Novel approaches to the treatment of tendinopathy the case of the patellar tendon Physiotherapy management - the first line

Transcription

1 Novel approaches to the treatment of tendinopathy the case of the patellar tendon Physiotherapy management - the first line Ben Clarsen PT PhD Research Fellow Oslo Sports Trauma Research Center Specialist Sports Physiotherapist Norwegian Olympic Training Centre

2 The first-line treatment for tendinopathy is physiotherapy

3 Therapeutic exercise? Massage? Dry needling? But what is "physiotherapy"? Electrophysical agents? Heat/cold? Taping/bracing?

4 Massage? Dry needling? Therapeutic exercise? But what is "physiotherapy"? Electrophysical agents?? Heat/cold? Taping/bracing?

5 Therapeutic exercise Specific exercises to load the patellar tendon Single-leg squat with 25 decline board Leg extension, leg press, lunge Variety of different approaches Eccentric Concentric-eccentric Isometric Images: Malliaras et al. 2015

6 Loading to treat "overload" Huh? Overuse injuries not necessarily caused by excessive total load, but by load mismanagement (e.g. too much too soon) The main treatment aim is to gradually increase the athlete/tendon's capacity to tolerate high loads

7 Cook et al. 2015

8 Effects of load in tendinopathy Tissue-level effects Improving the load capacity of the healthy tendon tissue Stimulating repair of degenerative tissue? Image: Rudavsky & Cook 2014

9 (picture of mechanotherapy paper)

10 Effects of load in tendinopathy Tissue-level effects Improving the load capacity of the healthy tendon tissue Stimulating repair of degenerative tissue? CNS effects Altered pain thresholds and pain tolerance Altered pain perception Image: Rudavsky & Cook 2014

11 Evidence for loading 9/10 trials of patellar tendinopathy loading involve eccentric training Dosage based on Alfredson protocol for treating Achilles tendinopathy 3 x 15 twice daily, 12 weeks Exercise should be mildly painful Progress by adding weight when pain resolves

12 Eccentric loading 8/9 trials of eccentric loading report improved pain and function Recent review pooled results from 5 studies 105 athletes 12 weeks of eccentric training Same outcome measure (VISA-P) 61% mean improvement in VISA-P score Everhart et al. 2017

13 Eccentric training No improvent in VISA-P scores in elite volleyball players who continued to train and compete during rehabilitation Total loading volume too high? Studies with better outcomes have restricted tendon loading for 8 weeks, light exercise permitted after 4 weeks Visnes et al. 2005

14 Heavy, slow resistance training Concentric & eccentric loading 3x per week 12-6 repetitions Slow movement Similar results to eccentric training Higher patient satisfaction (70% v. 22%) Improved tendon fibril density Kongsgaard et al. 2009, 2010

15 Isometric loading 45 second isometric contractions reduce tendon pain in short term May provide athletes with a management strategy during competitive season Rio et al. 2015, 2017; van Ark et al. 2016

16 Applying research in practice Eccentric, heavy/slow, or isometric loading? Depends on the patient? Status on presentation (e.g. reactive vs. degenerative tendinopathy) Patient preferences Cook & Purdam 2009

17 Applying research in practice Rehabilitation phases 1. Modify load, reduce pain (isometric loading) 2. Strengthening phase (eccentric or heavy-slow loading) 3. Introduce sport-specific exercises Jumping/landing Acceleration/deceleration Cutting/direction change 4. Gradual return to sport 5. Maintenance exercise Malliaras et al. JOSPT 2015

18 Malliaras et al. JOSPT 2015

19 So, is loading a "magic bullet"? Not all athletes get a satisfactory result from loading Bahr (2006) found only 55% of elite volleyball players treated with 12 weeks of eccentric training had an excellent or good result But... they had severe symptoms at baseline & were prepared to undergo surgery And success rates from surgery don't seem much better

20 Take home messages

21 The first-line treatment for tendinopathy is physiotherapy

22 The first-line treatment for tendinopathy is structured, progressive loading!

23 Take home messages Many unanswered questions about optimal loading type and dose But the good news lots of different approaches seem to work! Not all athletes will achieve satisfactory results... but many will Loading should be tried before any other form of treatment is considered (and should play a major role in any treatment plan)

24 The Oslo Sports Trauma Research Center has been established at the Norwegian School of Sport Sciences through generous grants from the Royal Norwegian Ministry of Culture, the South-Eastern Norway Regional Health Authority, the International Olympic Committee, the Norwegian Olympic Committee & Confederation of Sport, and Norsk Tipping AS