Henning Langberg: Professor at the Institute of Health University of Copenhagen, Copenhagen, Denmark

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From basic science to rehabilitation of tendinopathy – What have we learned?

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Henning Langberg: Professor at the Institute of Health University of Copenhagen, Copenhagen, Denmark

  1. 1. From basic science to rehab of tendinopathy What have we learned? Henning Langberg Professor, DMSc, PhD, Pt, SSPT, ISSPT Ins$tute  of  Public  Health  –  University  of  Copenhagen,  Denmark     Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  2. 2. PREVALANCE   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  3. 3. Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  4. 4. Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  5. 5. Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  6. 6. Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  7. 7. Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  8. 8. Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  9. 9. (Kahn  2009)   WHAT HAPPENS IN TENDONS WITH EXERCISES?   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  10. 10. Collagen  Turnover   (Magnusson Langberg, Nature Rev Rheum, 6: 262-68, 2010) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  11. 11. Collagen synthesis (%/hour) Collagen synthesis in tendon and exercise load 0.10   36 km run 0.05   Strength training Rest 10 0 1000 1-h kicking 10,000 100,000 Cumulative loading (BW) (Magnusson Langberg, Nature Rev Rheum, 6: 262-68, 2010) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  12. 12. Effect  of  1-­‐hour  kicking  on  patella  tendon     collagen  expression   (Dideriksen 2013) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  13. 13. Increase  in  atmospheric  14C  due  to  tesFng  of     nuclear  bombs  in  1955-­‐63   e.g.  Time  of  birth   No  turnover   Sampling   Carbon  in  atmosphere   Carbon-­‐12  99%   Carbon-­‐13  1%   Carbon-­‐14  small  frac$on   14C  level  measured  with     accelerator  mass     spectrometry  (AMS)   High  turnover   (Heinemeier  et  al.,  FASEB  J,  27:  2074-­‐9,  2013)   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  14. 14. RelaFvely  good  fit  of  14C  levels  in  Achilles  tendon  samples     with  0-­‐17  year  moving  average  curve   Bomb  pulse   -­‐  moving  average  (0-­‐17  years)   Bomb  pulse   Achilles  tendon   autopsy  samples   (18-­‐55  yrs)     Tendon  core  only  limited  renewal  aer  growth   (18  y)     In  contrast,  (14)C  levels  in  muscle  indicated   (Heinemeier  et  al,  FASEB  J,  27:  2074-­‐9,2013)   con$nuous  turnover     Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  15. 15. The effect of habitual unilateral high load on patella tendon properties Knee ext. force 300 weak side strong side 22 % ** Knee extensor MVC (Nm) 250 200 150 0 stro g sid n e w a sid ek e Tendon area * 2 ) 10 8 Patellar tendonCSA(mm 10 6 10 4 28 % 20 % ** 10 2 10 0 8 0 Couppé et al, JAP 2008 0 p x a ro im l m d id le Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com   d l ista
  16. 16. Training induce tendon growth and increased stiffness Force Strength Stiffness Deformation Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com   Injury resistant
  17. 17. WHY  THEN  TENDINOPATHY?   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  18. 18. Muscle-tendon overload (0,2,4,8,16 days) in rat M.  plantaris   MUSCLE TENDON Overload  &  Sham  on  Day  8   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com   (Olesen,  2006)  
  19. 19. Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  20. 20. What  is  going  on  in  the  injured  tendons?   PATHOLOGY   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  21. 21. Patology of tendons Increased  thickness   In-­‐growth  of  vessels   In-­‐growth  of  nerve  endings   Pain   Reduced  func$on   SUMMERY  OF  PATHOLOGY   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  22. 22. Symptoms of overuse in rat Achilles tendon Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  23. 23. Healthy   Tendinopathy   )   (Pinge  et  al  2013 Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  24. 24. Tendon  biopsies   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  25. 25. Structural  changes   (Healthy tendon area) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  26. 26. Structural  changes   (Healthy tendon area) (Injured tendon area) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  27. 