78
What are some diagnostic tests associated with DeQuervain's tenosynovitis?
1) Tenderness elicited by palpating the 1st DORSAL
compartment of the WRIST
2) Pain when the THUMB is FLEXED and the WRIST is passively, ULNAR DEVIATED (Finkelstein’s test)
79
What is the treatment overview for DeQuervain's Tenosynovitis?
1) Corticosteroid injection --> effective in about 50% of cases
2) Splinting can relive symptoms but compliance can be hard
3) Surgery --> 100% success rate
80
What is the PT involvement in the treatment of DeQuervain's tenosynovitis?
1) Analyze the activity – break it into component activities – see if the movement can be made less stressful
2) Prescribe exercises to safely maintain hand/wrist/elbow
strength and ROM
PHTH 511 - Pathophyisology I
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