Clinical Facts. Are we paying sufficient attention to? Presentation Outline

Transcription

1 The science and practice of tissues specific pathologies: tendon My hurts, the doctor said I have tendonitis. What can I do for it?, PT, PhD, FAPTA Associate Professor of Clinical Physical Therapy Division of Biokinesiology and Physical Therapy Department of Orthopaedic Surgery University of Southern California Stephen Reischl, PT, DPT, OCS Adjunct Associate Professor of Clinical Physical Therapy Division of Biokinesiology and Physical Therapy University of Southern California Reischl Physical Therapy, Inc, Signal Hill, California CPTA 2011 Annual Conference, Long Beach, CA September 22-23, 2011 Clinical Facts High percentage of patients treated by physical therapists arrived with a diagnosis of tendonitis Achilles tendon injuries are among three most frequent sports-related injuries of foot and ankle 1 Patellar tendon injuries have high prevalence amongst competitive athletes 2 1 Werd, JAPMA, Lian et al., Am J Sports Med, 2005 Current Practice Patterns 2010 Clinical Practice Guidelines Linked to ICF. Achilles Pain, Stiffness and Muscle Power Deficits: Achilles Tendinitis 1 Diagnosis based on self-reported pain and perceived stiffness Interventions targeting tendon and foot only Soft tissue mobilization Expert Opinion Taping Expert Opinion Heel lift Conflicting Evidence Stretching Weak Evidence Orthoses Weak Evidence Low-level laser Moderate Evidence Iontophoresis Moderate Evidence Eccentric loading to tendon Strong Evidence Hence Today s First Objective What are the biological foundations for some of these interventions? 1 Carcia CR et al. Clin Pract Guide, JOSPT, 2010 Are we paying sufficient attention to? Tissue Mal-Adaptations and Re-Adaptations Tendon and Muscle Whole Body Movement Patterns & Coordination Including Remote Impairments Relevant to Task Performance Hence Today s Second Objective What is the role of movement evaluation? Presentation Outline Clinical distinction between itis & -osis Histopathology of tendons Mechanical properties of tendons Movement strategies in persons with tendinosis Non-surgical interventions 1

2 Tendon Pain? Tendonitis Tendinosis ICD9 = Clinical Differentiation between itis & -osis Occurrence: first time or repeated Preceding uncommon activity: yes or no Swelling? Warmth? present or absent Responding to anti-inflammatory medication? yes or no Corroborating with imaging? yes or no Achilles Tendon Superficial Proximal Distal Deep Normal Macro-Morphology Degenerated Normal Micro-Morphology Peak Spatial Frequency = 2.75 mm -1 Chronic Use Adaptations Chronic Overuse Mal-adaptations Cellularity Vascularity Collagen type III Degenerated Peak Spatial Frequency = 0.91 mm -1 Determines degeneration & differentiates from inflammation Bashford G, Kulig K, IEEE Med Imaging, 2007 Water content 2

3 Altered Tendon Mechanical Properties Stiffness Resistance of a material to elastic deformation under load Mechanical stiffness is NOT perceived stiffness as discussed in 2010 Clinical Guidelines for Achilles Tendonitis Achilles Tendon Stiffness (N/mm) Ratio of: Force (N) Elongation (mm) 16 Video clip: Isometric Plantarflexion Achilles Tendon Stiffness, N=12, N=12 Medial Gastrocnemius Aponeurosis Arya S and Kulig K, J App Physiol.,

