Jill Cook: Professor Monash University , Melbourne Australia.


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Managing Tendinopathy in season

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Jill Cook: Professor Monash University , Melbourne Australia.

  1. 1. Treating athletes with tendinopathy in season Jill Cook 5th MuscleTech Network Workshop Barcelona 2013
  2. 2. Why are tendons a problem? •  Disabling –  Athletes unable to perform at their usual level •  Lose power –  Jumping, change of direction, deceleration –  Anti-gravity tendons affected most »  Achilles, patellar •  Slow to respond –  Very happy to give bone and ligament weeks to recover yet we expect tendons to be ready the next week –  Collagen turnover may be non–existent or very limited after puberty •  Heinnemeyer et al 2013
  3. 3. Is the problem pathology or pain or both? •  Interesting question –  Pain & pathological change are unrelated •  Mainly pain –  Stops function, stops performance –  May not have (imaging) pathology •  But can be pathology –  Tendons rupture if not enough intact tendon left to take load •  Quantity of intact tendon may be the key factor •  Can be painfree prior to rupture
  4. 4. When does tendinopathy occur? •  Both pain and pathology occur when the load placed on the tendon exceeds the tendons capacity •  Load has to include –  Energy storage and release •  Tendon acting as a spring –  Compression •  Against bone or retinacular structures –  Combination of both
  5. 5. Sequence of pathological events"
  6. 6. What is the tendon response to overload? Mechanically weaker tendon Sedentary Normal or excessive load +/- individual factors Optimised load Normal tendon Excessive load + individual factors Appropriate modified load Optimised Load Adaptation Strengthen Reactive tendinopathy Tendon dysrepair Degenerative tendinopathy Cook & Purdam 2009
  7. 7. This is what we want Optimised Load Normal tendon Pathological tendon Adaptation Strengthen the normal part of the tendon •  Balance between load capacity of the tendon and the load placed on it •  Load must always be close to what is required in sport otherwise the tendon capacity will decrease •  Like bone, use it or lose it
  8. 8. This is what we often get •  Reactive after unloading Mechanically  weaker  tendon   –  Unloading decreases •  Tendon mechanical properties •  Tendon capacity to tolerate load –  Present after a period of time off •  Injury, off-season –  Return to loading at previous levels •  Tendon reacts to load Normal   or  excessive   load  +/-­‐   individual   factors   Unloaded Normal tendon    Reac<ve  tendinopathy  
  9. 9. What about the commonest clinical presentation? • An  increase  in  pain  is  most  likely  to  be  a  degenera<ve  lesion   Your key forward with  some  reac<ve  aspects   who has occasional • What  causes  a  degenera<ve   starts ecome   Achilles tendon paintendon  to  ba reac<ve?   • Mismatch  between  load  tolerance  and  capacity  of  the   plyometric program andt  then hobbles tendon  and  the  load  placed  on  i •  egenera<ve  tendon  bears  liEle   oad   in forDtreatment a couple lof days later Normal  tendon   Degenera(ve  area   Reac(ve  tendon   Degenera(ve  area  
  10. 10. Management of in season tendinopathy
  11. 11. Aetiology •  A change in load –  One session or over several sessions •  One session –  Single high intensity session –  Direct blow •  Several sessions –  Increased frequency of training esp high loads –  Pre-season training! •  Either –  Different drills »  Sprints at the end of training –  Change in footwear –  Change in track/surface »  Soft sand »  Uneven surfaces
  12. 12. Treating tendons in season •  Challenges –  Full rehabilitation is impossible –  Kinetic chain dysfunction increases over season –  Activated tendon difficult to settle when abusive loads continue Visnes  et  al  2005   •  Research –  Eccentric exercises do not help »  Visnes et al 2005, Fredberg et al –  ESWT does not help »  Zwerver et al 2011 Zwerver  et  al  2011  