27. Fibril area distribution Number of fibrils in the fraction Fibril area distribution 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 -10 * * (Injured tendon area) (Healthy tendon area) More small collagen fibrills tendon Tendinotic Tendinopathy Healthy tendon Healthy * 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 11000 12000 13000 14000 Area fractions nm2 (Pingel BMC 2012) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  28. 28. Does  exercise  cause  inflamma$on  in  tendinopathy?   Achilles   Tendinopathy   Healthy   (Pingel et al, 2013) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  29. 29. WHAT  HAPPENS  WITH  AGING?   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  30. 30. Effect of rhGH on collagen turnover (Døssing 2010) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  31. 31. Age and GH – role of growth factors (Boesen, Langberg 2013) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  32. 32. Effect of GH during immob and rehab ! Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  33. 33. Effect of GH during immob and rehab (Boesen, Langberg 2013) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  34. 34. Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  35. 35. Model  for  Tendinopathy  and  healing     based  on  clinical  experiences     Thanks to Dr. Gil Rodas (FC Barcelona) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  36. 36.     HOW  TO  REHABILITATE  TENDONS?   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  37. 37. Tendon ”overuse” a major clinical problem   Non-operative treatments •  •  •  •  •  •  •  •  •  •  •  •  •  •  Rest – decreased activity Orthodics Eccentric exercise training Massage + controlled motion Cryotherapy – heat therapy El-stimulation Laser – Ultrasound – Shock wave NSAID (local, systemic) Corticosteroid injection Low-dose heparin Topical nitroglycerine Platelet rich autolog inj. (PRP) Calf’s blood injection Sclerosant injection Operative treatments   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  38. 38. PREVENTION   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  39. 39. ProphylacFc  Training  in  AsymptomaFc  Soccer  Players  With   Ultrasonographic  AbnormaliFes  in  Achilles  and  Patellar  Tendons   The  Danish  Super  League  Study   •  Prophylac$c  eccentric  training  and  stretching  reduces  risk  of  developing   UL  abnormali$es  in  the  patellar  tendons     •  No  posiFve  effects  on  the  risk  of  injury   •  In  asymptoma$c  UL  abnormal  patellar  tendons,  prophylacFc  eccentric   training  and  stretching  increased  the  injury  risk   •  No  effect  on  the  Achilles  tendons     (Fredberg, Bolvig, Andersen; Am J Sports Med 2008 36:451) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  40. 40. Thanks to Dr. Gil Rodas (FC Barcelona) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  41. 41. Thanks to Dr. Gil Rodas (FC Barcelona) Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  42. 42. HOW  CAN  THE  PRESENTED  EVIDENCE    HELPED   CLINICIANS  IN  THE  MANAGEMENT  OF   TENDINOPATHIES  ??         Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  43. 43. Case  1   •  A  young  talented  player   with  symptoms  in  the   patella  tendon  (on  and  off   pain  during  warm  up  or   aer  training,  beger   during  ac$vity)  during  the   preseason  training     •  What  to  do?   –  con$nue  training?     –  adjust  training?     –  add  treatment?     Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  44. 44. Case  2   •  A  very  important   player  during  season   experience  increasing   symptoms  (pain  and   s$ffness  in  the   morning)  in  the  Patellar   Tendon    weeks  before   an  important  match   •  What  to  do  ??   Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  45. 45. Case  3   •  One  of  you  players   experiences  sudden   unset  of  pain  in  the   Inser$onal  Achilles   tendon  during  training   but  only  during  high   loading.   •  What  to  do  ?     Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  46. 46. Prepare  athletes  to  sport??       -  -  -  -  -  Peak forces Plyometric loading Contraction velocity Muscular fatigue Rotation = shear forces Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  
  47. 47. More  quesFons  than  answers   •  Tendons can adapt to loading •  Tendons adapt slower than muscle •  The core of the tendon may heal differently from the outside •  All tendons are not alike, no treatment fits all •  We need to cover the gap between rehab and return to sport Copyright  Henning  Langberg  –  Email:  henninglangberg@gmail.com  

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