Over the 2 days there were some fantastic, inspirational break out sessions. Here, Sarah Martin (Lecturer in Sports Therapy & Rehabilitation, & Programme Leader for the MSc Sport Rehabilitation) shares her notes on the Tendinopathy breakout session.
Genetics play a key role in tendinopathies. Bill Ribbans presented the potential links
between blood group and tendon injuries which is amongst his research.
Genetic variants on Musculoskeletal Soft-Tissue Injury include Inter-Individual
biological variation (Structure, Mechanical Properties of tendons, ligaments
etc.) Genetic variants may also contribute to variation in response to
mechanical loading and other stimuli. Many intrinsic risk factors for MSK
injury are multi-factorial and are determined by genetic factors and
environmental factors. For example, flexibility is 64-70% determined by genetic
factors alone. Type I is structurally important but diameter and strength are
regulated by Collagen Type V. Tenocyte responsiveness is affected by mechanical
load factors including age, nutrition and training load.
 |
| Magnusson et al. (2010) |
Jon Rees
presentation ‘When is a tendinopathy not an
injury’ where effective tendon management relies on the right diagnosis at
the right place at the right time. His model suggests the stages of
tendinopathy management should include:
Injury – Diagnose – Address Cause – Manage Pain – Relative Rest
– Normal Movement – Strengthen – Late Stage Rehabilitation – RTP
It is important to remember that tendinopathies aren’t
always overload-related. Genetics, psoriasis, Ankylosing Spondylosis, Reactive
Arthritis, IBD, gout, diabetes, obesity, hyperlipidemia and certain medications
such as quinolones, corticosteroids and omeprazole have all been discussed as
risk factors for tendinopathy. Chronic pain management (neuroplasticity,
central sensitisation and peripheral sensitisation) should be considered and
you must treat the whole patient.
The use of injection therapies for tendinopathies (Justin
Lee) is well reported in literature. Mathijs
van Ark et al. (2011) Systematic
Review suggests that there is some promise with all 7 injection treatments (dry
needling, autologous blood, high-volume, platelet-rich plasma, sclerosis,
steroids and aprotinin). However it is worth considering that Prolotherapy
& PRP will increase the patients pain in the initial stages. Good evidence
supports corticosteroid effectiveness but caution should be taken as there is a
high relapse rate and risk of re-rupture. Do not inject HIVI or Prolotherapy
with a partial tear as the fluid will travel into the tear; PRP is most
effective in these cases.
Jon Fearn discussed Chelsea Football Clubs management of
Tendinopathies. Most commonly these are found in adductor longus, proximal
hamstring, patellar and Achilles tendon. ECSWT is an effective option for
tendinopathy but should be applied on an individual basis, especially in
adductor longus and proximal hamstring tendinopathy.
Management options available for tendinopathy include;
manual therapy, medications/NSAIDs, exercise therapy (manual, isokinetics &
gym-based), functional sports training and for symptoms lasting longer than 28
days, extracorpeal Shockwave Therapy (every 3-4 days), Injection Therapy (PRP).
Regarding tendon loading, Jarrod Antflick highlighted Malliaras et al.’s (2015) paper which discussed
the clinical diagnosis, load management and advice for challenging case
presentations.
Tendinopathies have a significant effect on performance:
- - Rate of force development positively influenced
by tendon stiffness (Bojsen-Mǿller
et al., 2005)
- - Reduced tendon stiffness, greater mechanical
hyteris & lower energy storage (Wang, 2012; Arya, 2010, Child et al., 2010)
- - Economical runners showed higher contractile
strength and a higher tendon stiffness in triceps surae (Arampatzis et al., 2008)
The magnitude of intra-tendinous load in walking is 3.5
times body weight, sub-maximal hopping (skipping activity) 5 times body weight
and in running 12 times body weight (Komi
et al., 1992).
Mechanotransduction
promotes collagen synthesis. Peak eccentric force decreases in tendinopathies.
New research suggests that growth hormone can increase circulation in the
tendon. Remember that tendons are slower to change their properties but quicker
to atrophy but habitual loading increases the CSA of a tendon (see research by Magnusson et al., 2010). Eccentric is more
effective than Heavy Slow Resistance (HSR) but frequency and load must be
considered. Eccentrics are very time consuming versus HSR which may be something
to consider in relation to patient compliance.
Do not load the tendons every day; consider analgesic
loading strategies. High Force Isometric Contraction – elastic properties
increased with longer holds and magnitude of load. Tenocytes don’t respond to
plyometric activities. Consider activities such as the Stiff Knee Jump which
appear to be effective rehabilitation exercises post Achilles Tendon repair,
and focus on HSR and eccentric training in pre- and post-season due to
associated fatigue and muscle soreness.
Regarding analgesic loading strategies, isometric loads (21%
MVC) have a hypoanalgesic effect on the segmental and extra-segmental
descending pain pathways (Rio et al., 2015). Loads of 70% of MVC x
45 sec x 5 are effective for analgesia in a non-compressive mid to inner range
portion (Rio
et al., 2013) however no effect
from “Heavy” 45 sec isometric holds in Achilles Tendinopathy (O’Neill et al., in press).
Take home messages to consider for exploring Tendinopathies
are:
- - Literature rarely differentiates
- - Achilles – Insertional vs Mid-portion
- - Inflammatory vs Mechanical
- - Overload vs Metabolic
- - Athletic vs Sedentary
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