Lecture 7: Tendon Injury

________ causes can create tendinopathy

Frictional causes can create tendinopathy

What is the first treatment for tendon injury caused by a compressive force?

To get rid of the extrinsic force causing the irritation

What are the two broad categories of how tendon damage can occur?

• Load amount/pattern increases because of functional demands AND tendon composition remains the same

• Tendon composition changes AND load remains the same

When does tendon have the greatest amount of stretch and is the longest?

Just before the eccentric turns to concentric

Mechanical load can initiate a(n) _________ response which leads to…

Mechanical load can initiate an inflammatory response which leads to matrix destruction

What is the theory of “failed healing?”

• Results in chronic tendon conditions (tendinopathy)

• Stuck in Fibroblastic Phase (2nd Phase)

• Matrix metalloproteinases (MMPs) don’t shut off and collagen degradation continues

What is indicative of a failed healing response? (Hint: collagen)

• Unequal and irregular crimping (loosening of the waviness pattern)

• Increase in Type III collagen

When tendon injuries become chronic, markers of _________ are no longer present.

When tendon injuries become chronic, markers of inflammation are no longer present

What three factors predispose tendon to chronicity?

1. Injury

2. Repeated mechanical stress

3. Tissue hypoxia

What are some extrinsic risk factors for developing tendon injuries?

Extrinsic — those acting externally on the body

• Excessive loading

• Training errors

• Improper equipment

• Environmental elements

What are some intrinsic risk factors for developing tendon injuries?

Intrinsic — those acting within the body

• Muscle imbalances

• Muscle / joint mobility restrictions

• Limb dominance

• Leg-length discrepancy

What factors affect tendon tolerance?

• Aging (less compliant tendon)

• Immobilization / Disuse

• Co-Morbidities

  • Diabetes / Obesity (affects healing)

  • Hypercholesterolemia (fatty deposits in tendon, muscle, etc.)

  • Hypertension (associated with tendon pathology)

• Pharmacologic Agents

  • Anti-Inflammation

  • Fluoroquinolones

  • Statins

Treatment should be based on _________.

Treatment should be based on symptoms

What treatment should we be giving to someone in the inflammatory phase of tendon injury?

PRICE principle to prevent prolonged inflammation

Other Treatment Considerations:

• ROM (PROM, go until pain which is prior to end-feel)

• Short holds (2-5 seconds, <10 sets)

• Strengthening: Isometrics in pain-free range

What treatment should we be giving to someone in the fibroblastic phase of tendon injury?

Gradual introduction of stress

Treatment Considerations:

• Low load, high reps (for strength)

• Longer holds (30-60 second holds)

• Pain at end-feel

• Beginning to switch focus from ROM → strengthening

What are the goals of treatment in the fibroblastic phase?

• Increase collagen synthesis

• Improve collagen alignment

• Prevent excessive atrophy

What treatment should we be giving to someone in the maturation phase of tendon injury?

Focus shifts to strengthening

Treatment Considerations:

• High load, low reps

• Pain past end-feel

• Longer holds (30-60 seconds, higher intensity)

What are the goals of treatment in the maturation phase?

• Increase cross-linking of collagen

• Increase fibril size (in order to optimize tissue healing)

For an individual in chronicity, we should treat them like they are in what phase of healing?

Treat them like they are in the maturation phase → either will put individual back to proper inflammation or body will lay down “better CT”

What is paratendinopathy?

Inflammation of the paratenon

What is occurring with acute tendinopathy? What is another term for this type of tendinopathy?

Tendinitis

• Tearing of the tendon fibers

• Inflammation is present

What is occurring with chronic tendinopathy? What is another term for this type of tendinopathy?

Tendinosis

• Increased cellularity

• Fibril disorder

• Neovascularization

• (May create an inflammatory situation)

How do we treat someone with chronic tendinopathy (tendinosis)?

Treat with progressive loading exercise

What is pantendinopathy?

Inflammation of the sheath plus degenerative changes of the tendon

If someone’s tendon disorder was classified as “Level 1”, what is their pain and disability like?

Pain: no pain

Disability: no effect on activities

If someone’s tendon disorder was classified as “Level 2”, what is their pain and disability like?

Pain: with extreme exertion; strops when activity ceases

Disability: little to no effect on activities

If someone’s tendon disorder was classified as “Level 3”, what is their pain and disability like?

Pain: with extreme exertion; lasts 1-2 hours afterward

Disability: will still participate but likely limited with strenuous activities

If someone’s tendon disorder was classified as “Level 4”, what is their pain and disability like?

Pain: with moderate exertion; lasts 4-6 hours afterward

Disability: performance levels decreased; unable to perform some necessary tasks

If someone’s tendon disorder was classified as “Level 5”, what is their pain and disability like?

