tendon, lig, cartilage

macrotraumatic

microtraumatic

what are 2 categories of CT injuries?

macrotraumatic

(micro/macrotraumatic):

-Imposition of load in excess of tissue tolerance in a single event
-Patient recalls time and place

microtraumatic

(micro/macro)traumatic:

-Associated with repetitive overloading of the involved tissue
-Forces do not exceed tissue tolerance in a single event, but it is the cumulative, repetitive nature of this loading that interferes with the body's normal tissue response and leads to injury
-overuse or chronic injuries

tension
compression
bending
shear
torsion
combined loading

what are different types of forces/stresses that can be placed on CT?

strains

-Indirect muscle injury
-Consequence of combination of muscle lengthening and eccentric action

lengthening
eccentric

muscle strains are the consequence of the combination of muscle ______ and ________ action

true

T/F: Active contraction without stretch is not sufficient to injure muscle

2 joint

type II

muscle strains typically occur in (1/2) joint muscles and muscles with high proportion of type (I/II) fibers

contusion

-direct blow to muscle
Intermuscular or intramuscular

intermuscular
intramuscular

(intramuscular is more concerning because it is within the muscle itself so the fluid build up within the sheath of the muscle creates a lot of pressure)

what are 2 categories of muscle contusion?

which one is worse/more concerning?

strains
contusions
lacerations

lacerations

what are 3 common muscle injuries?

which is least common?

mild (first degree)

grade of muscle strain:

Minimal structural damage
Quick resolution

moderate (second degree)

grade of muscle strain:

-Partial tear
-Large spectrum of injury
-Significant functional loss early on

severe (third degree)

grade of muscle strain:

-Complete tear
-May require aspiration or surgery

Pain
swelling
ecchymosis
muscle weakness

what are some impairments seen with muscle strains?

destruction phase (2 days)
repair phase (3 weeks)
remodeling phase (8 weeks)

what are the phases on muscle healing?

destruction phase

phase of muscle healing:

Necrosis of muscle tissue
Hematoma and edema form
Leukocytes infiltrate

repair phase

phase of muscle healing:

3 steps:
1. hematoma formation- invaded by inflammatory cells and starts to dispose of blood clot
2. Matrix formation - Primary scaffold created, fibroblasts invade and start rebuilding ECM
3. Collagen formation - Fibroblasts produce type I collagen

hematoma formation
matrix formation
collagen formation

what are the 3 steps of the repair phase of muscle healing?

remodeling phase

phase of muscle healing:
-Maturation of myofibrils
-Reorganization & contracture of scar
-Functional recovery

-Dependent on stage of healing
-Promote tissue healing
-Minimize pain and swelling --> PRICE
-Minimize effects of immobilization - Early focus on pain-free ROM
-Restoration of muscle length & strength
-Return to function - monitor pain
-Keep Wolff's law in mind (tissue adaptation to load)

what are some PT interventions/intervention guidelines for muscle strains?

musculotendinous unit

consists of the muscle, the tendon, and the fascia that surrounds the muscle

type III

the connective tissue sheaths at musculotendinous unit are primarily made of which type of collagen?

epimysium --> epitendon
perimysium --> endotendon
endomysium --> endotendon

match the muscle sheath with the tendon sheath it connects into at the musculotendinous unit:

epimysium -->
perimysium -->
endomysium -->

both

musculotendinous unit has (parallel/series/both) elastic components

organized, parallel

tendon is made of Highly _______, ________ collagen fiber bundles

65-80%

type I

_____-______% of tendon is collagen (95% being Type ______)

viscoelasticity

tenocytes (tendon cells)

elastin gives tendons _______

______ sit between collagen fibers in tendons

myotendinous junction
midsubstance
osteotendinous junction

what are the 3 primary sections of tendon macrostructure?

myotendinous junction

part of tendon:

-Interdigitations between muscle and tendon tissues (interlocking fingers- makes it stronger)
-Most common site of muscle strain

midsubstance

part of tendon:

-AKA "midportion" or "free tendon"
-Common site of injury (both overuse and rupture)

osteotendinous junction

part of tendon:

