International Scientific Tendinopathy Symposium, Vancouver, 2012
Session 2
TENDINOPATHY – MORE QUESTIONS
THAN ANSWERS – Henning Langberg
Studies demonstrate a ceiling
response to exercise
Habitual unilateral high load
results in an increase in strength in the leading leg with a correlation in the
size of the patellar tendon
Increase size & stiffness might indicate an increased ability to load
Overload of the muscle tendon unit results in quicker adaptation in the
affected muscles in comparison to tendons
Response to chronic overload - healing response
Injury = ? Failed healing
Failure to balance the degeneration & regeneration (synthesis) of the
tendon in response to exercise
Heavy slow resistance training
achieved improved collagen structure & improved patient response in
comparison to eccentric or corticosteroid
Patient should experience pain
during loading
Norregaard, J et al (2007). Eccentric exercise in treatment of Achilles
tendinopathy. Scand J Med Sci Sports;
17(2): 133-8
OVERVIEW OF TENDINOPATHY
REHABILITATION – Jill Cook
Focus on pain first for the
patient & function for elite athlete
Deren et al - PRP
injections...all testimonials or case reports
Load is the only thing that will restructure the matrix & load the cell
appropriately
Are eccentrics the only exercise needed?
Yes: load the elastic component
No: don't strengthen muscles, or
restore musculotendinous strength
Isotonic contractions seem to work just as well as eccentric exercise
Correct load must account for stage of tendinopathy, age etc. etc.
Continuum - if reactive tendinopathy, non irritating loads; if disrepair
the matrix needs to be restructured by load
Tendons take longer to respond to load than muscle
However, without load tendons lose function with degradation in the matrix
& cell
Slower, less, intense loading less likely to upregulate the tenocytes...isometrics
fulfill that role
Sustained 45 second holds away from compression & pain with loads as heavy
as possible, machine based if possible. Slower loads first, then later
increase speed with both concentric & eccentric phases.
Loads that exceed the tendon capacity are detrimental
A KNOWLEDGE TRANSLATION INITIATIVE TO ENHANCE EVIDENCE-INFORMED CLINICAL MANAGEMENT OF ACHILLES TENDINOPATHY - Alison Hoens & Alison Ezzat
It takes approximately 17 years
to get 14% of research findings adopted into practice...
THE JUMPER’S KNEE PARADOX. JUMPING ABILITY & CHANGE OF JUMPING ABILITY AS RISK FACTOR FOR DEVELOPING JUMPERS KNEE - Havard Visnes
Volleyball demands 100-300 jumps
per match
Jumping ability is a risk factor
for jumper’s knee
Jump testing of counter movement & standing jumps using a portable force
plate
Those male subjects that went on to develop jumpers knee, achieved better results
in the counter movement jump, whereas there was no difference detected between subjects
in the standing jump
Clinical Implications - Jump counts for young athletes, like young baseball program's
limitations on innings
THE EFFECTIVENESS OF AN INTENSIVE EXERCISE PROGRAM IN THE FUNCTIONAL RECOVERY OF A SEVERE DEGENERATIVE ACHILLES TENDINOPATHY. IS IT ENOUGH BY ITSLEF? A CASE REPORT- Daniel Martinez Silvan
Case study - 33 year old
footballer
Intrinsic, extrinsic &
environmental factors (training) for injury
Intervention:
1) Orthotics
2)
Medical (ibuprofen
post exercise & single methylprednisolone injection in the paratenon
initially)
3)
Exercise - specific
Achilles exercises commencing with isometric to concentric, then eccentric,
explosive & stretch-shortening cycle combined with EMS, adding load, then
adding velocity
4) Functional retraining & general
health measures (aerobic exercise & weight loss)
Criteria 1) effort perception
(70-80%) of max
Criteria 2) load response
Clinical implications –
exercises focussed on the strengthening of the muscle tendon unit &
recovery of musculotendinous function were effective in the treatment of
degenerative tendinopathy
ADVANCES IN US IMAGING - Hans Van Schie
Ultrasound tissue
characterisation – enables visualisation of tendon structure, using a
high-resolution probe, fixed in a tracking device, which moves automatically
along a tendon’s long axis to provide reproducibly objective images that can be
used to monitor the progress of pathology or repair.
3D ultrasound, giving early
detection of matrix degradation
Transverse images are collected
each 0.2mm over a 12cm long axis of a tendon
Using the reflections of the
pixels, the UTC algorithms can discriminate between 4 different echo types:
1) Echo-type 1 generated by reflections at
intact & aligned tendon bundles
2)
Echo-type 2
generated by reflections at discontinuous or wavy tendon bundles
3)
Echo-type 3
generated by interfering echoes from mainly fibrillar components
4) Echo-type 4 generated by mainly
cellular components & fluid in amorphous tissue.