  13. 13. Bases of tendon management in season –  Define the stage of tendinopathy •  Assume it is reactive or reactive on degenerative –  Quantify tendon symptoms and kinetic chain function •  Subjective •  Objective –  Modify load •  Training •  Biomechanical, kinetic chain –  Maintain whatever you can •  Strength, power
  14. 14. Bases of reducing in season tendon pain •  Reduce the sensitisation of the tenocytes –  Key if the cells are the source of pain •  Attempt to reduce the proteoglycan deposition in the matrix –  Key to prevent further matrix disruption and poorer load tolerance •  Local interventions to the neurovascular structures
  15. 15. What are we trying to achieve with in-season rehab? •  Maintain/improve function of muscle •  Unload the affected tendon –  Maximise other contributions to the kinetic chain •  Avoid exacerbation of the tendon –  Load management •  Unload and load appropriately •  Prioritise performance and pain control
  16. 16. How do we do manage tendinopathy with unloading? •  Decrease frequency of high tendon load –  Energy storage and release –  Train every second or third day •  Decrease length of loading –  Shorten training •  Decrease load in training –  Take out key overloads •  Drills and training that excessively load the tendon •  Decrease compressive loads –  Specific movements and drills
  17. 17. Reload appropriately •  Isometric loading –  Great to decrease pain in a reactive tendon –  Mechano-transduction •  Cells are activated and producing excess proteins –  Slower/less intense loading less likely to up-regulate the tenocytes •  Cells are integrally connected to the matrix –  Connections through proteoglycans and integrins with connection through to the cell nucleus –  Through cilia (Lavorgnino) »  Alter gene expression in response to mechanical load •  So attempt to load the tendon without stimulating cell through matrix movement
  18. 18. How we use it in tendons •  Sustained contraction –  Away from compression –  Short tendon length –  Often have no or little pain •  Heavy loads –  Needs to be machine based is possible •  Don’t be shy with load •  Research loads are 80% MVC, 4 x 45 sec holds •  Avoid exercise that requires postural control –  Seated or lying –  If standing, good support •  Do 3-4 times a day if needed –  Immediate and sustained pain relief –  Can be done pre training and playing •  No detriment to function •  Even post playing
  19. 19. Can imaging help in season? •  Ultrasound tissue characterisation (UTC) –  Improve staging and diagnosis –  Detect asymptomatic changes in tendon structure –  Determine load tolerance in at risk tendons –  Monitor recovery of structure independent of symptoms
  20. 20. Ultrasound tissue characterisation Echotype  I-­‐  Intact,  aligned  bundles   Echotype  II-­‐  Increased  waviness/separa:on  of  fibrils   Echotype  III-­‐  Decreased  fibrillar  integrity   Echotype  IV-­‐  Absence  of  fibrillar  organisa:on    
  21. 21. Diagnosis – staging the pathology Reactive tendinopathy
  22. 22. Diagnosis – staging the pathology Reactive on degenerative pathology January   August   Pathological  lesion  has  not  changed  over  3  years.  The  tendon  has  had  no   symptoms  between  January  and  August  
  23. 23. Monitoring load response •  Achilles tendon response in AFL players –  20 players screened •  Day 0 ,2 and 4 –  All normal Achilles •  Some had patellar tendinopathy –  Clear temporal response in those without tendinopathy •  Those with had a variable response
  24. 24. Monitoring recovery 31st  Jan,  2011   Prox   Mid   11th  Jun,  2012   14th  Jan,  2013  
  25. 25. Monitoring recovery Overall  echopa2ern  for  R  patellar  tendon   100%   Percentage  of  each  echotype   90%   80%   70%   60%   50%   40%   30%   1/31/2011   6/29/2011   6/11/2012   1/14/2013   Black   10,9%   2,7%   2,5%   1,6%   Blue   24,2%   22,5%   16,3%   16,4%   Red   16,6%   3,2%   2,4%   1,2%   Green   48,3%   71,5%   78,9%   80,8%  