4 Proximal Stiffness Modulus of the Achilles Tendon but the tendinotic tendons are thicker and, the length of the tendons may vary between subjects Therefore, we normalize force to CSA and elongation to resting tendon length, N=12, N=12 Patellar Tendon Structural and Mechanical Properties 1 Control Group (N = 9) Patellar tendon CSA (mm 3 ) Patellar Tendinopathy 2 Group (N = 8) Quadriceps CSA (mm 3 ) Peak Knee Ext Moment (Nm) Deformation (mm) Strain (%) Stress (MPa) Stiffness (N/mm) Modulus (GPa) Arya S and Kulig K, J App Physiol., copied from Kongsgaard M et al., AJSM, mean symptoms period of months; mean activity hrs/week. Mechanical response to pathology NORMAL Superficial Proximal Deep Distal Deep Superficial Distal DEGENERATED Calc NORMAL TENDON? More Compliant & Less Stiff DEGENERATED TENDON Calc Current Practice Patterns 2010 Clinical Practice Guidelines Linked to ICF. Achilles Pain, Stiffness and Muscle Power Deficits: Achilles Tendinitis 1 Diagnosis based on self-reported pain and perceived stiffness Interventions targeting tendon and foot only Low-level laser Iontophoresis Stretching Soft tissue mobilization Orthoses Taping Heel lift Eccentric loading to tendon -- Strong Evidence To produce a mechanically stiffer tendon 1 Carcia CR et al. Clin Pract Guide, JOSPT, 2010 Do patients present to a clinic because one of their tendons is less stiff? PAIN Where is the pain coming from? 4

5 Length change (mm) SHORTENING LENGTHENING Superficial Patella Distal Proximal Deep Lavagnino et al Does reduction of pain within 2 weeks equate to the absence of pathology? Hypothetical Characteristics of a More Compliant Tendon Slower rate of transmission of tensile forces to bone Impaired joint control during locomotion Diminished ability to store and release kinetic energy Body M-T unit The Role of Tendon in the Gastroc-Soleus Myotendinous Unit During Walking 15 SWING STANCE Body Joint M-T unit Tendon Joint Double support Single support Pushoff Muscle MTU 29 Fukunaga et al., Proc R Soc Lond,

6 Stiffness (N/cm) N/m Nm/degree Joint Stiffness Joint Angular Stiffness (torsional stiffness) K joint = Moment / Angle + Whole body Dynamics Leg Stiffness K vert = GRF vert / y y Body Joint M-T unit + K Achilles Tendinopathy Within Subject Comparison TENDINOSIS HEALTHY Support Moment accounts for contribution of the three joints = M Ankle + M Knee + M Hip ANKLE KNEE Kulig K, TENDINOSIS HEALTHY Percent Contribution to Support Moment during Running Pre- Intervention Post- Intervention VISA-A score 0 worst best Avid Runner, 56 y.o. male Running Single leg hopping 0 min unwilling due to pain min every other day 20+ hops (in the lab) Intervention Alfredson s Program 1993 first onset of Achilles pain March 2008 Latest episode of right Achilles pain Feb nd biomech. test 12 wks May rd biomech. test Belli, et al., Int J Sports Med,

7 Percent Contribution to Support Moment during Running Ultrasound Images of his Achilles Tendons Ankle Ankle, 42.0 Right 48.4 % (Involved) Hip, % Knee Knee, % Post-Treatment Pre-Treatment Hip, Ankle Ankle, % % Left % Knee Knee, % R Involved L Runner with unilateral Achilles tendinosis Data referenced to peak vertical GRF (vertical red line = 0) Minimum of 6 trials on each leg Temporal Variability Peak Ankle DF Peak Knee Flexion Peak Ankle Velocity Peak Knee Velocity Achilles tendinosis is not just a unilateral ankle problem. Peak Ankle Moment Peak Knee Moment Non-involved Involved The science and practice of tissues specific pathologies: tendon Best Repair Place, PT, PhD, FAPTA Associate Professor of Clinical Physical Therapy Division of Biokinesiology and Physical Therapy Department of Orthopaedic Surgery University of Southern California Stephen Reischl, PT, DPT, OCS Adjunct Associate Professor of Clinical Physical Therapy Division of Biokinesiology and Physical Therapy University of Southern California Reischl Physical Therapy, Inc., Signal Hill, California CPTA 2011 Annual Conference, Long Beach, CA September 22-23,

8 Load Tendinopathies of LE Patellar landing from jumping Achilles running/sports Posterior Tibial walking OTHERS? Yes, but not today. Acute: Recent onset Rupture itis osis Chronic: Reoccurrence osis Attenuated/insufficient Tendon Injury Metabolic Diabetes Hypercholesterolemia Antibiotics? Location of degeneration Location of rupture Tissue Stress Activity of patient Chosen activity Tolerance of Tissue The extremes Technique of the Activity Envelope of Function Dye, Clin Orthop Relat Res,1996 Frequency Tasks of Gait Walking Running Why does the tissue fail? Higher Level Function: Why is there pain/dysfunction? Are WE curious? Dose of Activity Technique Interaction of LE segments Support Moment! My multiple takeoffs and landings create overuse? Me Too! 8