-AKA "enthesis" or "bone-tendon interface"
-Gradual transition from tendon to bone (tendon--> fibrocartilage--> calcified fibrocartilage--> bone)

tendon--> fibrocartilage--> calcified fibrocartilage--> bone

what is the order of the gradual transition from tendon to bone at the osteotendinous junction?

muscle strain

the myotendinous junction is the most common site of _____ _____

•Transmit forces from muscle to bone
•Energy conservation (spring)
•Protect muscle from injury

what are the 3 main functions of tendons?

tension

compression

tendons are designed for (tension/compression/shear)

and

not well suited for (tension/compression/shear)

magnitude
rate

(viscoelastic structure)

tendons response to loading is dependent on ______ and ______ of loading

metabolically

tendons are _______ active

Tenocytes sense load which triggers a biological response (mechanotransduction)

Tenocytes experience shear and compression forces during loading which lead to remodeling

what does it mean that tendons are metabolically active?

decreased tensile strength
decreased collagen organization
increased myofibroblasts
increased inflammatory mediators
increased TSCs differentiating into nontenocytes
increased leukotrienes
increased edema

what is tendons response to excessive loading?

(decreased/increased) tensile strength
(decreased/increased) collagen organization
(decreased/increased) myofibroblasts
(decreased/increased) inflammatory mediators
(decreased/increased) TSCs differentiating into nontenocytes
(decreased/increased) leukotrienes
(decreased/increased) edema

decreased tensile strength
decreased size
decreased collagen production
decreased anabolic activities
increased catabolic activities

tendons response to low/underloading:

(decreased/increased) tensile strength
(decreased/increased)size
(decreased/increased) collagen production
(decreased/increased) anabolic activities
(decreased/increased)catabolic activites

acute
overuse

what are the 2 main categories of tendon injuries?

contusion
total rupture
partial rupture

what are the 3 types of acute tendon injuries?

partial rupture
bursitis
paratendinitis

what are the 3 acute phase overuse injuries of tendon?

tendinopathy

what is the chronic phase overuse tendon injury?

72 (make sure your patient is resting/allowing time for recovery!)

Tendon can take ≥ ______ hrs to recovery after a bout of heavy loading

tendinopathy

Clinical diagnosis of pain, loss of tissue integrity, impaired functional performance in tendon
-umbrella term
-separation of collagen fibers

type III (weaker)

with tendinopathy there is a greater proportion of type _____ collagen

-Separation of collagen fibers
-Type III collagen
-More proteoglycan (protein) and water content
-Neovascularization (blood vessel ingrowth)

with tendinopathy:

-Separation of _______fibers
Greater proportions of Type ______ collagen
(less/more) proteoglycan (protein) and water content
Neo_________

tendinosis

•Degenerative changes in tendon confirmed with histology or diagnostic imaging
•≠ Symptoms

does not (can have degenerative changes of the tendon without feeling any pain at all)

tendinosis (does/does not) = symptoms

tendinitis

tendon injury:
•Implies the presence of inflammatory cells
•Role of inflammation in chronic tendinopathy seems minimal but this topic is highly debated
•Embedded in our language but should be replaced by "tendinopathy"

increase

in general with tendinopathy an increase in load = a ______ in pain

-Isolated tendon/enthesis pain
-Load dependent: ↑ load = ↑ pain
(+) Palpatory tenderness
(+/-) Palpable thickening (superficial tendons)
(+) Sensation of stiffness (AM, prolonged sitting)

what are some of the signs/clinical presentations of tendinopathy?

-Early: Pain/stiffness after activity
-Middle: Pain/stiffness at onset of activity, improves after warm-up, may return after prolonged activity
-Late: Pain at rest, does not improve with warm-up

progression of symptoms with tendinopathy:

early on in injury/disease process=

middle=

late=

change in activity level (or something else that affected load tolerance; may note specific incident that initiated symptoms)

tendon injury/tendinopathy is typically preceded by _______ in _______ ________

Exercise therapy (AKA: mechanotherapy or tendon loading)

what is the best supported treatment for tendinopathy?

tendon remodeling (Improved tendon function, viscoelastic properties, structure, and pain)

what does mechanotherapy aka exercise therapy for tendinopathy treatment promote?

activity modification (type, duration, frequency and intensity)

______ ______ is considered a core component of mechanotherapy

higher (up to a point 90% MVC better than 55% MVC)

slower
longer

dynamic

Tendon appears to respond most favorably (more remodeling) to:

(lower/higher) loads

(slower/faster) speeds
(shorter/longer) duration

(dynamic/static) contractions

-Tendon does not respond differently to different contraction types

-Similar clinical improvements seen with isolated eccentric, isolated concentric, and combined protocols

does contraction type matter for loading a tendon during rehab/treatment?