  26. 26. Monitoring change in structure before symptoms 10th  Dec,  2012   17th  Dec,  2012   19th  Feb,  2013   100%   95%   90%   85%   80%   75%   70%   65%   60%   55%   50%   Black   Blue   Red   Green  
  27. 27. What else can we use for in season tendinopathy? •  Medications –  Affect the tendon response •  Injections –  Affect the tendon response –  Analgesia •  Adjunct treatments –  Analgesia
  28. 28. What medications can we use for the tendon? •  Tenocyte inhibitors –  Ibuprofen (Tsai et al 2004), celecoxib •  Aggrecan inhibitors –  Ibuprofen, naproxen, indomethacin (Dingle1999, Riley 2001) •  TNF alpha inhibitors –  Doxycycline (Fallon et al 2009) •  Inhibits MMP13 (Bedi et al 2010) –  Green tea (Cao et al 2007) –  Omega 3 (Mehra et al 2006)
  29. 29. What medications can we use for the tendon? •  Corticosteroid is a knock out blow on cell activity and proliferation –  –  –  –  Short acting and non-colloidal eg dexamethasone Not into tendon Can be oral ONLY in very reactive tendons •  What about the bad press? –  Used inappropriately •  •  •  •  Wrong stage Wrong corticosteroid Wrong rehab Wrong reasons
  30. 30. What about injections? •  Analgesia/ anaesthetic •  Well if it is only pain why not get rid of the pain? –  Progressive increase in symptoms •  Some steroid-like effects of local anaesthetics (Piper et al) •  Some long term effects of local anaesthetics •  Other injections – PRP, cells •  Intratendinous injections have no place for their use in in-season management •  Peri-tendinous injections used but untested to date
  31. 31. What else? •  Do NOT rest tendinopaths in the off season –  Immediately start to improve load capacity in the tendon •  Prehab •  Ensure good tendon capacity of all athletes •  Control the coach –  Ramp into pre-season training for tendinopaths •  Monitoring •  Monitor either pathology with UTC or pain with loading tests •  Early intervention •  Change load when tendon first declares its intolerance with pain or loss of structure –  Waiting and hoping not recommended
  32. 32. Summary •  Not just a simple assessment –  Stage pathology –  Determine response to load –  Determine what loads are affecting tendon •  Not a simple management –  Based on above •  Manage pathology •  Manage load •  Manage pain •  Manage long term outcome for the athlete
  33. 33. How can the presented evidence helped clinicians in the management of tendinopathies ?? •  One of your players experiences sudden onset of pain at the insertion of the Achilles tendon during training but only during high loading •  What to do? •  Sudden onset insertional pain unusual –  Examine the loading that is causing the pain •  Should be a compressive aetiology •  If not differential diagnosis –  May be insertional plantaris •  If it is tendon, decompress it –  High heel raise •  High during the day and as high as possible during training –  Consider training in good running shoes with heel raise •  Limit high loads •  Start isometrics and heavy slow loading away from dorsiflexion
  34. 34. Case 1 •  A young talented player with symptoms in the patellar tendon (on and off pain during warm up or after training, better during activity) during the preseason training •  What to do? –  continue training? –  adjust training? –  add treatment? 1.  Likely reactive on degenerative tendinopathy 1.  Not severe, but will be if not attended to immediately 1.  Back off loads, frequency, extreme load drills 2.  Attend to deficits in kinetic chain Especially quads and calf deficits 3.  Allow TIME for this to resolve 4.  Medicate with triple therapy 5.  Address fully in the off-season
  35. 35. Case 2 •  A very important player during season experience increasing symptoms (pain and stiffness in the morning) in the patellar tendon weeks before an important match •  What to do? •  Consider the diagnosis –  Patellar tendons are rarely sore in the am •  Balance the load with the tendon capacity –  Decrease abusive loads •  Frequency, length of training and specific drills •  Start loads that help pain and function –  Isometrics and heavy slow isotonics –  Strengthen calf and gluts to assist quads •  Medicate to settle