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

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
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

2. PREVALANCE
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Langberg
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henninglangberg@gmail.com

3. Copyright
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4. Copyright
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Langberg
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5. Copyright
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Langberg
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6. Copyright
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Langberg
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Langberg
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8. Copyright
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Langberg
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9. (Kahn
2009)
WHAT HAPPENS IN TENDONS
WITH EXERCISES?
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

10. Collagen
Turnover
(Magnusson Langberg, Nature Rev Rheum, 6: 262-68, 2010)
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Henning
Langberg
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henninglangberg@gmail.com

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)
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

12. Effect
of
1-­‐hour
kicking
on
patella
tendon
collagen
expression
(Dideriksen 2013)
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

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)
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

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
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

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
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Henning
Langberg
–
Email:
henninglangberg@gmail.com
d l
ista

16. Training induce tendon growth
and increased stiffness
Force
Strength
Stiffness
Deformation
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Henning
Langberg
–
Email:
henninglangberg@gmail.com
Injury resistant

17. WHY
THEN
TENDINOPATHY?
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

18. Muscle-tendon overload
(0,2,4,8,16 days) in rat
M.
plantaris
MUSCLE
TENDON
Overload
&
Sham
on
Day
8
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Henning
Langberg
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henninglangberg@gmail.com
(Olesen,
2006)

19. Copyright
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Langberg
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20. What
is
going
on
in
the
injured
tendons?
PATHOLOGY
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

21. Patology of tendons
Increased
thickness
In-­‐growth
of
vessels
In-­‐growth
of
nerve
endings
Pain
Reduced
func$on
SUMMERY
OF
PATHOLOGY
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

22. Symptoms of overuse in rat Achilles tendon
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Henning
Langberg
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henninglangberg@gmail.com

23. Healthy
Tendinopathy
)
(Pinge
et
al
2013
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

24. Tendon
biopsies
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Langberg
–
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henninglangberg@gmail.com

25. Structural
changes
(Healthy tendon area)
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

26. Structural
changes
(Healthy tendon area)
(Injured tendon area)
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

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)
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

28. Does
exercise
cause
inflamma$on
in
tendinopathy?
Achilles
Tendinopathy
Healthy
(Pingel et al, 2013)
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

29. WHAT
HAPPENS
WITH
AGING?
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Henning
Langberg
–
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henninglangberg@gmail.com

30. Effect of rhGH on collagen turnover
(Døssing 2010)
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

31. Age and GH – role of growth factors
(Boesen, Langberg 2013)
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

32. Effect of GH during immob and rehab
!
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

33. Effect of GH during immob and rehab
(Boesen, Langberg 2013)
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

34. Copyright
Henning
Langberg
–
Email:
henninglangberg@gmail.com

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.
HOW
TO
REHABILITATE
TENDONS?
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

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
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

38. PREVENTION
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Henning
Langberg
–
Email:
henninglangberg@gmail.com

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. Thanks to Dr. Gil Rodas (FC Barcelona)
Copyright
Henning
Langberg
–
Email:
henninglangberg@gmail.com

41. Thanks to Dr. Gil Rodas (FC Barcelona)
Copyright
Henning
Langberg
–
Email:
henninglangberg@gmail.com

42. HOW
CAN
THE
PRESENTED
EVIDENCE
HELPED
CLINICIANS
IN
THE
MANAGEMENT
OF
TENDINOPATHIES
??
Copyright
Henning
Langberg
–
Email:
henninglangberg@gmail.com

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. 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. 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. Prepare
athletes
to
sport??
-
-
-
-
-
Peak forces
Plyometric loading
Contraction velocity
Muscular fatigue
Rotation = shear forces
Copyright
Henning
Langberg
–
Email:
henninglangberg@gmail.com

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