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London, England
Wednesday 7th November 2012
After a couple of weeks back in the UK, everything seems to be settling down into somewhat of a routine...something I haven't really been used to over the last 6 months.  Meanwhile, the games of musical chairs, with athletes changing coaches, seem to have come to an end & those that remain in the HiPAC also seem to be settling back into their routines of off-season training.  

It seems that life in the sports physiotherapy world just goes on & the World keeps turning, despite the fact that I remain somewhat in limbo, not knowing what the imminent changes at UK Athletics are going to hold in store for me or the human performance department as a whole.

In the quiet moments since being back in Lee Valley on a regular basis, I have now managed to finish reviewing & writing up all my notes from the International Scientific Tendinopathy Symposium in Vancouver.  Where possible I have provided links to PDFs of the references, so you can read the papers alongside my notes.


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

 

Kingma, J.J. et al (2007).  Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review.  Br J Sports Med; 41(6): e3

 

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

 

Van Schie, H.T. et al (2010).  Ultrasonographic tissue characterisation of human Achilles tendons: quantification of tendon structure through a novel non-invasive approach.  Br J Sports Med; 44(16): pp1153-1159 

 

 

 

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

 

Hoksrud, A. et al (2008),  Colour Doppler ultrasound findings in patellar tendinopathy (jumper’s knee).  Am J Sports Med; 9: pp1813-1820





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

 

 

Arampatzis, A. et al (2007).  Adaptational responses of the human Achilles tendon by modulation of the applied cyclic strain magnitude.   J Exp Biol; 210 (pt 15): pp2743-2753  

 

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

 

Kongsgaard, M. et al (2005).  Structural Achilles tendon properties in athletes subjected to different exercise modes & in Achilles tendon rupture patients.  J Appl Physiol; 99(5): pp2743-2753





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.





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