-Promoted for pain relief in patellar tendinopathy
-Effect not found in Achilles tendon, plantar fascia, or lateral elbow pain

*can be analgesic* - can use isometrics at first but want to progress the patient to more functional exercises as soon as possible

Optimal Loading - What about isometrics?

-Symptom Management/Load Reduction Phase
-Recovery Phase
-Rebuilding Phase
-Return-to-Sport Phase

what are the 4 phases of Rehabilitation of Tendinopathies?

false (the phases are on a continuum-- May perform activities in multiple phases at the same time; some patients may start in later phases)

T/F: the phases of rehab for tendinopathies are set and progress in a linear order one at a time

Symptom Management/Load Reduction Phase

which phase of rehab for tendinopathies?

Goals:
-Halt abusive loading
-Manage symptoms and initiate loading
-Establish/manage expectations
-Establish baseline (outcome measures!)
-Initiate training diary

Patient status:
-Pain at rest or with daily activities

-Daily exercises
-Progress loading up to 100% body weight
-If highly irritable, may need to begin with isometric, aquatic therapy, or some form of bodyweight support
-Begin addressing other impairments & risk factors (proximal and distal joint ROM, strength, endurance)
-Interventions to reduce pain

what are some aspects of treatment during the Symptom Management/ Load Reduction Phase of rehab for tendinopathies?

no-
-Activity modification ≠ complete rest
-Activities that place minimal load on tendon are okay
-Pain-monitoring model (a little bit of pain is okay because means biological changes are happening but dont want excessive pain; to tolerance)

do patients with tendinopathies have to stop working out?

tendinopathy

_______ takes longer to fully recover than many other overuse injuries

does not

for tendinopathy patients: Lack of symptoms (does/does not) mean full recovery

-While possible, that vast majority of patients with painful tendons do not rupture
-Tendon loading exercises may be protective against rupture

what can you tell a patient with tendinopathy that is fearful that their tendon is going to rupture?

-Pain is actually a good sign that the tendon is being loaded enough to stimulate a biological response
-Transient (

what can you tell a patient with tendinopathy that says "I don't want to do anything that hurts, it's going to make it worse!"

true (While have periods of exacerbation, those are usually tied to increased activity)

T/F: recovery from tendinopathy is not linear

-Loading exercises
-Other physical activities (don't forget about occupational demands)
-Pain in the morning
-Highest pain during the day
-Average pain during exercises and physical activities

at minimum what things should a pt record in their training diary?

recovery phase

which phase of rehab for tendinopathies?

Goals:
-Regain strength/endurance
-Improve tendon's tolerance to load

Patient Status:
-Pain with exercise, morning stiffness, pain when performing loading exercises

-Continue/progress loading exercises
-If previously performing isometric exercises, progress to dynamic
-Add external resistance
-Increase speed
-Light energy storage activities (plyometrics)
-Prepare tendon for demands of sport

what are the treatment components of the recovery phase of rehab from tendinopathies?

rebuilding phase

which phase of rehab for tendinopathies?

Goals:
-Progress to heavy loading
-Promote energy storage ability

Patient Status:
-Tolerates the recovery phase exercises well
-Possibly decreased or increased morning stiffness

0Add additional external resistance
-Consider reducing loading exercises to 3x/week; Must be heavy!
-Increase movement speeds of plyometric activities

what are the treatment components of the rebuilding phase of rehab from tendinopathies?

return to sport

which phase of rehab for tendinopathies?

Goals:
-Return patient to full participation
-Continue to improve tendon and lower extremity function

Patient Status:
-Pain-free during daily activities and minimal pain during loading activities

-Continue to progress loading exercises
-Initiate return-to-sport
-Focus on previously aggravating activities (e.g. running/jumping)
-Sport specific training

what are the treatment components of the return to sport phase of rehab from tendinopathies?