Inter- & intra-observer
reliability of both data collection & analysis is high (ICC over 0.90),
which indicates the method has excellent reliability for longitudinal
monitoring
Clinical implications: enables monitoring & detection of pathological
tendons before they structure becomes symptomatic, whilst also accurately
monitoring the response to load in tendon structures
Docking, S.I. et al (2012). Tendon structure changes after maximal exercise
in the thoroughbred horse: Use of
ultrasound tissue characterisation to detect in vivo tendon response. Vet J;
DOI: 10.1016/tvjl.2012.04.024
THE LOCATION OF PATHOLOGY IN PATELLAR TENDINOPATHY - Jonathon Rees
Results of the retrospective analysis of 143 scans in a military rehabilitation
setting confirmed that patellar tendinopathy is not restricted to the proximal
pole.
Whilst proximal tendon issues were
most common, distal pole involvement was also common (occurring in 38% of scans). Mid patellar tendon involvement was less
common & the vast majority of cases involving the mid tendon occurred in
conjunction with either the proximal or distal poles.
Deep tendon pain most prominent, more markedly so in the proximal tendons
Pain predominantly central throughout
Clinical implications:
1) When scanning the patellar tendon, all
the anatomical areas should be scanned carefully, including the distal pole
2)
The term “patellar
tendinopathy” is imprecise & insufficient & as such the abnormalities should be referred
to as occurring at a specific site
3)
The term “jumper’s
knee” is imprecise & should be abandoned
4) Future studies should stratify for the
location of pathology in the patellar tendon as different treatments many have
different results depending on the location of the pathology
Archambault, J.M. et al
(1998). Can sonography predict the
outcome in patients with achillodynia? J Clin Ultrasound; 7: pp335-339
MORPHO-TEXTURAL CHANGES OF THE PATELLAR LIGAMENT IN PROFESSIONAL VOLLEYBALL PLAYERS: SIX MONTHS LONGITUDINAL STUDY - Ana de Groot-Ferrando
Textural analysis of ultrasound
images with grey level co-occurrence matrix (GLCM) is based on the comparison
of grey levels of pairs of pixels, which builds a matrix of co-occurrence
probability along the entire image.
The study aimed to determine
morpho-textural parameters of the patellar ligament in professional volleyball
players along one season
An observational longitudinal &
analytical study was designed with 66 cross-sectional ultrasonograms of
patellar ligament in male players
Validation of morphometry prior
to testing
The subjects were examined at 35
degrees knee flexion at the beginning & end of the season (6 months)
Echogenicity & echogenicity variation showed no significant changes along
the season
The width of the Patellar tendon
increases, whilst the thickness decreases, with the tendon losing circularity
as the season progresses
It was concluded that the
mechanical stress can generate adaptive changes in the tendons
Clinical implications – textural
complex algorithms provide information about the ultrasonography patterns,
although future studies should look to evaluate the relationship between
biochemical markers & textural parameters
Rios-Diaz, J. et al (2011). Discriminant analysis of the ultrasonographic
textural pattern with co-occurrence matrices as a new tool for ultrasonographic
analysis of tendon. Fisioterapia; 33(4):
pp157-165
Rios-Diaz, J. et al (2010). Reliability & reproducibility of a morpho-textural
image analysis method over a patellar ligament ultrasonography. Rheumatol
Clin; 6(6): pp278-284
TENDON RESPONSE IN ACHILLES TENDON OF AUSTRALIAN FOOTBALL PLAYERS USING ULTRASOUND TISSUE CHARACTERISATION - Sam Rosengarten
Football players experience high measurable loads, with a bias towards ballistic
movements, requiring high demands on the energy storing structures of which
tendons are some of the most important
Literature suggests that adaptation only occurs to maturity, so many players
have been subjected to very high loads & demonstrate tendon changes before
they arrive at the club
Docking et al (2012) was replicated with players in an ARFL setting
Tendon scanning position was
standardised in a knee to wall lunge position
Preliminary data analysis showed differences in baseline tendon structure in
players with & without a history of lower limb tendinopathy
Echo types changed for two days
post game but returned to baseline levels on day 4, with an even scattering of
type two tissue changes, suggesting that tendons were shown to be responding to
load
Clinical implications – UCT can
be used tom monitor individual responses to load, which will vary depending on
past history of tendon health
Docking, S.I. et al (2012). Tendon structure changes after maximal exercise
in the thoroughbred horse: Use of
ultrasound tissue characterisation to detect in vivo tendon response. Vet J;
DOI: 10.1016/tvjl.2012.04.024
ULTRASOUND GUIDED MEDICAL INTERVENTIONS FOR CHRONIC TENDINOPATHY - Kim Harmon
Biologic therapies such as autologus blood & platelet rich plasma
injections, aimed at stimulating healing of degenerative tendons, have shown
promise but clinical research is limited
Study was conducted on patients
over 18 with a 3 month or longer history of chronic tendinopathy & a
history of failed conservative treatment
Tendons were evaluated with MSK
ultrasound & patients received either AB or PRP (leukocyte rich) or PRP
(leukocyte poor) injection under US guidance.
Outcome measures - battery of
questionnaires over regular periods over the year
Study was poorly designed, with allocation
of injections dictated by cost & demand.
Therefore, there was potential for psychological bias in treatment
response & physician influence.
Results suggested some moderate
effect of injections in the treatment of recalcitrant tendinopathy but can’t
read too much into the scientific value of the results.
