11/23/10. An update on Achilles tendon rehabilitation. Research area the last y. Four-sequence in understanding Achilles injuries

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1 An update on Achilles tendon rehabilitation Research area the last y Tendon Collagen Muscle Collagen From science to rehab Dr.med Henning Langberg DMSc, PhD, PT Myofibril lar Institute of Sports Medicine Copenhagen, Denmark Four-sequence in understanding Achilles injuries Problem describtion incidence and severity Mechanisms risk factors injury mechanisms Evaluation of effect succes new problems? Intervention reducing risk of injuries Step 1 PREVALANCE (van Mechelen et al., Sports Med 1992; Bahr et al., BJSM 2005) Tendinopathy - prevalance Tendon in general (Alfredson 2000; Emerson 2009; Cook Injury preven+on IOC. 2009) Tendon injury can occur: in the mid-tendon Achilles tendon However most tendon pathology and pain arise at the tendon attachment to bone patellar tendon medial and lateral elbow tendon tendons of the groin (Cook 2009) 1

2 Exercise or overweight? Step 2 ETIOLOGY - MECHANISM Chronic painful Achilles tendinopathy Associated with: Overweight (Rolf & Movin, 1997; Fahlstrom et al., 2003; Holmes & Lin, 2006; Frey & Zamora, 2007) Hip ratio (Gaida et al., 2004; Shiri et al., 2006) What is going on in the injured tendons? Waist circumference (Shiri et al., 2006; Malliaras et al., 2007) PATHOLOGY Grayscale ultrasound Histopathology of tendinopathy No inflammatory cells An Achilles tendon with chronic tendinosis: - localized thickening - focal hypoechoic areas - an irregular tendon fiber structure Pain Collagen intact? (Shalabi, Acta Radiologica 2002; Movin, Acta Orthop Scand 1997; Astrom, Clin Orthop 1995; Kannus, Am J Bone Joint Surg 1991) 2

3 Acutely inflammalon IS present The inflammatory cytokines play an important role in wound healing aper ACL rupture TNF a IL 1b IL 6 IL 8 IL 1r a IL 10 (Irie K. et al., 2002) Hypervascularisation in chronic painful Achilles tendons and not in normal healthy tendons (Öhberg, KSST, 2001; Koenig, Scand J Med Sci Sports 2004) Patella tendon Interventions to remove flow Sclerosing injections Healthy tendon Chronic overloaded tendon Compression socks - C-Sock Not evidence El coagulation (Boesen, Langberg et al. Br J Sports Med 2006;40: ) 3

4 El coagulation Long term effect on Doppler (Boesen, Langberg et al. Br J Sports Med 2006;40: ) (Boesen, Langberg et al. Br J Sports Med 2006;40: ) Following effect VISA-A PAIN - THE SYMPTOM THAT PERSISTS (Malliaras 2008, 2010) Why is tendinopathy painfull? In growth of nerves 4

5 Tendon problem often resistant and no standardised treatment exists = becomes chronic Step 3 HOW SHOULD WE REHABILITATE TENDONS? (Silbernagel 2001, Kannus 2002, Maffulli 2003, Jozsa 1995, Kjaer 2004) Eccentric training Chronic (3-100 mths) Achilles tendon overuse (n=15)), not RCT Tendinopathies Midtendon >< insertion Eccentric training with straight/ bent knee 12 weeks, 7 days, 3x15 rep Increasing load Pain was accepted during training Running activity was allowed Calcification tidemark More fibrocartilage like All 15 were back to preinjury levels with full running activity (Alfredsson 1998) Fibrochondrocytes REVIEW OF THE EFFECT OF ECCENTRIC TRAINING 5

6 Tissue turnover collagen type I synthesis high level soccer players Before After Tendinopathy 44 ± 9 13 ± 9 Control 0 ± 0 0 ± 0 (Langberg 2007) Tissue turnover collagen type I synthesis high level soccer players Adaptation of tendons strength? Microtears Before After Tendinopathy 44 ± 9 13 ± 9 Control 0 ± 0 0 ± 0 Tendon degeneration No significant difference in breakdown [ICTP-concentration] (Langberg 2007) How to apply Eccentric training in the clinical practice? Not evidence Is pain important for fibroblast slmulalon? VAS Pain has to present during loading During loading < 5 Following load < 2 Before next training pain not enhanced Pain unchanged 3-4 weeks Progress: Increase load 6

7 Is pain important for fibroblast slmulalon? Patella tendon and eccentric rehab Reduced/suppressed EMG during pain suggests incomplete aclvalon of the motor neuron pools Relaxed, 90 deg knee angle. Standard squat, 90 deg knee angle. may lead to an unsmooth force output (reflected as higher frequency content of the GRF res in the 10 Hz frequency range) Good results Decline squat, 90 deg knee angle. Force vibralons around 10 Hz are classified as physiological tremors Poor results (Kongsgaard 2006) Difference between Achilles and patella tendon? ECCENTRIC OR CONCENTRIC (Kahn 2009) Effect of ex. type on max force in AT Eccentric or concentric? (Rees 2008) 7

8 Eccentric, corlcosteriod or heavy concentric exerise? Effect of eccentric, cor;costeriod, heavy conc. strength training Treatment sa;sfac;on a?er 12 weeks of treatment Corticosteroid (n=12) Decline (n=12) HSR (n=13) Satisfied Somewhat satisfied Unsatisfied No sign difference between groups WHY DON T WE JUST USE CORTICOSTERIODS? Treatment sa;sfac;on a?er 6 months No sign difference between groups (Haraldsson, Langberg et al. 2006) 8

9 Not all patients are alike HOW TO USE THE EVIDENCE IN CLINICAL PRACTICE? OVERUSE INJURIES SHOULD BE UNLOADED Effect of unloading UndersLmulated tendon cells Treatment of the a4ached gel with cytochalasin D disrupted the cytoskeletal organiza+on and resulted in the upregula+on of collagenase mrna and the inhibi+on of collagen mrna expression (Lavagnino & Arnoczky 2005) Adding eccentric rehab (Visnes et al 2005) Reduced sporting activity seems to be crucial Load management Avoid: Sudden increase in training volume Sudden increase in intensity Hard surfaces Unaccustomed sporlng aclvity Malalignments Fast progression Overweight Not evidence 9

10 PRP another new treatment Are we getting close? What is known about the size of the problem (step 1)? serious injuries, elite, professional (most) less serious injuries, community level, amateur, recreational activities (less) How to use evidence in rehab ScienLfic evidence Not evidence What is known about risk factors (step 2)? only few studies What is known about the effectiveness of preventive measures (step 3)? few RCT Are there systems in place to monitor sports injury (step 4)? OK systems are present Physiotherapist PaLent (Chalmers Inj Prev 2002) Heavy slow resistance training vs. eccentric training Not evidence Factors yes No Elite sport Female Male Familiar with strength training Member of a fitness center Acces to a fitness center Family and children Long working hours Disciplinated Previous tried eccentrisk traning Mainly hometraining Balance problems Bilateral tendinopathy = HSR = ECC How to apply the training? ECCENTRIC OR CONCENTRIC 10

11 Eccentric training Slow heavy strength training Summery take home message Tendons can adapt to loading Tendons adapt slower than muscle Still lacking a standardized treatment Eccentric or HSR training may help Prevention through eccentric training is difficult henninglangberg@gmail.com Links to training videos Youtube link to HSR: /look for: Tung langsom styrketræning mod tendinopati Youtube link to Eccentric exercise: /look for: Excentriske øvelser mod tendinopati Or 11