2/02/2011. Purdam et al , Silbernagel 2004 Structure towards high, low, medium

Transcription

1 The cornerstones Define the tendon as pain source Defining the stage of tendinopathy Patient history Diagnostic ultrasound Quantify tendon symptoms & function VISA - medium term Loading tests 24 hr response to rehab/training Modify the tendon load Training Biomechanical Progressive loading/exercise program individualised to athlete deficits & requirements Medical intervention as required Squat Lunge Squat on decline board Single leg decline squat Decline hop Better discriminative ability and reliability with latter 2 ( higher load) Purdam et al 03 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. Tendon injuries are a result of focused overload +/- person factors Long standing tendinopathy produces deconditioning of the m-t unit Whatever interventions must address not only the tendon and m-t unit, but also the overload (kinetic chain) and person factors Mono-therapy is rarely successful Prolonged periods (greater than 2-3 weeks) of unloading are not beneficial to the matrix Mechano-transduction 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 (elastic function) only every 3 rd or 4 th day Langberg 1999, Cook 2003, Silbernagel 2004 Structure towards high, low, medium 150 tendon load days 100 PICP [ g/l] 50 0 ** * * * Time [h] 1

2 Proliferative Take longer to settle (0-1/10), then progress relatively quickly** Really slow, moderate heavy loads early Load management and Return To Sport progression Failed Healing Can use a higher set-point (1-2/10) Address contractile deficits Graduate tendon load 3 day cycles (Hi Lo Med days) Degenerative Less irritable (can operate at 2-3/10) Address contractile deficits (muscle bulk) Graduate tendon load 3 day cycles (Hi Lo Med days) Eccentric programs as indicated Determine ideal end-point 4 Stages of graduated tendon load Slow isometrics inner range Slow isometrics graduate to outer range Increase speed of loading Final stage is elastic tendon loads 1 week to 3 months 2-4 times daily exs AIM: to switch down tendon sensitisation to compression with sustained loads to improve neuromuscular pathways increase muscle strength and bulk ( fatiguing stimulus every 2 days) HOW? Isometrics or Very Slow concentric to eccentric contractions Sustained loads in inner range, to avoid compression eg heel raises, knee extension holds Can generally progress quickly to moderate to high loads Stretch or load at length may aggravate an insertional tendinopathy ie most tendinopathies Increase compression and cell response Eg Achilles Hamstrings 2

3 PT AT Moderate to high loads. Time under tension secs. Eg 3-4 sets of 6-8 reps 3-4 secs conc/ecc; bodyweight (or less) resistance. Partial recovery between sets (30 secs) Main aim is high lactate (muscle burn ), stimulus for the deposition of type 2 glycolytic fibres Progress to higher load, lower duration (1-2 secs) & reps, increase sets. 3 sessions per week 2-8 weeks, every other day AIM: to apply sustained loads to the tendon in functional positions to continue motor pattern retraining HOW? DRAG, PUSH, PULL Progress to outer range work with increased resistance at slow speeds generally in weight bearing Low- moderate resistance later emphasis on slow eccentric motion Endurance PT AT ECRB 2-8 weeks Introduce speed Every second or third day Within familiar exercises Controlling range Limit end range/compression Lower resistance than stage 2 Speed adds substantial load Stage 1 and 2 exs on the off days 3

4 8-12 weeks Schedule High, Medium & Low tendon load days AIM: to progress loading to functional levels in: Speed of loading sport specific strength capacity to absorb repeated elastic loading Maintain stage 2 loading HOW? functional strength work Add High load days to stage 2 work ( M&L) Propulsion activities Faster loading with lower loads Eccentric/concentric turnaround Eg skipping, hopping, bounding Jump height, combinations Finally deceleration, acceleration, change of direction to functional levels and volumes 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 Single leg landing (technique) Progress numbers to sport specific levels AT Pool jumps Cycling Scooter 2 leg Skipping Run throughs Bounding Accelerations Starts Hill bounds **Rarely a need for plyometrics Monitor pain response at 24 hours with relevant provocative activity. Diarise loading activities and pain scores Suggest initial loading work in hip neutral (hams machine, russian curls, swiss ball curls) Maintain working over knee with higher loads. Eccentric hip flexion at late stage only as much as required for sport Avoid compression of enthesis through overload of squats, dead lifts esp single leg 4

5 Walking Stride throughs every 2-3 days, depending on irritability Increase distance as required (no. of run throughs & reps/session) Increase intensity high load every 3 rd day - running to bounding As tendon adapts (less irritable) may reduce loading interval, (steady state Medium day) but not high loads (MHL days) Finally introduce sprinting/ accelerations/ starts as a high load activity Avoid inside lanes early on the track with TA problems Monitor 24 hr forward hop pain Always control load time/number of landings, skills and intensity Controlled double leg jump/land Change of direction and jump stops count these too! Larger jumps double, then single leg landings* Return to training then play Kinetic chain analysis of at-risk group Off season pre-habilitation Avoid long periods of low/no load In season maintenance 1-2 strength sessions 1 elastic load session ( this may be a game) Regular monitoring (of at-risk muscle and tendons) & early intervention Care with programming of change in training surface Challenges: A full eccentric program is difficult generally not necessary Kinetic chain dysfunction must be addressed to avoid perpetuation or recurrence Activated tendon difficult to settle Injectables generally require down-time and slow return to full load Control tendon exacerbations principally through load management Medications should be viewed as an adjunct Maintain/increase contractile strength in m-t unit and kinetic chain to absorb load Enable adequate sports training to acheive sport outcomes Manage pain often to a level over a given week to 2-3 /10 Visnes et al

6 Kevin middle distance runner 22 year old 1 st episode Swollen tendon No vessels Unload 2-3weeks (think stress reaction/fracture!) Until hop pain is around 1/10**.. Medical interventions.?triple therapy Graduated slow loading in week 2&3 Slow loading of soleus, gastroc, split squats, gym work, cycling later Then progress functional tendon oriented loading Total leg work, bounding, strides. Avoid too much jogging (calf dominant) Monitor 24 hr response Graduate load to more dynamic activities, high/low/medium days Longer reps, higher speeds - > accelerations Short rest then isometrics then load management 6-8 weeks Monitor through season Steve 45 yo partial tear/degenerative patellar tendon - Grumbly 15 year history Hypoechoic regions and vessels Unload 1-2 weeks Until decline squat pain is 2-3/10 Medical interventions GTN patches or prolotherapy if rehab plateaux Graduated slow muscle focus in 4-8 weeks Slow loading of quads, calves gluts split squats, gym work Then progress functional tendon oriented loading months 4-6 weeks Total leg work, squats, step ups. Avoid too much impact work Monitor 24 hr response Graduate to more dynamic activities Hi, Lo Med days months 4-8 weeks as tolerated Skipping, jumping on appropriate days Graduate RTS Maintenance program of exs Short rest then progressive 6 month rehabilitation program Monitor through program and RTS 6