Pain: with any type of exertion; rapidly increases intensity; lasts 8-24 hours

Disability: causes immediate withdrawal from activity

If someone’s tendon disorder was classified as “Level 6”, what is their pain and disability like?

Pain: during daily activities

Disability: unable to participate in any sports; daily activities may also be restricted

What “Level” does a Physical Therapist tend to see someone at?

Level 4-5

What “Level” is considered to be chronic?

Level 6

What are the stages of tendinopathy?

• Reactive Tendinopathy

• Tendon Dysrepair

• Degenerative Tendinopathy

What are the general considerations for reactive tendinopathy?

• Non-inflammatory proliferative response in the cell and ECM (secondary to tensile or compressive loads)

• Short-term thickening of the tendon (reduces stress; increase stiffness)

• Collagen integrity maintained

• Capable of reverting to normal with appropriate reduction of load or rest between

What are the imaging findings of reactive tendinopathy?

General Findings:

• Slightly swollen tendon appearance

• Increased diameter

MRI Findings:

• Minimal or no increased signal

Ultrasound Findings:

• Intact collagen fascicles

• Diffuse hypoechogenicity (“decreased echo” — US looks darker)

What are the clinical factors of reactive tendinopathy?

• Acute tendon overload

• More common in younger population

• May be related to moderate overuse in the underloaded tendon (e.g., sedentary individual; detrained athlete)

What are the general considerations of tendon dysrepair?

• Similar healing process but with greater ECM breakdown

• Increased cellular activity and protein production

• Neurovascular ingrowth

What are the imaging findings of tendon dysrepair?

General Findings:

• Collagen and matrix disorganization

• Swollen tendon

MRI Findings:

• Swollen

• Increased signal in the tendon

Ultrasound Findings:

• Discontinuous collagen fascicle

• Focal areas of hypoechogenicity

• Increased vascularization

What are the clinical factors of tendon dysrepair?

• Chronically overloaded tendons in young or older individuals

• Localized tendon thickening noted with palpation

What are the general considerations for degenerative tendinopathy?

• Substantial ECM breakdown and disorganization

• Neovascular ingrowth

• Areas of cell death

What are the imaging findings of degenerative tendinopathy?

General Findings:

• Extensive cellular, ECM, and vessel changes

MRI Findings:

• Increased tendon size and intratendinous signal

• Focal rather than widespread diffuse intratendinous change

Ultrasound Findings:

• Hypoechoic areas with reduced collagen fascicle continuity

What are the clinical factors of degenerative tendinopathy?

• Chronically overloaded athlete

• More commonly see in older individuals

• Focal areas of tendon thickening (not necessarily widespread or homogenous)

• Frequently related to recurrent history of overload

Achilles Injury typically occurs due to…

Strenuous running

What are main symptoms of an achilles injury?

• Pain

• Popping

Higher loads leads to ________ amounts of deformation

Higher loads leads to greater amounts of deformation

What is angiofibrotic hyperplasia?

Degenerative process which is a precursor to failure (patient does not have enough time to heal)

When tendon undergoes a surgical repair, what occurs to the tendon sheaths?

They often become compromised (adhesions developed; scarring)

What factors are known to contribute to adhesion formation?

• Tendon suture

• Sheath injury

• Immobilization

With tendon repair, what occurs to the material strength within 4-5 days?

There is a dramatic drop in material strength

Most protocols call for immobilization for ___ weeks.

Most protocols call for immobilization for 3-4 weeks.

What movement may be allowed during the ‘immobilization period’ for tendon repair?

There may be passive movement allowed in the direction of shortening of the tendon; especially in long tendons

With an individual who underwent tendon repair, after immobilization what stage of healing would we use for treatment protocol?

Remodeling stage (for increased tendon strength and gliding)

Long tendon repairs (e.g., flexor tendons) have the best results with…

Immediate, controlled passive mobilization

• Led to better material properties

• Improved viscoelastic properties (greater gliding, function, and less scarring)

What are the benefits for early mobilization of short tendon repairs?

No real benefit for early mobilization (compared to delayed mobilization in long term outcomes)

• Can lead to faster recovery of ROM (but really depends on strength of tissue — too much early motion = increased risk for failure

Are steroids beneficial for tendonitis?

Can initially decreases inflammation, but inhibits collagen synthesis (which weakens the tissue)

What are the current guidelines for steroid injections?

No more than 3 injections in 1 year

Overuse leads to reduced tendon strength at which interfaces?

Musculotendinous or Ligament/Bone Interfaces

What are the benefits to Human Recombinant Epidermal Growth Factor (hrEGF)?

Improves…

• Neovascularization

• Tenocyte prevalenece

• Collagen synthesis

Which all leads to increased and accelerated tissue healing

What does “Platelet-Rich Plasma” (PRP) do for healing?

“Kick starts” the inflammatory phase of healing

Are there any side effects to PRP?

