Management of Tendinopathy

Transcription

1 Management of Tendinopathy Current concepts in tendon management Chris McCullough

2 The cornerstones Define the tendon as pain source Defining the stage of tendinopathy Pa;ent history Diagnos;c ultrasound Quan;fy tendon symptoms & func;on VISA Loading tests

3 Define the tendon as the pain source Increasing chronicity or complexity may involve adjacent structures History Pain behaviour on loading Differen;al palpa;on MRI, US Psoria;c arthri;s

4 Define the stage Pa;ent history Age History of onset First episode? Exercise history Periods of down- ;me Also ques;on for: General health

5 What can ultrasound tell us? Stage Reac;ve tendons with sensi;sed tenocytes & increased ground substance Dysrepair swollen tendons with neurovascular changes Degenera;ve hypoechoic regions and neurovascular changes less irritable Reac;ve on degenera;ve

6 Physical Examina;on Load- response test=> reproduce the pain Progressively load tendon to appropriate levels Determine pain response (must be local pain) Determine the rela;onship between the two How much load produces how much pain? Observe for unloading pa^erns

7 Provoca;ve tests for patellar Squat Lunge Squat on decline board Single leg decline squat Decline hop Be^er discrimina;ve ability and reliability with la^er 2 (higher load) Purdam et al 03

8 Provoca;ve tests for Achilles Double to single leg heel raises Hops to 5 forward hops In intra- tendinous lesions expect increased load to increase pain. If not consider other diagnoses.

9 Physical Examina;on Motor pa^erning/limb func;on Does this precede tendon pain? Biomechanics Musculotendinous func;on Inhibitory pa^erns Low to high level challenges Muscle compliance Joint restric;on esp ankle dorsiflexion, also hip flexion in H/S

10 Clinical decision making Reac;ve v FH v Degenera;ve Peritendon v tendon Severity & irritability of symptoms Kine;c chain func;on Strength deficits In- or post- season Medical issues Person factors

11 ASSESSMENT Prac;cal Provoca5ve test(s) AT PT HS Adductor Hip abductors Lat epicondylalgia

12 Management: The big picture. Tendon injuries are a result of focused overload +/- person factors Long standing tendinopathy produces decondi;oning of the m- t unit Whatever interven;ons must address not only the tendon and m- t unit, but also the overload (kine;c chain) and person factors We are gaining some more effec;ve op;ons for the tendon, but have no magic bullet!

13 Tendon unloading and reloading Prolonged periods (greater than 2-3 weeks)of unloading are not beneficial to the matrix Mechano- transduc;on theory would support slower/lower impulse loading in acute phase as this is less likely to up- regulate the tenocytes or matrix Later, higher tendon loading sessions (elas;c func;on)only every 3 rd or 4 th day Langberg 1999, Cook 2003, Silbernagel 2004 Structure towards high, low, medium tendon load days

14 Load at length a clinical (Elas5c) loading of a tendon at longer lengths, +/- compression is more damaging than loading it when it is shorter Jumping athletes, not runners, get patellar tendinopathy Hockey players and sprinters get hamstring tendinopathy Not lawn bowls because length but no energy storage Change of direc;on (soccer players) get adductor tendinopathy Kicking in ARF Court sports, sprinters and runners get Achilles tendinopathy onen starts and hills are the triggering factor

15 Load at length applica;on at Stretch or load at length may aggravate an inser;onal tendinopathy, ie. most tendinopathies Increase compression and cell response Eg Achilles Hamstrings

16 Treatment order Unloading interven;ons Sta;c/ slow tendon loads early Load manage esp hot tendons. Get strong Associated muscle was;ng address early Progress range of ac;vi;es Progress volume of func;onal ac;vi;es Progress speed of ac;vi;es

17 Standard tendon rehabilita;on 1st stage rehabilita5on AIM: 0 to 2-3 months 1 2 5mes daily exs to switch down tendon sensi;sa;on to compression to improve neuromuscular pathways HOW? Isometrics or Very Slow concentric to eccentric contrac5ons Sustained loads in inner range, to avoid compression eg heel raises, knee extension holds Can generally progress quickly to moderate to high loads

18 Stage 1: Inner range holds/very slow con/ecc30-60 secs 4-6 reps? Moderate loads 2-3 ;mes /day PT AT

19 Standard tendon rehabilita;on 2nd stage rehabilita5on 2-4 months, every other day AIM: to apply sustained loads to the tendon in func;onal posi;ons to con;nue motor pa^ern retraining HOW? DRAG, PUSH, PULL Progress to outer range work with increased resistance at slow speeds generally in weight bearing Low- moderate resistance

20 Stage 2: slow con/ecc contrac;ons progressing to func;onal ranges, mod- high loads every second PT AT ECRB

21 Stage 3 Introduce speed Every second or third day Within known exercises Controlling range - Limit end range/compression Low loads - Speed adds substan;al load

22 Stage 4: Introduc5on of high tendon load every 3 rd day. Retain stage 2 exs. Quan;fy (count landings!) and progress loads PT Pool jumps Box jumps Incline/sled jumps Double leg jump/land on sand Double leg jump and land on floor Jump stops Jump stops => Jump/land AT Pool jumps Cycling Scooter Bounding Skipping Run throughs Accelera;ons Starts Hill bounds **Rarely a need for plyometrics

23 Return to running Walking Stride throughs every 2-3 days Increase distance (number of run throughs & reps/session) Then increase intensity (speed) high load every 3rdday Finally introduce accelera;ons/ starts as a high load ac;vity Avoid inside lanes early on the track with TA problems Monitor 24 hr forward hop pain As tendon adapts (less irritable) may reduce loading interval,

24 Return to Jumping sports Always control load ;me/number of landings, skills and intensity Controlled double leg jump/land Change of direc;on and jump stops - count these too! Larger jumps double, then single leg landings* Return to training then play

25 Monitoring Monitor pain response at 24 hours with relevant provoca;ve ac;vity. Diarise loading ac;vi;es and pain scores

26 Errors in treatment Rehabilita;on too quick ensure stability (At a stage)before progression (house of cards) Too many medical (injectable) or electrotherapeu;c modali;es Inappropriate loads during rehabilita;on*** Not enough base strength/hypertrophy early Not enough single leg work Must progress to speed/elas;c work in some way Eccentric strength too early or aggressively

27 Errors in treatment Failure to unload the tendon within the func;onal kine;c chain Insufficient rehab of the whole limb Not enough management Manage the condi;on, not treat the symptoms Rehabilita;on ends on return to training maintenance programs * Inadequate engagement of the athlete

28 Conclusions - current thoughts Staging the condi;on is a key to op;mal medical and rehabilita;on management Latent (24 hr) pain on load- response test is probably the most useful guide to load progression Early tendinopathies are essen;ally load management Exercise is the most potent s;mulus to maintain and remodel the matrix in advanced tendinopathy 3 day cycles be^er tolerated at higher loads

29 Conclusions current thoughts Maintenance and preven5on Kine;c chain analysis of at- risk group Off season pre- habilita;on Avoid long periods of low load In season maintenance Regular monitoring (of at- risk muscle and tendons) & early interven5on Care with programming of change in training surface