Better to perform heavy loading/sports activities on same day with adequate time for recovery

(ex. Mon heavy loading/running or practice, tues-thurs rest days, friday heavy loading/running or practice)

is it better to have multiple days of smaller bouts of heavy loading/sports activities back to back throughout the week or to perform heavy loading/sports activities on same day with adequate time for recovery on the days in between?

true (Use a combination of RPE (0 = Nothing at all, 10 = Very, very hard), tendon RPE, and pain when determining exercise intensity)

T/F: An "easy" workout for the muscle/CV system may not be an "easy" workout for the tendon

•Patient education
•Complete Rest
•Ice
•Activity modification
•Orthotics
•Shoe modifications
•Electric stimulation
•Stretching
•Dry Needling
•Manual therapy
•Laser therapy
•Shockwave therapy
•Therapeutic ultrasound
•Blood Flow Restriction
•Night splinting
•Surgery
•Anti-inflammatories
•Injections (PRP, Corticosteriods)

what are some other treatments that can be used in combo with exercise therapy for tendinopathy? (huge list)

inflammatory (3-7 days)
repair or proliferative phase (3 wks)
remodeling or maturation phase (1 yr)

what are the 3 stages of tendon healing?

inflammatory

phase of tendon healing:

-Begins at the time of injury
-Migration of erythrocytes, macrophages, and neutrophils to injury
-Phagocytosis of necrotic materials occurs
-Leukocytes secrete angiogenic and chemotactic substances causing angiogenesis, stimulation of tendon stem cells differentiation into tenocytes, and initiation of collagen synthesis

repair or proliferative phase

phase of tendon healing:

-Synthesis of Type III collagen with non-collagenaceous proteins & proteoglycans
-Collagen fibers laid down in a random 3D orientation, forming scar in the region of tendon injury

remodeling or maturation phase

phase of tendon healing:

Gradual replacement of the Type III collagen with Type I collagen
Re-orientation of collagen fibrils along lines of strain within the tendon

Achilles
Plantaris
Quadriceps/Patellar
Rotator Cuff
Biceps Brachii (proximal)
Posterior Tibialis

which tendons are the most common to rupture?

Age
Inactivity
Tendinopathy history
Steroid use
Antibiotic use

what things may affect tendon mechanical properties?

Specific tendon ruptured
Full or partial rupture
Functional demand in work/sport

intervention choice (surgical vs. conservative) for tendon rupture depends on what 3 things?

joint stability

(Ligaments are first restraint for joints because muscle hasn't had time to fire yet usually)

ligaments are designed to provide _____ ______

collagen
parallel
strong

ligaments are composed of ______ fiber bundles organized in a _______ arrangement (like tendon, but not as _______)

intrinsic

extrinsic

Ligaments can be either __________, a thickening of the joint capsule (e.g. primary hip ligaments: pubofemoral, iliofemoral and ischiofemoral ligaments),

or ________, free from the joint capsule (e.g. lateral collateral ligament of the knee)

extraarticular (ex. LCL)
intraarticular (ex. ACL)

what are 2 subcategories of intrinsic ligaments?

grade I (mild)

ligament injury grade:

some stretching or tearing of the lig fibers
-mild pain
-little to no swelling
-minimal loss of structural integrity
-no abnormal motion
-minimal bruising
-minimal loss of function
-generally get better on their own

grade II (moderate)

grade of lig injury:
-some tearing and separation of the fibers
-moderate to severe pain
-joint stiffness
-sig structural weakening with abnormal motion
-often associated with hemarthrosis and edema
-tendency to reoccurence
-may need modified immobilization
-may stretch out further overtime

grade III (complete)

grade of lig injury:

total rupture of the lig
-severe pain initially followed by little or no pain (total disruption of nerve fibers)
-profuse swelling and bruising
-loss of structural integrity with marked abnormal motion
-needs prolonged protection
-surgery may be considered
-often permanent functional instability

sprains

ligament injuries are typically ______

a force causing the associated joint being moved into an excessive ROM and excessively lengthening the ligament

what is the most common mechanism of lig injury?

hemorrhagic
inflammatory
proliferation
remodeling and maturation

what are the 4 phases of ligament healing?

hemorrhagic phase

phase of lig healing:

-Blood clot (hematoma)
-Leukocytes and lymphocytes invade and recruit other cells