9 Movement Analysis Support Moment: M A + M K + M H Staging of Tendinopathy Onset of Initial Symptoms Stopped Running Return to Forced to Stop Running Running Again Successful? Support Moment (SM) sufficient to absorb forces Where might this pattern create overuse? PROBLEM OUTCOME Management framework for tendinopathy: EdUReP Educate Unload PAIN Reload 51 Prevent Davenport, Kulig, Matharu and Blanco, Phys Ther., Educate about Condition of the tendon - NOT inflammation; Degeneration! No direct association with pain Time course of intervention Unload: weeks Reload: months Unload the Tendon Decrease aberrant, excessive loads Relative unloading period Prevention as well! 53 Davenport, Kulig, Matharu, and Blanco, Phys Ther, 2005 Davenport, Kulig, Matharu,and Blanco, Phys Ther

10 Clinical Practice Guidelines Interventions targeting tendon and foot only Low-level laser Iontophoresis Stretching Soft tissue mobilization Orthoses Taping Heel lift UNLOAD: To decrease pain CONFLICTING EVIDENCE Eccentric loading to tendon* Unloading of Achilles Tendon Use of ½-inch heel lift 1 Carcia CR et al. Clin Pract Guide, JOSPT, 2010 Nichols, J Am Board Fam Pract, 1989; Lee et al., Arch Phys Med Rehabil, 1987 Reload the Achilles tendon Reloading of Achilles Tendon Eccentric Program Dose of Exercise 3 sets of 15 reps 2 positions Twice per day = 180 repetitions 12 weeks! Alfredson et al., A J Sports Med, Characteristics of an effective eccentric Achilles tendon Reloading program Very slow Within full range of motion; into a stretch Progressively resistive, and guided by: symptoms (to tolerance; into pain is desired) technique (full range, no help from arms) Progressively Resistive Reloading Program LEVEL 8: 25% BW LEVEL 7: 20% BW LEVEL 6: 15% BW in backpack LEVEL 5: 10% body weight in backpack LEVEL 4: full WB on step; heel lowered below There are no short-cuts NONE!!! Who uses the short cuts? 59 LEVEL 3: full WB on ground; minimal UE support LEVEL 2: partial WB on ground; extra upper extremity support LEVEL 1: non-weight-bearing eccentric ankle plantar flexion with theraband 10

11 Tendon Loading Progression Focus on the ECCENTRIC Training Velocity Force Concentric Contraction Clinical Practice Guidelines Interventions targeting tendon and foot only Low-level laser Iontophoresis Stretching Soft tissue mobilization Orthoses Taping Heel lift UNLOAD: To decrease pain CONFLICTING EVIDENCE Eccentric loading to tendon* Week Mafi N, Knee Surg Sports Traumatal Arthrosc, 2001 Velocity + RELOAD: To produce a mechanically stiffer tendon, STRONG EVIDENCE Where is education and prevention? 1 Carcia CR et al. Clin Pract Guide, JOSPT, 2010 Prevent recurrence of symptoms Prevention is a component of intervention Prevention Education Assess and Modify technique Other interventions Trunk LE Case Presentation Background Information RM, male, 52, teacher sided Achilles symptoms Onset 10/2010 now 3/11 Unable to run, B-ball Pain in achilles region General Health clear Goal: return to active lifestyle and health Functional Activity Gait ROM Flexibility MMT Palpation Case Presentation: Intervention Evidence for Treatment Clinical Guidelines JOSPT 2010 Clinical Experience Pattern Recognition, Cannot wait for tomorrow, because. Intervention Education about the condition Unload heel lifts and modification of activity Reload eccentric loading program Prevention LE and Trunk strength, flexibility and control Overlapping of EdUReP and progression of activity Case Presentation Results March 18, 2011 August 1, 2011 VISA-A 0 worst best 36/100 87/100 VAS (0-10) Worse 6 Current 1 Best 0 Activity Running unable B-ball 15 min. ½ court Single leg heel rise Involved 6 *** Uninvolved 15 Hip strength Glut Max 3+/5 Glut Med 3+/5 Plank time Palpation Side forward Tender mid substance, thickened Worse 1 Current 0 Best 0 Running 30 m. 3x/wk B-ball 60 min., full court Involved 25 Uninvolved 27 Glut Max 5/5 Glut Med 5/5 Side forward 16+ weeks Tender mid substance, thickened 11

