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Tendinopathy – What’s New?Presented by Ashley Spiegel, SPT
Objectives • Clinicians will…• Be able to differentiate between classifications
of tendon injuries• Understand the etiology and pathology
responsible for tendinopathies• Determine prognosis based on tendon healing
times• Be able to recognize the most common clinical
presentations for Patellar and Achilles tendinopathies
• Be able to prescribe evidence-based treatment options for Patellar and Achilles tendinopathies
True or False?1
Litzy, Karen and Jill Cook. "Busting Tendinopathy Myths". Healthy Wealthy and Smart. N.p.,
2016.
Eccentric exercises are the best and only exercises for patients with tendinopathy.
True or false?
Eccentric exercises are the best and only exercises for patients with tendinopathy.
• Most researched exercise form• Rationale: need for tendon strain > habitual use,
ability to tolerate higher loads in later stages of interventions, and preferentially targeting tendon2
• Actually deficient in being able to restore full function
• Treat the person in front of you!
False
You can use the same protocol to treat any and every tendinopathy.
True or false?
You can use the same protocol to treat any and every tendinopathy.• Principles are the same (to restore function)…• Pain reduction• Strength• Spring restoration • Endurance
• …but treatment should be individualized• Every tendon, every body is different!
False
Tendinopathy always involves inflammation.
True or false?
Tendinopathy always involves inflammation.
• It is a degenerative condition • Inflammation is not driving force of pain or
responsible for continuing the pathology• Pathology – overload of the tendon >
capacity of the tissue • Pain – response of nociceptive system to
the pathology
False
-itis, -osis, -opathy
• What’s the difference?• Tendin-opathy: denotes symptomatic tendon
presentation; does not denote underlying pathology, but that all is not well with the tendon3
• Tendin-itis: inflammation of the tendon that results from micro-tears from acute overload (load or speed)
• Tendin-osis: degeneration of the tendon’s collagen in response to chronic overuse
• Structural expressions of tendinopathy4:• Degeneration/disordered arrangement of collagen fibers • Increase in vascularity• Tendon thickening, but reduced energy-storing capacity • Increased signal intensity (MRI)
• 50% of asymptomatic individuals present with structural abnormalities consistent with tendinosis/opathy5
-itis, -osis, -opathy
• What’s the difference?• Why does it matter?
• NSAIDs, injections indicated for tendinitis are contraindicated for tendinosis due to effects of inhibiting collagen repair
Treatment Goal TimelineTendinitis Reduce inflammation Several days – 6 weeksTendinosis Break cycle of injury;
reduce ground substance, pathologic vascularization, and tendon thickening; optimize collagen production
6 weeks – 6 months
Tendon Healing Times
• Inflammatory phase: 1-2 days post injury
• Proliferative/reparative phase: 2 days-3 weeks post injury
•Remodeling phase: 1 month+ post injury
After return to sport, your patient does not have to continue with PT exercises because their tendon has healed.
True or false?
After return to sport, your patient does not have to continue with PT exercises because their tendon has healed.
• Pathology (degeneration in tendon) never changes
• Cortical integration highly associated with tendinopathy• Fear avoidance
• Continue strengthening for 12 months after return to sport as insurance!
False
Clinical Presentation and Evidence-Based Practice
A closer look at patellar and Achilles tendinopathies
Patellar Tendinopathy • Clinical presentation:• Localized pain at inferior pole of patella• Load-related pain that increases with
demand on knee extensors• Jumping athletes
• Differential Diagnosis:• Hoffa’s fat pad• PFPS• Osgood-Schlatter’s• Sinding-Larsen-Johansson
Patellar Tendinopathy • Clinical diagnostic tools6:
• Single-leg decline squat (SLDS)• Single leg squat performed on 30° decline ramp
from knee extension to 30° knee flexion• +ve with patellar pain during squat
• VISA-P questionnaire• 8 questions: 6 related to patellar tendon pian
during functional/sports activities, 2 realted to level of sports performance
• Scores < 80 indicative of patellar tendon abnormalities (PTA)
• Tendon pain history • Self reported patellar tendon pain
Patellar Tendinopathy • EBP treatment7:• Eccentric (ECC) – single leg decline squat• Heavy Slow Resistance (HSR)- bilateral
squats, hack squats, leg press• No significant differences!
• 4 stage progression• Isometric• Isotonic• Energy-storage• Progressive return to sport
Malliaras et al.7
Achilles Tendinopathy • Clinical presentation:• Localized pain at Achilles insertion above calcaneous • Load-related pain that increases with demand on
plantar flexors• Runners• Recent change in training program
• Differential diagnosis• Retrocalcaneal bursitis• Posterior ankle impingement• Posterior tibialis tendinopathy• Neural tension
Achilles Tendinopathy • Clinical diagnostic tools:• VISA-A questionnaire• 8 questions: 6 related to Achilles
tendon pain during functional/sports activities, 2 related to level of sports performance
• Scores < 80 indicative of Achilles tendinopathy
• Tendon pain history • Self reported Achilles tendon pain
Achilles Tendinopathy • EBP treatments8:• Eccentric (ECC) – single leg heel lowering
on incline step• Heavy Slow Resistance (HSR) - bilateral seated calf raise, calf raise on leg press, standing calf raise
Achilles Tendinopathy • EBP treatments8:• Eccentric (ECC)• Heavy Slow Resistance (HSR)• Assessed VISA-A, VAS during heel raises
and running• No significant differences between ECC
and HSR groups!• Both treatment approaches yielded
positive clinical results short- and long-term
Clinical Bottom Line
• Educate your patients – prognosis, timeline
• Variety of successful, evidence-based treatment options for patellar and Achilles tendinopathies
• Not all tendons are created equal – treat the person in front of you!
References 1. Litzy, Karen and Jill Cook. "Busting Tendinopathy Myths". Healthy
Wealthy and Smart. N.p., 2016.
2. Michener, Lori A., and Kornelia Kulig. "Not All Tendons Are Created Equal: Implications for Differing Treatment Approaches." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 45.11 (2015): 829-32.
3. Vicenzino B. Tendinopathy: Evidence-Informed Physical Therapy Clinical Reasoning. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy. 2015;45(11):816-818.
4. Scott, Alex, Ludvig J. Backman, and Cathy Speed. "Tendinopathy: Update on Pathophysiology." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 45.11 (2015): 833-41.
5. Ryan, Michael, Leanne Bisset, and Richard Newsham-West. "Should We Care About Tendon Structure? The Disconnect Between Structure and Symptoms in Tendinopathy." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 45.11 (2015): 823-25.
References 6. Mendonça, Luciana De Michelis, Juliana Melo Ocarino, Natália Franco
Netto Bittencourt, Ludmila Maria Oliveira Fernandes, Evert Verhagen, and Sérgio Teixeira Fonseca. "The Accuracy of VISA-P Questionnaire, Single-Leg Decline Squat and Tendon Pain History to Identify Patellar Tendon Abnormalities in Adult Athletes." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy (2016): 1-22.
7. Malliaras, Peter, Jill Cook, Craig Purdam, and Ebonie Rio. "Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 45.11 (2015): 887-98.
8. Beyer, R., M. Kongsgaard, B. Hougs Kjaer, T. Ohlenschlaeger, M. Kjaer, and S. P. Magnusson. "Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial." The American Journal of Sports Medicine 43.7 (2015): 1704-711.