Not many side-effects (and since plasma is auto-donated ,there is no chance of rejection)

Research is inconclusive — timing and dosage is not clear

In what type of patient is PRP typically used? Why?

Used in patient’s in chronic inflammatory states to get the environment in the inflammatory phase

You can get better results when you couple PRP and _______.

You can get better results when you couple PRP and exercise (including eccentric)

What are the different types of High Volume Injection (HVI)?

• Steroid

• Saline

• Local Anesthetic

What are the pros and cons to High Volume Injection (HVI)?

Pros: works better than PRP in the short term

Cons: same side effects as steroid injections long term

What are the effects of NSAIDs on healing?

• Enhance the healing process of collagen and protect the healing ligament in tendon (in the short term)

  • Long term use can reverse these effects

• NSAIDs increase blood flow to injured tissue

T/F: A patient on pain meds is at an increased risk for tissue damage.

True (pain perception is less)

How does hormone therapy (e.g., birth control) affect tendon and ligaments?

Increase laxity and lead to hypermobility

Diagnostic imaging tests look for ________ of tendon or ligament for diagnosis, but the _________ properties can be affected without ____________ of the tissue structure.

Diagnostic imaging tests look for intactness of tendon or ligament for diagnosis, but the mechanical properties can be affected without gross disruption of the tissue structure.

T/F: Complete failure of collagen fibers does not present as visually intact tissue

False (complete failure of collagen fibers can present as visually intact)

Can joint displacement occur because of tissue failure?

Yes

What are the general treatment principles for tendinopathy?

• Identify & remove negative external forces/factors

• Establish stable baseline treatment

• Determine tensile load starting point

• Use symptoms to guide loading

• Control pain

• Address use of whole kinetic chain

• Employ specificity

• Use maximum loading

• Load progression

What are the types of treatment you may use for a patient in the inflammatory phase? What are the goals during this phase?

Goals: decrease pain and edema

Treatment Types:

• May immobilize

• PRICE (protect, rest, ice, compression)

• Gentle soft tissue work

• Modalities

• Pain-free ROM

• Avoid excessive contracting muscle

What are the types of treatment may you use for a patient in the proliferative phase? What are the goals during this phase?

Goals: Lay down new collagen in functional pattern

Treatment Types:

• Increase motion

• Gentle tensioning of tissue (increases collagen production and decreases time need for healing)

• Eccentric exercise can be initiated

• Increase rate of loading as progression

• Small amplitude tensile loads (provides anti-inflammatory stimulus)

During the proliferative phase, the tissue is…

Fragile, we must be careful since we don’t always know the strength of the tissues

What are the types of treatment may you use for a patient in the maturation phase? What are the goals during this phase?

Goals: restore full pain-free function, increase strength, endurance, and restore neuromuscular coordination

Treatment Types:

• Functional exercises

  • Manipulate reps, intensity, and sets to focus on different types of muscular performance

When doing functional exercises in the maturation phase, what do we need to consider / take into account?

• Variation of loading rate

  • Higher rates with frequent loading can take tissue from fatigue → failure quickly (slower controlled rates of motion are more desirable)

• Fatigue considerations (especially in relation to viscoelastic properties)

• Time maintenance of low loads (affects creep properties; will cause stretching when desired)

• Fast loading rates of bone/ligament/bone produce more load at the mid-ligament region

  • Slow rates of loading → avulsion injuries (use moderate rates of loading)

When performing strength training, we need to consider increasing ______ before increasing _______.

When performing strength training, we need to consider increasing reps before increasing intensity.

When using isometric and resistance training, how long does it take to see increases in stiffness of tendon?

US studies show increases with 4 days/week x 12 weeks

We let _____ guide our progression

We let pain guide our progression

What type of stretching produces the greatest long-term increases in tissue length?

Cyclic stretching over time produces the greatest long term increases in tissue length; minimum of 30 seconds (60 seconds is better)

Long term stretching can cause a reduction in…? How does this alter the collagen fiber?

Long term stretching can cause a reduction of water content in tendon/ligament. This leads to a more brittle collagen fiber

What is the purpose of neuromuscular training as a treatment strategy?

Improves the quality and control of the movement first (including using the whole kinetic chain)

What is the purpose of taping and bracing as a treatment strategy?

Increases proprioception and many claim that it reduces pain (no functional studies show any objective improvement)

When would orthoses be a helpful treatment strategy?

If foot posture is the cause of stress on the tendon (otherwise it will likely not help)

When would dry needling be a helpful treatment strategy?

Currently, only has evidence to support use in Achilles and Subacromial Pain Syndrome

What types of manual therapy may be used as an alternative treatment strategy?

• Mobilization with Movement (MWM)

• Transverse Friction Massage

• ASTM (kind of like graston)

What is the purpose of shockwave therapy?

Increases the production of cytokines, which therefore increases fibroblastic activity