12 Prevent recurrence of symptoms Modify or alter technique Hip strength and flexibility Trunk holds and side-planks (sec) Patellar Tendinopathy: Non-operative Interventions Trunk hold side-plank Initial 22 16inv. /28 Post inv. /40 Eccentric loading 3 times a week. Patellar Tendinopathy: take off or landing issue? Who says take off? Who says landing? Jumping/landing too much? Not ready to jump/land that much? Jumping/landing incorrectly? Unload: Patellar Tendon Reload the Tendon Tent tape or V tape Stretch long hip flexors Modify overreliance of quadriceps Teach chair squatting vs. traditional Changing landing patterns

13 Reload the Patellar Tendon (1) Knee bends on slant board ECCENTRIC Exercise to knee extensors Slow (3 sec down), gradual but progressive Upward motion with upper extremity assist provides brief rest Pain < 5/10 12 weeks; 2 x day; 3 x 15 reps Prevent recurrence of symptoms Technique, trunk endurance and control Visnes H, Bahr R, Br J Sports Med, 2007 Insidious, Common Tibialis Posterior and Disabling Tendinopathy: Non-operative Interventions Function of Posterior Tibialis Tendon Plantar flexor/invertor Active throughout stance phase Anti-pronator functionally Antagonist to PL/PB preventing abduction of midfoot Dynamically supports the arch Smith, Clin Pod Med Surg:,1999 MLA Stability Active Mechanisms Passive Mechanisms Ligaments Boney Contact 56 year old woman with side PTTD Posterior Tibialis (+) Plantarflexors Rearfoot Inversion = midfoot stability Ligaments Spring Plantar fascia 13

14 Multi system Stage of tendon for most appropriate care Stage I Deformity? Decreased arch height (YES) Stage II Flexible foot deformity ligament damage Decreased function of muscle Unable to hold end range MMT Inability to heel raise Stage III Fixed foot deformity Loss of muscle function Decreased PAIN after walking Decreased PAIN on Foot Functional Index (FFI) Improved perceptions of function on FFI Resistive exercise further reduced pain and improved perception of function Educate about Condition of the tendon - NOT inflammation; Degeneration! No direct association with pain Time course of intervention Unload: weeks (orthoses, minimal barefoot walking) Reload: months 82 Davenport, Kulig, Matharu, and Blanco, Phys Ther, 2005 Unloading Footwear accommodates device Semi-rigid Shell Full contact of shell height Control midfoot motion Johanson et al., PTJ, 1994 Medial rearfoot post will: heel valgus, Tib Post demand Keenan, JBJS, 1991 Forefoot post to sulcus Attempt to frontal and transverse plane motion in late stance phase Tome, JOSPT, 2006 As patient tolerates device in post or reinforce the arch Reload: TibPost Loader Clinical visits 1/wk for 10 wks Progressive resistance in the transverse plane with static plantar flexion 3 sets of 15 repetitions Twice per day Shoes and orthoses worn = 90 repetitions Increased duration to 16 weeks Clinical visits 1/week first 8 weeks & every other week later Kulig et al., BMC Musc Disord,

15 What do you do without the TibPost loader? Prevent recurrence of symptoms Long term use of foot orthoses Attention of foot posture Body Mass Control LE/Trunk training Long term TibPost loading Frequency Sets and reps Prevent recurrence of symptoms Look for relevant impairments elsewhere, such as hip extensor and abductor strength in persons with PTTD JOSPT, 2011 Hip Extension Exercise Program Hip Abduction Exercise Program 15

16 Tendon Joint Whole Body 16